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Healing is Coming - February 2021 - Subscribe to Outpatient Surgery Magazine

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approved cardiac procedures needs to increase to drive adoption. "When CMS made the initial move to add cardiac procedures to our reimbursement list, they estimated if just 5% of coronary interven- tions moved from HOPDs to ASCs, it would save the Medicare program $20 million a year," he says. "If they don't set the reimbursement rate for these procedures correctly, you're not going to see that migration. I think [adoption] is going to be slow and steady. We need reimbursement policies that incen- tivize ASCs to want to take on this service line." What are the local regulations? Although CMS will reimburse for outpatient cardiol- ogy procedures, your state's government might not allow ASCs to perform them. "First make sure you're permitted to add the specialty," says Kelly Bemis, RN, BSN, chief clinical officer at Azura Vascular Care and National Cardiovascular Partners, which operates cardiac ASCs across the country. "The regulations are different in each state." As CMS continues to add codes, states are reacting in turn, says Kenneth Yood, a partner at Los Angeles law firm Sheppard Mullin. "The expansion of services on the federal side is driving an expansion of services on the state licensing side," he says. "California is a great example. Right now, cardiac catheterization services can't be performed in an ASC, but new legis- lation currently being considered would allow ASCs to provide those kinds of services." What are the equipment requirements? It's far from simple or seamless to add a cardiology service line. Ms. Bemis has a unique view of the playing field. National Cardiovascular Partners started in Texas in 2006, long before CMS approved cardiac procedures in ASC settings. However, some commercial payers did provide reimbursement, and combined with Texas' favorable legal and regulato- ry environment, the company has opened 15 prof- itable cardiac ASCs. Most of the firm's ASCs have one or two ORs, referred to as interventional suites. "The walls are lined with lead, due to requiring fluoroscopy throughout procedures," says Ms. Bemis. The main piece of equipment needed is a perma- nently fixed C-arm designed for cardiac procedures that mounts to the ceiling or floor. Smaller mobile units used for orthopedic, podiatry and other special- ties are not suitable for cardiac procedures. The real difference between a mobile C-arm and a fixed unit is the quality of imaging and the ease of use. As you can imagine, however, to house this large piece of equip- ment you'll need more space than a traditional OR. A cardiac operating room is comprised of three spaces: The interventional suite that's large enough for the fixed imaging system, a radiolucent table and ancillary equipment; a second room that houses needed equipment; and a control room where a monitor records what happens during the proce- dure. "Some ASCs have larger ORs if they're per- forming more complex orthopedic procedures such as total joints and spine cases, but you basically need the square footage of two traditional ORs to have enough space for the interventional suite, con- trol room and equipment room," says Ms. Bemis. The required capital equipment — along with an ultrasound machine, micropuncture needles and an assortment of sheaths, guidewires and stents — can cost upwards of $1 million. You might not need a sterile processing depart- ment (SPD), though. "Physicians aren't routinely making incisions for these procedures," says Ms. Bemis, whose centers' supplies are almost exclu- sively single-use. "For the most part, we have cho- sen to use disposable instrument trays, which have lowered concerns and risks surrounding infection control. In most of our centers, we didn't build an SPD." For the few reusable instruments and sup- plies involved, her centers contract with third-party vendors or local hospitals for reprocessing. What are the staffing requirements? Building a cardiac care team can be challenging. "It's a small pool of qualified providers you're pulling from, with a lot of entities trying to pull from it," says Ms. Bemis, who spent 20 years as an OR nurse. "You need experienced cardiology nurses and a dedicated radiology tech, which most tradi- tional ASCs don't have." F E B R U A R Y 2 0 2 1 • O U T P A T I E N T S U R G E R Y . N E T • 2 5

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