LAS VEGAS -- Reimbursement changes are underway that may shape how outpatient endovascular suites operate, physicians said here at a roundtable session at the annual Vascular InterVentional Advances (VIVA) conference.
The latest development in the turf war between hospitals and these independent centers -- office-based labs (OBLs), freestanding ambulatory surgery centers (ASCs), or their hybrids -- is the final ruling by the Centers for Medicare & Medicaid Services (CMS): starting January 2020, there will be changes to outpatient payments, including new coverage of the following coronary interventions performed at ASCs:
- Percutaneous transluminal coronary angioplasty
- Percutaneous transcatheter placement of intracoronary stents
- Percutaneous transcatheter placement of drug eluting intracoronary stents
Moreover, a site neutrality rule proposed by CMS also means the elimination of payment differences between the hospital outpatient setting and the ASC.
Several physicians joined together to discuss why ambulatory centers are deserving of better reimbursement.
OBLs and ASCs are typically favored by patients as these may feel more friendly and confer more "high-touch" care than a hospital outpatient department, according to session moderator Tony Das, MD, of Cardiology and Interventional Vascular Associates in Dallas.
The degree of patient satisfaction at these centers is "amazing" and is "far above what we see in hospital ratings," said Brian DeRubertis, MD, of UCLA-Ronald Reagan Medical Center.
As a result of this site neutrality, "suddenly hospitals are scrambling to see if they can incorporate ASCs into their portfolios," Das told the audience.
It's a "sad testimony" to healthcare in the U.S. that hospitals are not responsive enough to the physicians' and patients' needs when it comes to staffing and resources, commented John Rundback, MD, of Holy Name Medical Center's Interventional Institute in Teaneck, New Jersey. OBLs, on the other hand, can fulfill these daily needs without having physicians go through whole processes and committees, he suggested.
"We have control over our work environment," agreed DeRubertis, who said his group couldn't get a CO2mmander purchased for several months at the hospital. "OBLs can pivot to the needs of patients and providers," he said.
Not all procedures and patients are best suited for the OBL or ASC, however, as the choice of a procedure's setting can depend on patient factors and anesthetic requirements, according to DeRubertis.
Procedural factors also come into play as operators must consider the complexity of the operation and the location of the lesion.
"The goal is to provide optimal care while decreasing complication rates ... [to] practice optimal care through focused attention rather than reliance on redundant systems and standard operating procedures of the large healthcare systems to which most of us are accustomed," he said.
"Severe active coronary conditions, advanced pulmonary disease, and procedures expected to require many devices or significant operative duration may be better served in the inpatient setting," DeRubertis cautioned.
"We're not doing easy cases," said Rundback, emphasizing that operators be prepared to avoid and treat complications when they come up.
Indeed, quality of care depends on various measures such as radiation safety, verification of equipment standards, emergency back-up power, and regular quality control on imaging equipment, according to Das, whose center is accredited for high quality by the Joint Commission.
The Outpatient Endovascular and Interventional Society registry and similar databases will ultimately be used to determine quality-based payments in the future.
"Make sure that once you close the doors and walk into the procedure, it feels just like a hospital environment," Das stressed.
Jihad Mustapha, MD, of the Advanced Cardiac & Vascular Amputation Prevention Center in Grand Rapids, Michigan, said he works at an office with surgeons, cardiologists, and even podiatrists and lung care specialists, all with the sole focus on patients with critical limb ischemia.
Due to a high number of referrals for limb salvage, there is urgent revascularization going on "constantly" at this center. Such high volume gives it efficiency and the ability "to be nimble" and meet the urgent needs of patients in a relatively fast time frame, Mustapha said.
Occasionally, his group even treats patients without reimbursement, he said -- for example those who are transferred from hospitals for treatment at the office and then transferred back.
Yet not all OBLs and ASCs can be run by such elite operators involved in multiple clinical trials, an audience member pushed back at the end of the session. "Most are run by 'average operators' and they want to minimize expensive technologies. The elephant in the room is that [they're] not treating Medicaid patients," he said.
"We should find a way to treat [Medicaid patients]. We treat them with open arms because they deserve the same care as everyone else. We are working on this behind the scenes," said Mustapha.
It's not just about Medicaid, however, as operators at hospitals disproportionately use costly technologies, the audience member said. "The same operator will use a drug-eluting balloon in-hospital and a re-entry device. In the office he will accept less radiographic success and say 'We're done.'"
The VIVA session ended without a response from the discussants.
Europe needs guidelines for outpatient endovascular repair
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