Finn, Chrissy M: Hello and welcome to our webinar Act Now or Fall Behind Preparing for a Rise in
Finn, Chrissy M: Ambulatory Surgical Care.
Finn, Chrissy M: My name is Chrissy Finn. I'm the Director of Interqual Content
Finn, Chrissy M: Products. I'm a registered nurse and I've been with
Finn, Chrissy M: Interqual for the last 18 years. In my role,
Finn, Chrissy M: I'm responsible for the Interqual Content road map and managing and defining
Finn, Chrissy M: product enhancements. Today we're going to talk about shifts in
Finn, Chrissy M: ambulatory site of service and some strategies.
Finn, Chrissy M: And considerations your organization can put into motion to help manage the shifts.
Finn, Chrissy M: So we'll start today by looking at the current state of healthcare.
Finn, Chrissy M: Today we have an industry at a tipping point. As clinicians,
Finn, Chrissy M: we see it in our day-to-day. But so for me,
Finn, Chrissy M: the challenges the industry is facing is starting to creep into my personal life
Finn, Chrissy M: and conversations I'm having with friends.
Finn, Chrissy M: and see on social media about delays in care, people slipping through the cracks,
Finn, Chrissy M: medication shortages, and supply chain disruptions. Personally,
Finn, Chrissy M: last year I had a heck of a time trying to find an inhaler for my two-year-old,
Finn, Chrissy M: which was one of those shocking things that, you know,
Finn, Chrissy M: you don't expect to happen in 2020.
Finn, Chrissy M: 25 But these comments that I'm seeing, these conversations that I'm having
Finn, Chrissy M: really bring it back to the problems that we're facing.
Finn, Chrissy M: One of the biggest things coming out of the COVID pandemic is the impact on
Finn, Chrissy M: staffing. I think that this was a trend that we
Finn, Chrissy M: talked about coming for some time.
Finn, Chrissy M: Many years prior to COVID, but it's only been accelerated as nurses
Finn, Chrissy M: look to leave clinical roles. The rise of remote employment is
Finn, Chrissy M: attractive to a lot of employees, and nurses are no exception, right?
Finn, Chrissy M: Contributing to the desire to leave that clinical role is the amount of manual or
Finn, Chrissy M: duplicative work that we're starting to.
Finn, Chrissy M: Require folks to do it results in frustration and wasted time.
Finn, Chrissy M: We see 60% of authorizations as either being manual or duplicative.
Finn, Chrissy M: There has to be a better way to drive efficiency without putting that burden on
Finn, Chrissy M: already taxed staff.
Finn, Chrissy M: This authorization burden doesn't just impact nursing staff, though.
Finn, Chrissy M: We know that 86% of physicians rate the burden of authorizations as the biggest
Finn, Chrissy M: administrative challenge in their jobs, resulting in provider abrasion and
Finn, Chrissy M: dissatisfaction. As I mentioned earlier, patients are frustrated.
Finn, Chrissy M: The care that they're being provided isn't always appropriate.
Finn, Chrissy M: We see a lot of delays in care result related to staffing and scheduling or
Finn, Chrissy M: administrative burden. Patients are not being expedited out of
Finn, Chrissy M: the inpatient setting as quickly as they could due to post acute bed availability
Finn, Chrissy M: challenges and on top of that patients.
Finn, Chrissy M: They're taking on more financial risk, which is going to really help to drive
Finn, Chrissy M: that concept of patient as consumer. Patients are looking to take on a more
Finn, Chrissy M: active role in decision-making and they need education and support to help make
Finn, Chrissy M: informed decisions about the quality of their care and the potential cost impact.
Finn, Chrissy M: In my role as product owner at Interqual 5 to 10 years ago,
Finn, Chrissy M: I would say regulatory mandates didn't play a huge role in how we designed our
Finn, Chrissy M: content or how our content functioned in the market. Today,
Finn, Chrissy M: that's a completely different story, right?
Finn, Chrissy M: New federal and state mandates seem to be coming out every week.
Finn, Chrissy M: Most that have significant impact on payer.
Finn, Chrissy M: Provider workflow, either care decisions, audit reporting requirements.
Finn, Chrissy M: If I had a dollar for every time someone said Medicare Advantage final rule to me,
Finn, Chrissy M: I would be retired and working on a new passion project.
Finn, Chrissy M: But today it just simply is not possible to avoid that regulatory impact.
Finn, Chrissy M: And while we need standard operations, interoperability desperately to
Finn, Chrissy M: streamline some of the processes that are bogging down the system and generate
Finn, Chrissy M: efficiencies so that we can all start to focus, you know,
Finn, Chrissy M: or refocus on providing the best possible care to our patients.
Finn, Chrissy M: Industry standards like CMS 0057 are not things that just happen overnight.
Finn, Chrissy M: They require planning, preparation and implementation.
Finn, Chrissy M: Throughout all of this, clinical appropriateness remains as
Finn, Chrissy M: relevant today as when Interqual was first introduced to support quality
Finn, Chrissy M: within the.
Finn, Chrissy M: Within the healthcare system, we have finite clinical resources.
Finn, Chrissy M: We need to preserve them for the right patients,
Finn, Chrissy M: become more consistent in how we apply them,
Finn, Chrissy M: and allow for more rapid adoption of best practice.
Finn, Chrissy M: No one wants utilization management to stand in the way of providing care to
Finn, Chrissy M: patients.
Finn, Chrissy M: But it remains a necessary process to safeguard our resources and to help drive
Finn, Chrissy M: quality patient outcomes.
Finn, Chrissy M: In some ways, the COVID-19 pandemic helped us out.
Finn, Chrissy M: I hesitate to say that, but there really is nothing like a crisis
Finn, Chrissy M: to help focus the mind. COVID-19 really forced us to think about
Finn, Chrissy M: a different way to deliver the necessary care that patients needed,
Finn, Chrissy M: just differently. We were forced to manage resource
Finn, Chrissy M: constraints by.
Finn, Chrissy M: Allocating resources to areas of the hospital system that needed the most
Finn, Chrissy M: right. Innovations in care delivery like
Finn, Chrissy M: hospital in the home programs gained rapid expansion during this time.
Finn, Chrissy M: Minimizing infection risk forced us to think twice about inpatient admissions or
Finn, Chrissy M: even on campus ambulatory visits.
Finn, Chrissy M: During the pandemic, we saw elective surgery triage guidelines
Finn, Chrissy M: come out from the American College of Surgeons.
Finn, Chrissy M: Patients as consumers began accessing care in different ways,
Finn, Chrissy M: in many cases out of fear, but also driven by convenience.
Finn, Chrissy M: As we all started working at home, we realized, well,
Finn, Chrissy M: there's other aspects of our lives that could also be done.
Finn, Chrissy M: From home, new capabilities driven by telehealth
Finn, Chrissy M: technology have really transformed the way that we interact with our healthcare
Finn, Chrissy M: providers. In some cases, like behavioral health,
Finn, Chrissy M: this flexibility has really improved access.
Finn, Chrissy M: I think about how many people I know that have started going to therapy just
Finn, Chrissy M: because it's so much easier to make time for.
Finn, Chrissy M: For these innovations were also supported by increased payer flexibility because as
Finn, Chrissy M: we all know, the fastest way to drive adoption is
Finn, Chrissy M: through financial impact or incentive. I mentioned hospital in the home earlier.
Finn, Chrissy M: The CMS Acute Hospital Care at Home waiver is a great example of how
Finn, Chrissy M: flexibility.
Finn, Chrissy M: Drove adoption and I'm personally very excited to see how that waiver gets
Finn, Chrissy M: extended in the next coming months.
Finn, Chrissy M: So let's start talking about some of these shifts. What what's happening?
Finn, Chrissy M: So the inpatient procedural volume is increasingly starting to shift to
Finn, Chrissy M: outpatient care settings such as ambulatory surgical centers,
Finn, Chrissy M: hospital outpatient, outpatient departments and offices.
Finn, Chrissy M: You can see certain service lines and procedures are shifting outpatient faster
Finn, Chrissy M: than others. Musculoskeletal is a great example of
Finn, Chrissy M: that. When the first surgery with anesthesia
Finn, Chrissy M: was done inside the ether Dome at MGH in 1846,
Finn, Chrissy M: or when the concept of aseptic surgery was introduced 55 years later in 1900.
Finn, Chrissy M: It was probably pretty hard to imagine that surgery is going to take place
Finn, Chrissy M: anywhere but in the hospital, but there have been a lot of innovations
Finn, Chrissy M: in patient care. Consumer convenience and updates to
Finn, Chrissy M: coverage policies and reimbursement models have really helped to drive
Finn, Chrissy M: surgical care outside of the hospital.
Finn, Chrissy M: Data estimates that about 50 to 65% of all surgical procedures are performed in
Finn, Chrissy M: the outpatient setting and that volume continues to rise.
Finn, Chrissy M: Ambulatory surgical care is one of the fastest growing segments of the
Finn, Chrissy M: healthcare industry. In the last five years,
Finn, Chrissy M: we've seen a 20% increase in pacemaker.
Finn, Chrissy M: Repentations happening outside the in the outpatient space and 83% shift in joint
Finn, Chrissy M: replacements and an 18% shift in spinal fusion.
Finn, Chrissy M: It should be noted that total joint replacement of the knee came off of the
Finn, Chrissy M: inpatient only list in January of 2018, which is really what.
Finn, Chrissy M: Started the shift here and then the addition of TJR to the ASC eligible list
Finn, Chrissy M: in 2020 really helped to expedite it. So if you're looking here for an example
Finn, Chrissy M: of how regulatory drivers can impact a shift, well, there you have it.
Finn, Chrissy M: That's the one.
Finn, Chrissy M: Secondarily, we're also starting to see procedures
Finn, Chrissy M: shift from the hospital outpatient department to the ambulatory surgical
Finn, Chrissy M: center and the office setting. And So what really what is the difference?
Finn, Chrissy M: CMS defines a hospital outpatient department as a portion of the hospital
Finn, Chrissy M: that provides diagnostic interventional therapeutic both surgical.
Finn, Chrissy M: Surgical and non-surgical and rehabilitation services to sick or
Finn, Chrissy M: injured persons who do not require hospitalization or institutionalization.
Finn, Chrissy M: Hospital outpatient departments can be both on campus and off campus.
Finn, Chrissy M: An ASC is defined as a freestanding facility other than a doctor's office
Finn, Chrissy M: where surgical or diagnostic services are provided on an ambulatory basis. So,
Finn, Chrissy M: as data on quality, safety, and patient satisfaction um supports the
Finn, Chrissy M: Effectiveness of surgery in the ambulatory space,
Finn, Chrissy M: we're starting to see this secondary shift of procedures from the hospital
Finn, Chrissy M: outpatient department to the ambulatory surgical center.
Finn, Chrissy M: This is driven by financial incentives, right, pushing payers,
Finn, Chrissy M: providers and patients towards these freestanding sites.
Finn, Chrissy M: Models predict a 9% increase in ASC volumes between 2023 and 2028,
Finn, Chrissy M: compared to a 7% increase in hospital outpatient department volumes and a 1%
Finn, Chrissy M: increase in inpatient volumes. So what makes the ASC so attractive?
Finn, Chrissy M: ASC are.
Finn, Chrissy M: ASC are typically more conveniently located than hospitals.
Finn, Chrissy M: I for one will call out the benefits of free parking and being able to walk right
Finn, Chrissy M: to the front door without having to take a shuttle as one of the major benefits.
Finn, Chrissy M: ASCS are only permitted to address 23 hours of care,
Finn, Chrissy M: so that means getting patients back home.
Finn, Chrissy M: to their own pillow more quickly. It increases comfort and decreases
Finn, Chrissy M: infection risk. Because the ASC is a more intimate
Finn, Chrissy M: setting than a larger hospital, it gives patients a perceived sense of
Finn, Chrissy M: personalized care and a care team that is more accessible for all those questions
Finn, Chrissy M: that you might have right after surgery or even before surgery.
Finn, Chrissy M: Then there's the cost component. The entire operating component of an ASC
Finn, Chrissy M: is really just configured at a lower cost base. Everything, staffing, supplies,
Finn, Chrissy M: equipment, facilities, it's all cheaper and the reimbursement
Finn, Chrissy M: for procedures remains relatively the same.
Finn, Chrissy M: The cost of elective OR time is less than $15.00 per minute in an ASC versus $40.
Finn, Chrissy M: 00 per minute in a hospital OR. So that's a big time savings.
Finn, Chrissy M: So let's walk through the trends that are leading this leading us towards this
Finn, Chrissy M: shift. And there are several key drivers that
Finn, Chrissy M: support the shift of procedures out of the inpatient space and into the
Finn, Chrissy M: ambulatory surgical center.
Finn, Chrissy M: New developments in clinical technology has led to growth in the ambulatory
Finn, Chrissy M: surgical space by supporting faster recovery.
Finn, Chrissy M: Things like using more localized or regional approaches to anesthesia,
Finn, Chrissy M: better monitoring equipment, new medications to treat side effects of
Finn, Chrissy M: anesthesia like nausea and fatigue.
Finn, Chrissy M: and muscle relaxants that don't last as long and better pain control.
Finn, Chrissy M: Advancements in microsurgical techniques that allow for procedures with smaller
Finn, Chrissy M: wound sites is a good example. Hardware has also improved. For example,
Finn, Chrissy M: the screws that are used in fusion surgeries coupled with changes in
Finn, Chrissy M: In anesthesia has led to an increase in outpatient spinal surgeries, for example.
Finn, Chrissy M: Consumer demand and patient satisfaction play a key role.
Finn, Chrissy M: While cost is also a significant driver, it's not the only driver here.
Finn, Chrissy M: Surgery that was once considered to be daunting and maybe avoided seems to be
Finn, Chrissy M: more manageable and convenient. Patient satisfaction tends to be the most
Finn, Chrissy M: convenient and less intimidating.
Finn, Chrissy M: Settings. Patients are looking for enhanced
Finn, Chrissy M: convenience and a better care experience with greater comfort and less hoops to
Finn, Chrissy M: jump through to get access to care. As at-risk contracts and value-based care
Finn, Chrissy M: incentives rise, payers and providers have new incentives
Finn, Chrissy M: to find the lowest cost site of care.
Finn, Chrissy M: Providers are seeing financial opportunities of shared ownership model
Finn, Chrissy M: models, excuse me, and physician autonomy. Through ownership opportunities,
Finn, Chrissy M: doctors now have the incentive and opportunity to channel patients to
Finn, Chrissy M: procedures outside the hospital.
Finn, Chrissy M: They also have increased autonomy and really value things like predictability
Finn, Chrissy M: and efficiency in their OR schedule. The ASC setting gives the surgeon more
Finn, Chrissy M: time to do what they want to be doing, operating on patients and because surgery
Finn, Chrissy M: times tend to be shorter by 31 minutes in an ASC, they are also.
Finn, Chrissy M: Much more productive, serving the needs of more patients and
Finn, Chrissy M: seeing more financial benefit. Regulatory changes continue to have a
Finn, Chrissy M: huge impetus in moving procedures as with the example in total joint replacement as
Finn, Chrissy M: procedures come off of the.
Finn, Chrissy M: CMS inpatient list and move on to the ASC list.
Finn, Chrissy M: CMS is sending a strong signal that a procedure can safely be performed outside
Finn, Chrissy M: the inpatient setting. Just last week, CMS dropped its proposed outpatient
Finn, Chrissy M: prospective payment system rule for 2026 and indicated that it's planning to phase
Finn, Chrissy M: out the inpatient only list over.
Finn, Chrissy M: Over the next three years to quote, give beneficiaries more choices on where
Finn, Chrissy M: to obtain care with the potential for lower cost out-of-pocket expenses.
Finn, Chrissy M: And that's a big, a big thing that's coming potentially for
Finn, Chrissy M: us to to all operationalize.
Finn, Chrissy M: And the outpatient shift really is beneficial across all healthcare
Finn, Chrissy M: stakeholders, right? So consumers, providers, payers,
Finn, Chrissy M: we can all see benefits from the site of care shift.
Finn, Chrissy M: Consumers will realize out of pocket savings and a more convenient patient
Finn, Chrissy M: experience.
Finn, Chrissy M: Generally returning home the same day of surgery,
Finn, Chrissy M: faster access to scheduling and shorter stays lead to greater patient
Finn, Chrissy M: satisfaction, increased productivity, new sources of revenue,
Finn, Chrissy M: better control over operations and savings are seen on the provider side,
Finn, Chrissy M: the operating costs at.
Finn, Chrissy M: Hospital outpatient department are higher than an ASC and reimbursement is
Finn, Chrissy M: generally the same. This shift provides an opportunity for
Finn, Chrissy M: cost savings. From a system perspective, the shift to ASC allows systems to defend
Finn, Chrissy M: their outpatient market share, maintain alignment among physicians.
Finn, Chrissy M: And differentiate themselves from competitors on quality and cost.
Finn, Chrissy M: Payers will also see significant cost savings compared to hospital based care.
Finn, Chrissy M: So sounds like there's a lot of opportunity here.
Finn, Chrissy M: Identifying where to get started, finding the low hanging fruit,
Finn, Chrissy M: and operationalizing complex organizational workflows are really the
Finn, Chrissy M: only things in the way. Sounds easy, right?
Finn, Chrissy M: Yeah.
Finn, Chrissy M: So now that we know that the shift's coming,
Finn, Chrissy M: what are the steps to take in order to be successful? To be truly effective,
Finn, Chrissy M: the site of care shift has to be approached from a systems and process
Finn, Chrissy M: perspective. Systems should really look to create a
Finn, Chrissy M: shared mission to prioritize patient safety and offer more point more access.
Finn, Chrissy M: Points to procedures based care align on decision-making frameworks and processes
Finn, Chrissy M: to identify the procedures and patients that belong in the ambulatory settings is
Finn, Chrissy M: really a crucial critical step. Decision-making frameworks give all
Finn, Chrissy M: stakeholders a better chance at making consistent decisions.
Finn, Chrissy M: Decisions and once ideal procedures have been targeted,
Finn, Chrissy M: an organization can evaluate new opportunities for reimbursement models
Finn, Chrissy M: and invest in alternative care sites.
Finn, Chrissy M: Shared decision-making plays a hugely valuable role in supporting the shift by
Finn, Chrissy M: providing patient education on the benefits,
Finn, Chrissy M: efficiency and safety of alternate care settings.
Finn, Chrissy M: And as care moves to new settings, teams are going to need infrastructure,
Finn, Chrissy M: innovation and training in order to maintain quality and safety in.
Finn, Chrissy M: Patient care. And finally, unleashing the power of data and
Finn, Chrissy M: leveraging analytics is going to help pinpoint the right patients,
Finn, Chrissy M: identify the right patients and the right procedures to capture that opportunity.
Finn, Chrissy M: So what kinds of things should be considered from a patient selection
Finn, Chrissy M: perspective? I would say patient selection and
Finn, Chrissy M: procedure selection are the two most important components of operationalizing
Finn, Chrissy M: a safe site of service shift. Patient selection must consider system
Finn, Chrissy M: factors, social factors, and procedure-related factors.
Finn, Chrissy M: um From a systems perspective, regulatory requirements,
Finn, Chrissy M: state restrictions, and infrastructure are going to play a
Finn, Chrissy M: role in decision making. So, for example, limits on length of stay, age,
Finn, Chrissy M: and the type of facility and its capabilities, like, for example,
Finn, Chrissy M: the ability to handle an emergency will impact procedure appropriateness at a
Finn, Chrissy M: In ASC, social factors like the availability of
Finn, Chrissy M: or caregiver impact has has an impact.
Finn, Chrissy M: Poor health literacy and the ability to follow discharge instructions are an
Finn, Chrissy M: important consideration because they've been shown to influence compliance with
Finn, Chrissy M: post-operative instructions and can be associated with higher rates of acute
Finn, Chrissy M: care visits or readmission to the hospital.
Finn, Chrissy M: Patients are going to have to take on more of the logistics in the immediate
Finn, Chrissy M: post-operative period, like transportation to get home,
Finn, Chrissy M: filling prescriptions and then monitoring themselves for complications.
Finn, Chrissy M: There are also a lot of procedure related factors to be considered,
Finn, Chrissy M: things like the type of procedure being performed.
Finn, Chrissy M: We're probably a long way from coronary artery bypass in the ASC,
Finn, Chrissy M: but maybe not as far away as I think the duration of the procedure,
Finn, Chrissy M: the potential for blood loss or the need for transfusion or other emergency or
Finn, Chrissy M: specialized postoperative care.
Finn, Chrissy M: Interventions may dictate the appropriateness of a setting.
Finn, Chrissy M: Comorbid conditions can influence post-operative outcomes after outpatient
Finn, Chrissy M: surgery and play a significant role in patient selection. In general,
Finn, Chrissy M: comorbid conditions may not be a deal breaker depending on the type of
Finn, Chrissy M: procedure or the presence of a modifiable risk factor.
Finn, Chrissy M: Some very complex patients have done well.
Finn, Chrissy M: In the outpatient setting, for example, certain low risk procedures such as
Finn, Chrissy M: cataract surgery or cystoscopy may be safely performed at a freestanding ASC on
Finn, Chrissy M: higher risk patients who would maybe not qualify for a more invasive procedure at
Finn, Chrissy M: the same facility.
Finn, Chrissy M: And the use of evidence-based screening tools that evaluate procedure-related
Finn, Chrissy M: risk factors can help to identify the optimal surgical setting and will further
Finn, Chrissy M: support preoperative optimization for potentially high risk patients.
Finn, Chrissy M: Assessment of risk should involve A multidisciplinary approach seeking to.
Finn, Chrissy M: Answer the question, will postoperative hospitalization
Finn, Chrissy M: influence patient care or postsurgical outcome?
Finn, Chrissy M: Walking through a couple of these examples will help to demonstrate the
Finn, Chrissy M: need for careful consideration of comorbid status and preoptimization.
Finn, Chrissy M: And really demonstrate that it's the delicate balance in decision making.
Finn, Chrissy M: So for one, the ASA score is routinely used by
Finn, Chrissy M: anesthesia clinicians in order to assess a patient's overall health and risk.
Finn, Chrissy M: It's generally considered that a patient with an ASA score greater than three is
Finn, Chrissy M: not an appropriate.
Finn, Chrissy M: Candidate for an ambulatory surgical center. But again,
Finn, Chrissy M: those with stable comorbid conditions may be appropriate for low risk surgeries.
Finn, Chrissy M: Similarly, age and frailty have been used as markers
Finn, Chrissy M: of appropriateness, but we all know age is just a number and
Finn, Chrissy M: shouldn't really be considered as the sole.
Finn, Chrissy M: Exclusion factor. The evolution or the sorry,
Finn, Chrissy M: the evaluation of a patient's frailty characteristics will likely play a more
Finn, Chrissy M: important role in decision making. So frailty is associated with increased
Finn, Chrissy M: perioperative morbidity and readmission after ambulatory procedures.
Finn, Chrissy M: There are, however, opportunities for improved outcomes among
Finn, Chrissy M: frail patients having ambulatory surgery due to the additional efforts and
Finn, Chrissy M: safeguards that they are typically incorporated in in with the
Finn, Chrissy M: infrastructure of an ASC. For example, things like prescribed home visits or
Finn, Chrissy M: more.
Finn, Chrissy M: Regular telephonic follow-ups and remote patient monitoring.
Finn, Chrissy M: Because the focus is on quality of care and improved outcomes,
Finn, Chrissy M: these systems are already in place. Risk from COPD, for example,
Finn, Chrissy M: can be mitigated with smoking cessation and.
Finn, Chrissy M: Optimizing bronchodilator therapy, patients with diabetes and good glycemic
Finn, Chrissy M: control may also be considered ambulatory surgery. So again,
Finn, Chrissy M: just going through like a handful of these comorbid examples to illustrate the
Finn, Chrissy M: need for the careful evaluation, preparation and you know,
Finn, Chrissy M: a multidisciplinary approach to determine the right.
Finn, Chrissy M: Setting for each patient and what is the perioperative plan to help maximize this
Finn, Chrissy M: patient prior to surgery?
Finn, Chrissy M: As I mentioned previously, you know, taking this evidence-based approach to
Finn, Chrissy M: incorporate complex patient considerations and identify inpatient
Finn, Chrissy M: clinical exceptions inside of care decisions is an essential part of the
Finn, Chrissy M: process as payers and policy makers try to shift behavior with medical policy and
Finn, Chrissy M: financial incentives.
Finn, Chrissy M: Providers really need to be able to continue to support the needs of their
Finn, Chrissy M: unique patients. Patients are complex and there are always
Finn, Chrissy M: going to be outliers who require individualized care.
Finn, Chrissy M: Taking an evidence-based approach provides support and ensures that those
Finn, Chrissy M: individualized patient management decisions are considered.
Finn, Chrissy M: Consistent and defensible. The next step to this,
Finn, Chrissy M: as more and more procedures shift to the ambulatory setting,
Finn, Chrissy M: is creating procedure specific exclusion criteria.
Finn, Chrissy M: We've already talked about the importance of preop optimization for modifiable risk
Finn, Chrissy M: factors like smoking cessation and diabetes control, blood pressure control,
Finn, Chrissy M: weight loss.
Finn, Chrissy M: Loss to help support better outcomes and increase the safety of ambulatory
Finn, Chrissy M: settings for more complex patients. Patient education really ensures that the
Finn, Chrissy M: patient plays an active role in decision making and helps to support compliance
Finn, Chrissy M: and quality outcomes.
Finn, Chrissy M: Patients who are motivated by the convenience and accessibility of
Finn, Chrissy M: ambulatory surgery are much more likely to adhere to pre-op optimization efforts,
Finn, Chrissy M: and procedure specific recovery pathways should also be established to ensure
Finn, Chrissy M: safety and quality.
Finn, Chrissy M: So we've talked through some of the drivers of the shift and identified the
Finn, Chrissy M: strategies. So let's now walk through ways to
Finn, Chrissy M: operationalize those strategies. In order to identify the right setting at
Finn, Chrissy M: the right time for the right patient, organizations will need an efficient
Finn, Chrissy M: evidence-based approach to capture clinical.
Finn, Chrissy M: Exceptions and provide necessary supporting documentation for site of care
Finn, Chrissy M: decisions. Utilizing a data-driven approach at the
Finn, Chrissy M: code level helps to provide a more accurate and detailed setting
Finn, Chrissy M: determination based on a national benchmark.
Finn, Chrissy M: With that, an evidence-based setting algorithm helps
Finn, Chrissy M: to ensure that patients are receiving care at the most appropriate level based
Finn, Chrissy M: on their unique clinical scenarios and helps to provide consistency in making
Finn, Chrissy M: those decisions.
Finn, Chrissy M: Using a code driven benchmark provides an objective marker for the appropriate
Finn, Chrissy M: setting for a given patient and helps to inform organizational strategy.
Finn, Chrissy M: Sometimes when we are lucky, the benchmark will provide clear guidance
Finn, Chrissy M: of the setting for procedures where the site of service is shifting or evolving
Finn, Chrissy M: the setting.
Finn, Chrissy M: May be unclear and in those situations, supplemental data can help the make a
Finn, Chrissy M: clinically informed decision about an individual patient or identify
Finn, Chrissy M: opportunities to start shifting procedures from an inpatient to
Finn, Chrissy M: outpatient setting or from the hospital outpatient department to the ambulatory
Finn, Chrissy M: surgical center.
Finn, Chrissy M: Coming this fall, Interqual site of service functionality
Finn, Chrissy M: will provide enhanced data transparency and functionality to support managing
Finn, Chrissy M: shifts to the ambulatory setting in addition to the CPT code level settings
Finn, Chrissy M: that was that were rolled out in the content for the March 2020.
Finn, Chrissy M: 25 annual release additional functionality will support an expanded
Finn, Chrissy M: library of codes available outside of the context of a medical review.
Finn, Chrissy M: This will allow a reviewer to determine procedure setting without the need to
Finn, Chrissy M: complete a full medical review when only the setting determination is needed.
Finn, Chrissy M: Additional data visualization will also help to inform setting designations.
Finn, Chrissy M: This transparency can help inform setting designations when the data or the
Finn, Chrissy M: benchmark fell below a 75% threshold, and it's going to help to support
Finn, Chrissy M: organizations in directing procedures.
Finn, Chrissy M: To the safest ambulatory care settings.
Finn, Chrissy M: An evidence-based alternate setting review captures additional clinical
Finn, Chrissy M: factors that may support a change in setting based on a unique patient
Finn, Chrissy M: scenario. A reviewer can use this setting review to
Finn, Chrissy M: capture more information for a second level determination.
Finn, Chrissy M: If a requested inpatient setting does not align with an Interqual or a CMS setting,
Finn, Chrissy M: the reviewer can conduct setting review to gather more information for that
Finn, Chrissy M: second level review piece. And we're going to walk through some of
Finn, Chrissy M: this new functionality
Finn, Chrissy M: let's take a look here at how benchmarks can help inform decision-making at an
Finn, Chrissy M: individual patient level or at a system level. When applying data,
Finn, Chrissy M: Interqual uses the 75% threshold for making a definitive determination.
Finn, Chrissy M: um So in this example, let's go ahead and select a CPT code here,
Finn, Chrissy M: laparoscopic surgical cholecystectomy code 47562.
Finn, Chrissy M: You can see here that this benchmark shows 86% of lap choles are being done in
Finn, Chrissy M: the open.
Finn, Chrissy M: Setting, meaning that the majority of patients
Finn, Chrissy M: should be having this procedure done outpatient.
Finn, Chrissy M: This is really the low hanging fruit for an organization.
Finn, Chrissy M: LAP COLIs done on the inpatient side really should be carefully evaluated for
Finn, Chrissy M: clinical exceptions. Clinical exceptions will always exist.
Finn, Chrissy M: There will always be outliers.
Finn, Chrissy M: The key here is knowing when we should be looking for them.
Finn, Chrissy M: This procedure also demonstrates an opportunity for that hospital outpatient
Finn, Chrissy M: department to ASC shift. We can see in the data that 95% of the
Finn, Chrissy M: time when it is done outpatient, this procedure is occurring.
Finn, Chrissy M: At the hospital outpatient department, but it's on the ASC eligible list,
Finn, Chrissy M: so it's a good one to consider moving to the Ambulatory Surgical Center.
Finn, Chrissy M: And if I toggle up here to see the CMS data up at the top,
Finn, Chrissy M: you can see that it is on the ASC eligible list.
Finn, Chrissy M: So a good example of one that we might want to look at critically.
Finn, Chrissy M: when considering where in the ambulatory site it should occur.
Finn, Chrissy M: Now let's move on to another example. We'll go ahead and change subsets and
Finn, Chrissy M: we'll look at fusion lumbar spine.
Finn, Chrissy M: And I'm navigating through the criteria quickly to get to the end of the review
Finn, Chrissy M: so that we can look specifically at the codes and the setting determinations here.
Finn, Chrissy M: So for lumbar spine fusion here we can see that um.
Finn, Chrissy M: You know, we really talked about this one in in
Finn, Chrissy M: earlier when we were talking about improvements in hardware,
Finn, Chrissy M: things like fusion screws has really started to increase prevalence of these
Finn, Chrissy M: procedures occurring in the ambulatory surgical center,
Finn, Chrissy M: other factors contributing to a shift in ambulatory spine.
Finn, Chrissy M: Surgeries are faster recovery, a quicker return to activity thanks to
Finn, Chrissy M: microinstrumentation, minimally invasive procedures and
Finn, Chrissy M: improvements in anesthesia. This is a big one for regional versus
Finn, Chrissy M: general anesthesias is having a big impact here.
Finn, Chrissy M: In this example though, we can also see how really it's the
Finn, Chrissy M: specific procedure that's being done that impacts the setting and highlights the
Finn, Chrissy M: importance. This is a good one to look at when we're
Finn, Chrissy M: thinking about the importance of using coding or codes to make these
Finn, Chrissy M: determinations. So based on code selection here.
Finn, Chrissy M: This procedure is either strongly inpatient or strongly outpatient in both
Finn, Chrissy M: the Interqual proprietary setting data as well as within the CMS coverage policy.
Finn, Chrissy M: So if we look at 20931, which is this code here,
Finn, Chrissy M: you can see that that is.
Finn, Chrissy M: Fairly strongly on the outpatient determination side,
Finn, Chrissy M: 80% of the time this is being done outpatient. If we toggle to CMS,
Finn, Chrissy M: we can see that it's on the CMS ASC eligible list,
Finn, Chrissy M: also indicating that that's a strong outpatient determination there. However,
Finn, Chrissy M: if we look at code 22.
Finn, Chrissy M: 22533 So let's Scroll down a little bit 22533 here.
Finn, Chrissy M: If we select this code you can see that it this one is very strongly inpatient,
Finn, Chrissy M: so it is 82 of the time done on the inpatient setting.
Finn, Chrissy M: CMS has it on the CMS inpatient only list. You can see here there's some logic in
Finn, Chrissy M: the way that our interqual site of service functionality works,
Finn, Chrissy M: so that if you select more than one code at a time.
Finn, Chrissy M: It will always sort of go towards the highest setting.
Finn, Chrissy M: So both of these codes were selected, maybe they were both being done together
Finn, Chrissy M: as part of a single procedure. The overall setting for this procedure
Finn, Chrissy M: would be inpatient based on those two being selected together.
Finn, Chrissy M: Now I mentioned earlier that the site of service functionality for Interqual site
Finn, Chrissy M: of service that's coming out in the fall also has the ability to look at setting
Finn, Chrissy M: outside of the context of doing a medical review.
Finn, Chrissy M: So in these previous examples we've really been looking at doing a medical
Finn, Chrissy M: necessity.
Finn, Chrissy M: Review for the procedure. And then once we've determined that the
Finn, Chrissy M: procedure was appropriate for the patient based on their clinical findings,
Finn, Chrissy M: we were looking at setting. We know that that's not always the case,
Finn, Chrissy M: right? You don't always need to do a full review
Finn, Chrissy M: for the procedure. Maybe it's something that's not on your
Finn, Chrissy M: prior author list.
Finn, Chrissy M: But if it's being requested as inpatient, you are definitely going to want to take
Finn, Chrissy M: a look at those settings. So this new functionality for setting
Finn, Chrissy M: lookup lives under the menu here. So if I go to the menu,
Finn, Chrissy M: you can see the first thing on the list is the setting lookup.
Finn, Chrissy M: It allows me to just go ahead and pop in a code. So for this one,
Finn, Chrissy M: we'll look at Pacemaker.
Finn, Chrissy M: Then go ahead and pop in the code there. It's going to identify a particular code
Finn, Chrissy M: and I can go ahead and select that and it's going to give me all of the
Finn, Chrissy M: information across either the both age age groups,
Finn, Chrissy M: adults and pediatrics for interqual or as well for CMS.
Finn, Chrissy M: And here's where you're starting to see some Gray area, right.
Finn, Chrissy M: So if we look at this data, we can start to see an example of a late
Finn, Chrissy M: inpatient to outpatient shift in progress. So this procedure is almost nearly at the
Finn, Chrissy M: outpatient threshold of 75%.
Finn, Chrissy M: It's 71% outpatient at this very moment, but you can also see some additional
Finn, Chrissy M: support for this shift and noting that it's on the CMS ASC eligible list.
Finn, Chrissy M: So the benchmark setting data is not always going to be definitive, right?
Finn, Chrissy M: It's not every procedure is going to reach that.
Finn, Chrissy M: 75% threshold where we are comfortable saying for sure every single patient
Finn, Chrissy M: should be inpatient or every single patient should be outpatient,
Finn, Chrissy M: but it is going to play a role in helping to inform that final determination.
Finn, Chrissy M: So whether you're a provider submitting the request for an inpatient pacemaker.
Finn, Chrissy M: or your payer receiving the request, you can utilize this data to help inform
Finn, Chrissy M: your decision-making. So in scenarios like this one,
Finn, Chrissy M: uh evaluation of the data behind the setting determination and the patient's
Finn, Chrissy M: clinical factors are going to both play a role in the decision-making process.
Finn, Chrissy M: Decision making and they need to go hand in hand.
Finn, Chrissy M: So if this request was for a straightforward patient with no comorbid
Finn, Chrissy M: conditions or comorbid conditions that have been optimized,
Finn, Chrissy M: it might make sense to go with the data and recommend an outpatient setting.
Finn, Chrissy M: Having this insight into the data is gonna help providers know when perhaps to.
Finn, Chrissy M: request or reconsider a requested setting or or when to spend the time maybe
Finn, Chrissy M: pulling the data together for the the additional clinical data to support an
Finn, Chrissy M: inpatient setting. All All of this is with the goal of
Finn, Chrissy M: getting the right setting for the patient upfront and really minimizing that back
Finn, Chrissy M: and forth to drive efficiency.
Finn, Chrissy M: In documentation and decision making if we look at another example here.
Finn, Chrissy M: For carpal tunnel disease, an example of an ambulatory shift in
Finn, Chrissy M: progress. So this procedure has been likely done in
Finn, Chrissy M: the outpatient setting for some time and we're starting to see a shift from the
Finn, Chrissy M: hospital outpatient department to the ASC. So 99% of median nerve decompressions for
Finn, Chrissy M: the wrist for carpal.
Finn, Chrissy M: Tunnel are being done outpatient, with 28% being done in an ASC.
Finn, Chrissy M: This code has been on the CMS ASC eligible list since at least 2003,
Finn, Chrissy M: which is just an aside, but also speaks really to how slow the
Finn, Chrissy M: shift has been happening historically.
Finn, Chrissy M: This is a great example of a procedure that's unlikely to have any complications
Finn, Chrissy M: requiring a higher level of care or emergency services.
Finn, Chrissy M: This could be considered an organizational opportunity.
Finn, Chrissy M: If your organization isn't doing these in an ASC,
Finn, Chrissy M: it should be something high on the list for consideration.
Finn, Chrissy M: One more example here.
Finn, Chrissy M: If we look at Salpingo oophorectomy bilateral or oophorectomy bilateral,
Finn, Chrissy M: this data shows a clear outpatient setting at 97%.
Finn, Chrissy M: It is on the ASC eligible list. So this is another opportunity for a
Finn, Chrissy M: shift into the ASC.
Finn, Chrissy M: You can already see that we're starting to see 6% of them are being done in the
Finn, Chrissy M: ambulatory surgical center, but a whole lot still being done in the
Finn, Chrissy M: hospital outpatient department.
Finn, Chrissy M: So now let's go back to our slides.
Finn, Chrissy M: And do a case example here. So in this case example,
Finn, Chrissy M: we have a 75 year old patient.
Finn, Chrissy M: Oh, sorry, 72 year old patient. She is undergo a status post laparoscopic
Finn, Chrissy M: hysterectomy with bilateral Salpingo oophorectomies.
Finn, Chrissy M: She has endometrial cancer. She's also has hypertension.
Finn, Chrissy M: She's not well controlled on her medication. She's an active smoker.
Finn, Chrissy M: With COPD and type 2 diabetes and you can see her hemoglobin A1C is 8.
Finn, Chrissy M: 2 and her American College of Anesthesiology or her ASA score is a
Finn, Chrissy M: class 3. She is a Medicare beneficiary, so there's been no prior authorization
Finn, Chrissy M: received for this surgical procedure.
Finn, Chrissy M: We also know that a lap hysterectomy is an outpatient procedure,
Finn, Chrissy M: but we will look at that code in the setting.
Finn, Chrissy M: Look up due to her comorbid conditions and her higher risk for complications,
Finn, Chrissy M: her surgeon's expecting her to require two days of postoperative management.
Finn, Chrissy M: Including management of her COPD, hypertension and diabetes before she's
Finn, Chrissy M: safe to return home. She had a stable OR course.
Finn, Chrissy M: She has post-op orders for pain control and diabetes management.
Finn, Chrissy M: So we'll go ahead and take a look at her case within Interqual.
Finn, Chrissy M: So the first thing we'll do is go ahead and look up that code.
Finn, Chrissy M: That we had for her. So it's 58550. She is a CMS beneficiary.
Finn, Chrissy M: So we can see that this is not on the inpatient only list.
Finn, Chrissy M: It is a CMS ASE eligible procedure, but it's being requested inpatient
Finn, Chrissy M: following the procedure.
Finn, Chrissy M: So because we're not looking at prior authorization here,
Finn, Chrissy M: we can go ahead and look at doing an inpatient admission for her in our
Finn, Chrissy M: general surgical subset. So it's operative day for her day of
Finn, Chrissy M: procedure. We'll go ahead and look at the requested
Finn, Chrissy M: level of care, which is the acute.
Finn, Chrissy M: Level of care. We do not see that the surgery has been
Finn, Chrissy M: designated as inpatient either on the CMS list,
Finn, Chrissy M: the Interqual benchmark setting report or we do not have a prior authorization.
Finn, Chrissy M: So that's really not the appropriate selection for us here.
Finn, Chrissy M: We do have an ambulatory procedure with higher risk for complications requiring
Finn, Chrissy M: inpatient management based on the documentation that we got with our
Finn, Chrissy M: request for an inpatient setting for this procedure.
Finn, Chrissy M: Physician is documentation is supporting the need for post procedure management
Finn, Chrissy M: for at least two days.
Finn, Chrissy M: And let's look at sort of her complications.
Finn, Chrissy M: She does have an ASA score of three. Let's see,
Finn, Chrissy M: what else did she have in her case? She also had uncontrolled diabetes.
Finn, Chrissy M: Really indicating that she is of a higher list of complications.
Finn, Chrissy M: She also had some diabetes, some COPD issues that were uncontrolled.
Finn, Chrissy M: So really utilizing this section of the criteria we can help support.
Finn, Chrissy M: You know her clinical risk for needing an inpatient setting based on her clinical
Finn, Chrissy M: specific findings that might differ from sort of everyone else, right?
Finn, Chrissy M: You might have had another patient who was appropriate to have this procedure in
Finn, Chrissy M: the outpatient setting, but for her based on her clinical
Finn, Chrissy M: documentation.
Finn, Chrissy M: Her increased risk physician documentation supporting the need for at
Finn, Chrissy M: least two days of postoperative management.
Finn, Chrissy M: She is appropriate at the inpatient setting of care.
Finn, Chrissy M: So we talked through a couple of examples here and really there's a huge amount of
Finn, Chrissy M: opportunity as we think about this ambulatory shift.
Finn, Chrissy M: This data here comes from a study done by McKenzie evaluating the opportunity in
Finn, Chrissy M: the rise of ambulatory care. As you can see here,
Finn, Chrissy M: the majority of codes.
Finn, Chrissy M: fall into clear inpatient or outpatient buckets. So in both of these groups,
Finn, Chrissy M: benchmarking data shows that a high percentage of cases are being done either
Finn, Chrissy M: inpatient or outpatient. Nearly 30% of procedures, though,
Finn, Chrissy M: have notable variation in site of care choice, and this represents
Finn, Chrissy M: $132 billion of opportunity. So you can see here in the CPT code,
Finn, Chrissy M: the inpatient CPT code bucket is much smaller, right?
Finn, Chrissy M: We're looking at 676 codes versus 5300 codes in the mixed or all outpatient
Finn, Chrissy M: grouping. So that's pretty significant.
Finn, Chrissy M: Things are, it's late in the shifting from inpatient
Finn, Chrissy M: to outpatient, right? The majority of what's being shifted has
Finn, Chrissy M: shifted. In their analysis, though, Mackenzie set out to analyze what was the
Finn, Chrissy M: source of the variation and what is the opportunity in reducing that variation.
Finn, Chrissy M: Found was that in the mixed group of codes,
Finn, Chrissy M: it really represents that bucket really represents a number of procedures that
Finn, Chrissy M: are being done in the ambulatory setting safely and that the approach,
Finn, Chrissy M: technology and clinical protocols exist to support in doing them in that setting.
Finn, Chrissy M: And so then you look at maybe some financial aspects at play here,
Finn, Chrissy M: you can see that there is a cost savings of between of $21,
Finn, Chrissy M: 000 between inpatient and ambulatory settings for the same procedure.
Finn, Chrissy M: They really defined low hanging fruit opportunities as those were 65.
Finn, Chrissy M: To 95% of encounters are already being done at the outpatient setting.
Finn, Chrissy M: And you can think back, this is a great example of our pacemaker
Finn, Chrissy M: example where we saw 71% of pacemaker insertions were being done in the
Finn, Chrissy M: outpatient setting. And so the data here is the key,
Finn, Chrissy M: you know in order to.
Finn, Chrissy M: Capitalize on the opportunity.
Finn, Chrissy M: So what is driving the variation? When they looked at it,
Finn, Chrissy M: what they found was a couple of key things,
Finn, Chrissy M: the variation across how different specialties and specific procedures are
Finn, Chrissy M: shifting. So specialty was a great example.
Finn, Chrissy M: Joint replacement is one of the procedures that experienced the greatest
Finn, Chrissy M: shift.
Finn, Chrissy M: Due to aligning regulatory physician and hospital incentives, spinal surgeries,
Finn, Chrissy M: prostatectomy and appendectomy are also starting to shift due to the advance of
Finn, Chrissy M: minimally invasive operating techniques, making them more likely to be performed
Finn, Chrissy M: laparoscopically in the hospital outpatient department.
Finn, Chrissy M: Cardiac procedures are starting to shift, albeit slowly.
Finn, Chrissy M: CMS has approved ambulatory care for procedures like diagnostic cath,
Finn, Chrissy M: ICD implants, pacemaker implants and PCI. But change can start to happen quickly
Finn, Chrissy M: when the regulatory changes push folks in the new direction and so.
Finn, Chrissy M: With the proposed OPPS rule, things could start happening very quickly
Finn, Chrissy M: and so we all want to make sure that we are on track to to be able to react to
Finn, Chrissy M: that change. Patient risk is another factor
Finn, Chrissy M: contributing to variation.
Finn, Chrissy M: Either related to comorbidities or other risk factors like the need for more
Finn, Chrissy M: complex anesthesia or increased clinical backup.
Finn, Chrissy M: Generally the younger and low risk commercial population is more suitable
Finn, Chrissy M: for outpatient procedures than the Medicare population,
Finn, Chrissy M: so that can contribute to the risk to the variation.
Finn, Chrissy M: And geography is also another area where we see impact.
Finn, Chrissy M: Change does not happen everywhere all at once.
Finn, Chrissy M: It varies across different healthcare systems and geographic locations and
Finn, Chrissy M: typically can be driven by local market conditions and incentives.
Finn, Chrissy M: So things like local regulations, physician independence,
Finn, Chrissy M: health plan policies.
Finn, Chrissy M: and patient volume for a given procedure can really influence the variability
Finn, Chrissy M: across different areas of the country.
Finn, Chrissy M: So having a data-driven determination for where the service should be performed
Finn, Chrissy M: tied with a way to evaluate unique patient characteristics is going to be
Finn, Chrissy M: key to help ensure that the patients are being treated in the safest and most
Finn, Chrissy M: cost-effective setting for them.
Finn, Chrissy M: Focusing on finding the right setting where that variation exists will help to
Finn, Chrissy M: reduce cost, denials and administrative burden,
Finn, Chrissy M: decrease the need for second level review, enhance efficiency,
Finn, Chrissy M: and really most importantly, improve patient safety and overall
Finn, Chrissy M: outcomes.
Finn, Chrissy M: Thank you for joining me today. I hope you're walking away from this
Finn, Chrissy M: session more informed about the shift in ambulatory care so that you can take this
Finn, Chrissy M: back to your organization and determine the most cost-effective and and use
Finn, Chrissy M: data-driven and cost-effective strategies to identify the safest.
Finn, Chrissy M: And most cost effective setting for each patient based on their specific clinical
Finn, Chrissy M: scenario. At the end of the day, this is all about providing patients with
Finn, Chrissy M: the safest and most efficient cost effective care.
Finn, Chrissy M: So as a system we can partner together and use some new tools,
Finn, Chrissy M: some new data to help achieve that outcome.
Finn, Chrissy M: If you're interested in learning more about the Interqual site of service
Finn, Chrissy M: functionality that we reviewed today, please reach out to your account manager
Finn, Chrissy M: or your sales executive for more information.
Finn, Chrissy M: We'd be happy to talk to you about it and show it to you in more detail. Thank you,
Finn, Chrissy M: everyone.