What it takes to grow a successful ambulatory enterprise

Due to advancements in technology, improved methods for pain control and the shift toward value-based care, surgery procedures are moving steadily to the outpatient setting. Even higher acuity procedures in complex specialties, such as neurosurgery, are making the move to the outpatient arena.

"If you think of surgery today in America, it's really in the ambulatory business," said Jeff Peters, CEO of Surgical Directions, in a Feb. 14 webinar hosted by Becker's Hospital Review and sponsored by Surgical Directions. "It's not like 'how do we grow the ambulatory business?' The ambulatory business is really where surgery is today."

With the shift in surgery site, hospitals are becoming more interested in building out an ambulatory enterprise. Here are some key considerations for hospitals looking to enter the outpatient care arena.

Specialty growth areas
The range of procedures that can be performed at ambulatory facilities is increasing, with orthopedics, spine and gastroenterology being particularly ripe for growth. In these specialties, the number of procedures performed exclusively in the inpatient setting are dropping, while outpatient cases are growing.

Within orthopedics, sports medicine is a subspecialty seeing especially strong growth as it is in high demand and has a high margin. Additionally, sports medicine typically has a good payer mix and its patient mix tends to skew younger, which means outcomes tend to be good, resulting in consistent reimbursement from a variety of payers.

Mr. Peters said that five years ago almost all spine surgery was inpatient, but today with the advent of minimally invasive technologies and more effective pain control methods, several spine procedures can be done successfully in the outpatient arena at a lower cost.

"What [payers] are looking at is what's the procedure that's going to have the best clinical outcome, the highest improvement in patient satisfaction at the lowest cost," he said. "And if we are going to succeed in this ambulatory environment, we have to pay attention to those three factors: outcome, patient engagement and cost."

Opportunities for hospitals
A major opportunity exists for hospitals to acquire existing ASCs where the surgeons are growing older and more mature in their skill set. ASCs need capital and costly technology, and surgeons are increasingly opting for hospital employment. So, hospitals looking to advance their ambulatory strategy can consider acquiring surgery centers and employing the surgeons who work there.

"It allows hospitals to have ready access to a market where there is an ongoing volume or capacity that they can capture with that investment," Mr. Peters said. "So, taking advantage of where the market is, but rather than just competing, acquiring."

However, hospitals must decide between an ambulatory strategy that invests in hospital outpatient departments or an ASC. The question comes down to what is more important for a hospital — having a center away from the hospital to capture new volume or having an HOPD on its campus to increase reimbursement. Reimbursement for HOPDs is much higher than freestanding ASCs.

Managing an ambulatory enterprise
Success in the ambulatory space requires the following three elements:

1. A governance body. The governance body should include physician leadership and hospital leadership, both looking at strategic direction, resource allocation and data dissemination. The body also needs to establish benchmarks across quality and cost measures and create dashboards where providers can see how they are performing against the benchmark. Physicians need to see that information and, if needed, the governance body can step in and have crucial conversations with physicians who are not performing well, said Mr. Peters.

2. A clinical redesign. There needs to be a focus on optimizing the clinical performance, from how providers prepare for surgery to how they prepare patients for surgery. Every aspect of the care journey needs to be coordinated. For example, prior to surgery, providers can call patients scheduled for a simple procedure to find out their health-related baselines or what medications they are on; and for more complex procedures, providers can set up an in-person meeting with the patient to go over details related to the procedure.

Providers must also look at the post-acute care arena as well, said Mr. Peters, and ensure they are following up with patients. Most complications crop up postsurgery once the patients have left the facility. Patients need to know they have the support they need postoperatively.

3. A focus on patient engagement. Patients want to be engaged and understand the processes related to their procedure, including preoperative and postoperative care, said Mr. Peters. They want to have someone answer their questions and be an advocate for them. They also want to have an attachment to the facility where they are receiving their care. Providers can facilitate this via technology that patients can use to easily communicate with caregivers. Technology can also be used to offer educational modules to patients.

"What we've found is that the organizations moving beyond the simple ambulatory procedures to the more complex ambulatory procedures are getting a financial return," Mr. Peters said. "But you've got to evaluate whether that capital investment is worth it and whether you have the clinical, financial data and organizational skills to manage this new population. But that's clearly where the growth opportunity is in surgery."

To learn more about Surgical Directions, click here, and view the full webinar here.


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