Preparing for a rise in ambulatory surgical care

Hello and welcome to our webinar Act Now or Fall Behind Preparing for a Rise in Ambulatory Surgical Care.
My name is Chrissy Finn. I'm the Director of Interqual Content Products. I'm a registered nurse and I've been with Interqual for the last 18 years. In my role, I'm responsible for the Interqual Content road map and managing and defining product enhancements. Today we're going to talk about shifts in ambulatory site of service and some strategies.
And considerations your organization can put into motion to help manage the shifts.
So we'll start today by looking at the current state of healthcare. Today we have an industry at a tipping point. As clinicians, we see it in our day-to-day. But so for me, the challenges the industry is facing is starting to creep into my personal life and conversations I'm having with friends.
and see on social media about delays in care, people slipping through the cracks, medication shortages, and supply chain disruptions. Personally, last year I had a heck of a time trying to find an inhaler for my two-year-old, which was one of those shocking things that, you know, you don't expect to happen in 2020.
25 But these comments that I'm seeing, these conversations that I'm having really bring it back to the problems that we're facing. One of the biggest things coming out of the COVID pandemic is the impact on staffing. I think that this was a trend that we talked about coming for some time.
Many years prior to COVID, but it's only been accelerated as nurses look to leave clinical roles. The rise of remote employment is attractive to a lot of employees, and nurses are no exception, right? Contributing to the desire to leave that clinical role is the amount of manual or duplicative work that we're starting to.
Require folks to do it results in frustration and wasted time. We see 60% of authorizations as either being manual or duplicative. There has to be a better way to drive efficiency without putting that burden on already taxed staff.
This authorization burden doesn't just impact nursing staff, though. We know that 86% of physicians rate the burden of authorizations as the biggest administrative challenge in their jobs, resulting in provider abrasion and dissatisfaction. As I mentioned earlier, patients are frustrated.
The care that they're being provided isn't always appropriate. We see a lot of delays in care result related to staffing and scheduling or administrative burden. Patients are not being expedited out of the inpatient setting as quickly as they could due to post acute bed availability challenges and on top of that patients.
They're taking on more financial risk, which is going to really help to drive that concept of patient as consumer. Patients are looking to take on a more active role in decision-making and they need education and support to help make informed decisions about the quality of their care and the potential cost impact.
In my role as product owner at Interqual 5 to 10 years ago, I would say regulatory mandates didn't play a huge role in how we designed our content or how our content functioned in the market. Today, that's a completely different story, right? New federal and state mandates seem to be coming out every week. Most that have significant impact on payer.
Provider workflow, either care decisions, audit reporting requirements. If I had a dollar for every time someone said Medicare Advantage final rule to me, I would be retired and working on a new passion project. But today it just simply is not possible to avoid that regulatory impact.
And while we need standard operations, interoperability desperately to streamline some of the processes that are bogging down the system and generate efficiencies so that we can all start to focus, you know, or refocus on providing the best possible care to our patients.
Industry standards like CMS 0057 are not things that just happen overnight. They require planning, preparation and implementation. Throughout all of this, clinical appropriateness remains as relevant today as when Interqual was first introduced to support quality within the.
Within the healthcare system, we have finite clinical resources. We need to preserve them for the right patients, become more consistent in how we apply them, and allow for more rapid adoption of best practice. No one wants utilization management to stand in the way of providing care to patients.
But it remains a necessary process to safeguard our resources and to help drive quality patient outcomes.
In some ways, the COVID-19 pandemic helped us out. I hesitate to say that, but there really is nothing like a crisis to help focus the mind. COVID-19 really forced us to think about a different way to deliver the necessary care that patients needed, just differently. We were forced to manage resource constraints by.
Allocating resources to areas of the hospital system that needed the most right. Innovations in care delivery like hospital in the home programs gained rapid expansion during this time. Minimizing infection risk forced us to think twice about inpatient admissions or even on campus ambulatory visits.
During the pandemic, we saw elective surgery triage guidelines come out from the American College of Surgeons. Patients as consumers began accessing care in different ways, in many cases out of fear, but also driven by convenience. As we all started working at home, we realized, well, there's other aspects of our lives that could also be done.
From home, new capabilities driven by telehealth technology have really transformed the way that we interact with our healthcare providers. In some cases, like behavioral health, this flexibility has really improved access. I think about how many people I know that have started going to therapy just because it's so much easier to make time for.
For these innovations were also supported by increased payer flexibility because as we all know, the fastest way to drive adoption is through financial impact or incentive. I mentioned hospital in the home earlier. The CMS Acute Hospital Care at Home waiver is a great example of how flexibility.
Drove adoption and I'm personally very excited to see how that waiver gets extended in the next coming months.
So let's start talking about some of these shifts. What what's happening? So the inpatient procedural volume is increasingly starting to shift to outpatient care settings such as ambulatory surgical centers, hospital outpatient, outpatient departments and offices.
You can see certain service lines and procedures are shifting outpatient faster than others. Musculoskeletal is a great example of that. When the first surgery with anesthesia was done inside the ether Dome at MGH in 1846, or when the concept of aseptic surgery was introduced 55 years later in 1900.
It was probably pretty hard to imagine that surgery is going to take place anywhere but in the hospital, but there have been a lot of innovations in patient care. Consumer convenience and updates to coverage policies and reimbursement models have really helped to drive surgical care outside of the hospital.
Data estimates that about 50 to 65% of all surgical procedures are performed in the outpatient setting and that volume continues to rise. Ambulatory surgical care is one of the fastest growing segments of the healthcare industry. In the last five years, we've seen a 20% increase in pacemaker.
Repentations happening outside the in the outpatient space and 83% shift in joint replacements and an 18% shift in spinal fusion. It should be noted that total joint replacement of the knee came off of the inpatient only list in January of 2018, which is really what.
Started the shift here and then the addition of TJR to the ASC eligible list in 2020 really helped to expedite it. So if you're looking here for an example of how regulatory drivers can impact a shift, well, there you have it. That's the one.
Secondarily, we're also starting to see procedures shift from the hospital outpatient department to the ambulatory surgical center and the office setting. And So what really what is the difference? CMS defines a hospital outpatient department as a portion of the hospital that provides diagnostic interventional therapeutic both surgical.
Surgical and non-surgical and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Hospital outpatient departments can be both on campus and off campus.
An ASC is defined as a freestanding facility other than a doctor's office where surgical or diagnostic services are provided on an ambulatory basis. So, as data on quality, safety, and patient satisfaction um supports the
Effectiveness of surgery in the ambulatory space, we're starting to see this secondary shift of procedures from the hospital outpatient department to the ambulatory surgical center. This is driven by financial incentives, right, pushing payers, providers and patients towards these freestanding sites.
Models predict a 9% increase in ASC volumes between 2023 and 2028, compared to a 7% increase in hospital outpatient department volumes and a 1% increase in inpatient volumes. So what makes the ASC so attractive? ASC are.
ASC are typically more conveniently located than hospitals. I for one will call out the benefits of free parking and being able to walk right to the front door without having to take a shuttle as one of the major benefits. ASCS are only permitted to address 23 hours of care, so that means getting patients back home.
to their own pillow more quickly. It increases comfort and decreases infection risk. Because the ASC is a more intimate setting than a larger hospital, it gives patients a perceived sense of personalized care and a care team that is more accessible for all those questions that you might have right after surgery or even before surgery.
Then there's the cost component. The entire operating component of an ASC is really just configured at a lower cost base. Everything, staffing, supplies, equipment, facilities, it's all cheaper and the reimbursement for procedures remains relatively the same.
The cost of elective OR time is less than $15.00 per minute in an ASC versus $40.00 per minute in a hospital OR. So that's a big time savings.
So let's walk through the trends that are leading this leading us towards this shift. And there are several key drivers that support the shift of procedures out of the inpatient space and into the ambulatory surgical center.
New developments in clinical technology has led to growth in the ambulatory surgical space by supporting faster recovery. Things like using more localized or regional approaches to anesthesia, better monitoring equipment, new medications to treat side effects of anesthesia like nausea and fatigue.
and muscle relaxants that don't last as long and better pain control. Advancements in microsurgical techniques that allow for procedures with smaller wound sites is a good example. Hardware has also improved. For example, the screws that are used in fusion surgeries coupled with changes in
In anesthesia has led to an increase in outpatient spinal surgeries, for example.
Consumer demand and patient satisfaction play a key role. While cost is also a significant driver, it's not the only driver here. Surgery that was once considered to be daunting and maybe avoided seems to be more manageable and convenient. Patient satisfaction tends to be the most convenient and less intimidating.
Settings. Patients are looking for enhanced convenience and a better care experience with greater comfort and less hoops to jump through to get access to care. As at-risk contracts and value-based care incentives rise, payers and providers have new incentives to find the lowest cost site of care.
Providers are seeing financial opportunities of shared ownership model models, excuse me, and physician autonomy. Through ownership opportunities, doctors now have the incentive and opportunity to channel patients to procedures outside the hospital.
They also have increased autonomy and really value things like predictability and efficiency in their OR schedule. The ASC setting gives the surgeon more time to do what they want to be doing, operating on patients and because surgery times tend to be shorter by 31 minutes in an ASC, they are also.
Much more productive, serving the needs of more patients and seeing more financial benefit. Regulatory changes continue to have a huge impetus in moving procedures as with the example in total joint replacement as procedures come off of the.
CMS inpatient list and move on to the ASC list. CMS is sending a strong signal that a procedure can safely be performed outside the inpatient setting. Just last week, CMS dropped its proposed outpatient prospective payment system rule for 2026 and indicated that it's planning to phase out the inpatient only list over.
Over the next three years to quote, give beneficiaries more choices on where to obtain care with the potential for lower cost out-of-pocket expenses. And that's a big, a big thing that's coming potentially for us to to all operationalize.
And the outpatient shift really is beneficial across all healthcare stakeholders, right? So consumers, providers, payers, we can all see benefits from the site of care shift. Consumers will realize out of pocket savings and a more convenient patient experience.
Generally returning home the same day of surgery, faster access to scheduling and shorter stays lead to greater patient satisfaction, increased productivity, new sources of revenue, better control over operations and savings are seen on the provider side, the operating costs at.
Hospital outpatient department are higher than an ASC and reimbursement is generally the same. This shift provides an opportunity for cost savings. From a system perspective, the shift to ASC allows systems to defend their outpatient market share, maintain alignment among physicians.
And differentiate themselves from competitors on quality and cost. Payers will also see significant cost savings compared to hospital based care.
So sounds like there's a lot of opportunity here. Identifying where to get started, finding the low hanging fruit, and operationalizing complex organizational workflows are really the only things in the way. Sounds easy, right?
Yeah.
So now that we know that the shift's coming, what are the steps to take in order to be successful? To be truly effective, the site of care shift has to be approached from a systems and process perspective. Systems should really look to create a shared mission to prioritize patient safety and offer more point more access.
Points to procedures based care align on decision-making frameworks and processes to identify the procedures and patients that belong in the ambulatory settings is really a crucial critical step. Decision-making frameworks give all stakeholders a better chance at making consistent decisions.
Decisions and once ideal procedures have been targeted, an organization can evaluate new opportunities for reimbursement models and invest in alternative care sites.
Shared decision-making plays a hugely valuable role in supporting the shift by providing patient education on the benefits, efficiency and safety of alternate care settings. And as care moves to new settings, teams are going to need infrastructure, innovation and training in order to maintain quality and safety in.
Patient care. And finally, unleashing the power of data and leveraging analytics is going to help pinpoint the right patients, identify the right patients and the right procedures to capture that opportunity.
So what kinds of things should be considered from a patient selection perspective? I would say patient selection and procedure selection are the two most important components of operationalizing a safe site of service shift. Patient selection must consider system factors, social factors, and procedure-related factors.
um From a systems perspective, regulatory requirements, state restrictions, and infrastructure are going to play a role in decision making. So, for example, limits on length of stay, age, and the type of facility and its capabilities, like, for example, the ability to handle an emergency will impact procedure appropriateness at a
In ASC, social factors like the availability of or caregiver impact has has an impact.
Poor health literacy and the ability to follow discharge instructions are an important consideration because they've been shown to influence compliance with post-operative instructions and can be associated with higher rates of acute care visits or readmission to the hospital.
Patients are going to have to take on more of the logistics in the immediate post-operative period, like transportation to get home, filling prescriptions and then monitoring themselves for complications. There are also a lot of procedure related factors to be considered, things like the type of procedure being performed.
We're probably a long way from coronary artery bypass in the ASC, but maybe not as far away as I think the duration of the procedure, the potential for blood loss or the need for transfusion or other emergency or specialized postoperative care.
Interventions may dictate the appropriateness of a setting.
Comorbid conditions can influence post-operative outcomes after outpatient surgery and play a significant role in patient selection. In general, comorbid conditions may not be a deal breaker depending on the type of procedure or the presence of a modifiable risk factor. Some very complex patients have done well.
In the outpatient setting, for example, certain low risk procedures such as cataract surgery or cystoscopy may be safely performed at a freestanding ASC on higher risk patients who would maybe not qualify for a more invasive procedure at the same facility.
And the use of evidence-based screening tools that evaluate procedure-related risk factors can help to identify the optimal surgical setting and will further support preoperative optimization for potentially high risk patients. Assessment of risk should involve A multidisciplinary approach seeking to.
Answer the question, will postoperative hospitalization influence patient care or postsurgical outcome? Walking through a couple of these examples will help to demonstrate the need for careful consideration of comorbid status and preoptimization.
And really demonstrate that it's the delicate balance in decision making. So for one, the ASA score is routinely used by anesthesia clinicians in order to assess a patient's overall health and risk. It's generally considered that a patient with an ASA score greater than three is not an appropriate.
Candidate for an ambulatory surgical center. But again, those with stable comorbid conditions may be appropriate for low risk surgeries. Similarly, age and frailty have been used as markers of appropriateness, but we all know age is just a number and shouldn't really be considered as the sole.
Exclusion factor. The evolution or the sorry, the evaluation of a patient's frailty characteristics will likely play a more important role in decision making. So frailty is associated with increased perioperative morbidity and readmission after ambulatory procedures.
There are, however, opportunities for improved outcomes among frail patients having ambulatory surgery due to the additional efforts and safeguards that they are typically incorporated in in with the infrastructure of an ASC. For example, things like prescribed home visits or more.
Regular telephonic follow-ups and remote patient monitoring. Because the focus is on quality of care and improved outcomes, these systems are already in place. Risk from COPD, for example, can be mitigated with smoking cessation and.
Optimizing bronchodilator therapy, patients with diabetes and good glycemic control may also be considered ambulatory surgery. So again, just going through like a handful of these comorbid examples to illustrate the need for the careful evaluation, preparation and you know, a multidisciplinary approach to determine the right.
Setting for each patient and what is the perioperative plan to help maximize this patient prior to surgery?
As I mentioned previously, you know, taking this evidence-based approach to incorporate complex patient considerations and identify inpatient clinical exceptions inside of care decisions is an essential part of the process as payers and policy makers try to shift behavior with medical policy and financial incentives.
Providers really need to be able to continue to support the needs of their unique patients. Patients are complex and there are always going to be outliers who require individualized care. Taking an evidence-based approach provides support and ensures that those individualized patient management decisions are considered.
Consistent and defensible. The next step to this, as more and more procedures shift to the ambulatory setting, is creating procedure specific exclusion criteria. We've already talked about the importance of preop optimization for modifiable risk factors like smoking cessation and diabetes control, blood pressure control, weight loss.
Loss to help support better outcomes and increase the safety of ambulatory settings for more complex patients. Patient education really ensures that the patient plays an active role in decision making and helps to support compliance and quality outcomes.
Patients who are motivated by the convenience and accessibility of ambulatory surgery are much more likely to adhere to pre-op optimization efforts, and procedure specific recovery pathways should also be established to ensure safety and quality.
So we've talked through some of the drivers of the shift and identified the strategies. So let's now walk through ways to operationalize those strategies. In order to identify the right setting at the right time for the right patient, organizations will need an efficient evidence-based approach to capture clinical.
Exceptions and provide necessary supporting documentation for site of care decisions. Utilizing a data-driven approach at the code level helps to provide a more accurate and detailed setting determination based on a national benchmark.
With that, an evidence-based setting algorithm helps to ensure that patients are receiving care at the most appropriate level based on their unique clinical scenarios and helps to provide consistency in making those decisions.
Using a code driven benchmark provides an objective marker for the appropriate setting for a given patient and helps to inform organizational strategy. Sometimes when we are lucky, the benchmark will provide clear guidance of the setting for procedures where the site of service is shifting or evolving the setting.
May be unclear and in those situations, supplemental data can help the make a clinically informed decision about an individual patient or identify opportunities to start shifting procedures from an inpatient to outpatient setting or from the hospital outpatient department to the ambulatory surgical center.
Coming this fall, Interqual site of service functionality will provide enhanced data transparency and functionality to support managing shifts to the ambulatory setting in addition to the CPT code level settings that was that were rolled out in the content for the March 2020.
25 annual release additional functionality will support an expanded library of codes available outside of the context of a medical review. This will allow a reviewer to determine procedure setting without the need to complete a full medical review when only the setting determination is needed.
Additional data visualization will also help to inform setting designations. This transparency can help inform setting designations when the data or the benchmark fell below a 75% threshold, and it's going to help to support organizations in directing procedures.
To the safest ambulatory care settings.
An evidence-based alternate setting review captures additional clinical factors that may support a change in setting based on a unique patient scenario. A reviewer can use this setting review to capture more information for a second level determination.
If a requested inpatient setting does not align with an Interqual or a CMS setting, the reviewer can conduct setting review to gather more information for that second level review piece. And we're going to walk through some of this new functionality
 let's take a look here at how benchmarks can help inform decision-making at an individual patient level or at a system level. When applying data, Interqual uses the 75% threshold for making a definitive determination.
um So in this example, let's go ahead and select a CPT code here, laparoscopic surgical cholecystectomy code 47562. You can see here that this benchmark shows 86% of lap choles are being done in the open.
Setting, meaning that the majority of patients should be having this procedure done outpatient. This is really the low hanging fruit for an organization. LAP COLIs done on the inpatient side really should be carefully evaluated for clinical exceptions. Clinical exceptions will always exist. There will always be outliers.
The key here is knowing when we should be looking for them. This procedure also demonstrates an opportunity for that hospital outpatient department to ASC shift. We can see in the data that 95% of the time when it is done outpatient, this procedure is occurring.
At the hospital outpatient department, but it's on the ASC eligible list, so it's a good one to consider moving to the Ambulatory Surgical Center. And if I toggle up here to see the CMS data up at the top, you can see that it is on the ASC eligible list. So a good example of one that we might want to look at critically.
when considering where in the ambulatory site it should occur. Now let's move on to another example. We'll go ahead and change subsets and we'll look at fusion lumbar spine.
And I'm navigating through the criteria quickly to get to the end of the review so that we can look specifically at the codes and the setting determinations here. So for lumbar spine fusion here we can see that um.
You know, we really talked about this one in in earlier when we were talking about improvements in hardware, things like fusion screws has really started to increase prevalence of these procedures occurring in the ambulatory surgical center, other factors contributing to a shift in ambulatory spine.
Surgeries are faster recovery, a quicker return to activity thanks to microinstrumentation, minimally invasive procedures and improvements in anesthesia. This is a big one for regional versus general anesthesias is having a big impact here.
In this example though, we can also see how really it's the specific procedure that's being done that impacts the setting and highlights the importance. This is a good one to look at when we're thinking about the importance of using coding or codes to make these determinations. So based on code selection here.
This procedure is either strongly inpatient or strongly outpatient in both the Interqual proprietary setting data as well as within the CMS coverage policy. So if we look at 20931, which is this code here, you can see that that is.
Fairly strongly on the outpatient determination side, 80% of the time this is being done outpatient. If we toggle to CMS, we can see that it's on the CMS ASC eligible list, also indicating that that's a strong outpatient determination there. However, if we look at code 22.
22533 So let's Scroll down a little bit 22533 here. If we select this code you can see that it this one is very strongly inpatient, so it is 82 of the time done on the inpatient setting.
CMS has it on the CMS inpatient only list. You can see here there's some logic in the way that our interqual site of service functionality works, so that if you select more than one code at a time.
It will always sort of go towards the highest setting. So both of these codes were selected, maybe they were both being done together as part of a single procedure. The overall setting for this procedure would be inpatient based on those two being selected together.
Now I mentioned earlier that the site of service functionality for Interqual site of service that's coming out in the fall also has the ability to look at setting outside of the context of doing a medical review. So in these previous examples we've really been looking at doing a medical necessity.
Review for the procedure. And then once we've determined that the procedure was appropriate for the patient based on their clinical findings, we were looking at setting. We know that that's not always the case, right? You don't always need to do a full review for the procedure. Maybe it's something that's not on your prior author list.
But if it's being requested as inpatient, you are definitely going to want to take a look at those settings. So this new functionality for setting lookup lives under the menu here. So if I go to the menu, you can see the first thing on the list is the setting lookup. It allows me to just go ahead and pop in a code. So for this one, we'll look at Pacemaker.
Then go ahead and pop in the code there. It's going to identify a particular code and I can go ahead and select that and it's going to give me all of the information across either the both age age groups, adults and pediatrics for interqual or as well for CMS.
And here's where you're starting to see some Gray area, right. So if we look at this data, we can start to see an example of a late inpatient to outpatient shift in progress. So this procedure is almost nearly at the outpatient threshold of 75%.
It's 71% outpatient at this very moment, but you can also see some additional support for this shift and noting that it's on the CMS ASC eligible list. So the benchmark setting data is not always going to be definitive, right? It's not every procedure is going to reach that.
75% threshold where we are comfortable saying for sure every single patient should be inpatient or every single patient should be outpatient, but it is going to play a role in helping to inform that final determination. So whether you're a provider submitting the request for an inpatient pacemaker.
or your payer receiving the request, you can utilize this data to help inform your decision-making. So in scenarios like this one, uh evaluation of the data behind the setting determination and the patient's clinical factors are going to both play a role in the decision-making process.
Decision making and they need to go hand in hand. So if this request was for a straightforward patient with no comorbid conditions or comorbid conditions that have been optimized, it might make sense to go with the data and recommend an outpatient setting. Having this insight into the data is gonna help providers know when perhaps to.
request or reconsider a requested setting or or when to spend the time maybe pulling the data together for the the additional clinical data to support an inpatient setting. All All of this is with the goal of getting the right setting for the patient upfront and really minimizing that back and forth to drive efficiency.
In documentation and decision making if we look at another example here.
For carpal tunnel disease, an example of an ambulatory shift in progress. So this procedure has been likely done in the outpatient setting for some time and we're starting to see a shift from the hospital outpatient department to the ASC. So 99% of median nerve decompressions for the wrist for carpal.
Tunnel are being done outpatient, with 28% being done in an ASC. This code has been on the CMS ASC eligible list since at least 2003, which is just an aside, but also speaks really to how slow the shift has been happening historically.
This is a great example of a procedure that's unlikely to have any complications requiring a higher level of care or emergency services. This could be considered an organizational opportunity. If your organization isn't doing these in an ASC, it should be something high on the list for consideration.
One more example here.
If we look at Salpingo oophorectomy bilateral or oophorectomy bilateral, this data shows a clear outpatient setting at 97%. It is on the ASC eligible list. So this is another opportunity for a shift into the ASC.
You can already see that we're starting to see 6% of them are being done in the ambulatory surgical center, but a whole lot still being done in the hospital outpatient department.
So now let's go back to our slides.
And do a case example here. So in this case example, we have a 75 year old patient.
Oh, sorry, 72 year old patient. She is undergo a status post laparoscopic hysterectomy with bilateral Salpingo oophorectomies. She has endometrial cancer. She's also has hypertension. She's not well controlled on her medication. She's an active smoker.
With COPD and type 2 diabetes and you can see her hemoglobin A1C is 8.2 and her American College of Anesthesiology or her ASA score is a class 3. She is a Medicare beneficiary, so there's been no prior authorization received for this surgical procedure.
We also know that a lap hysterectomy is an outpatient procedure, but we will look at that code in the setting. Look up due to her comorbid conditions and her higher risk for complications, her surgeon's expecting her to require two days of postoperative management.
Including management of her COPD, hypertension and diabetes before she's safe to return home. She had a stable OR course. She has post-op orders for pain control and diabetes management. So we'll go ahead and take a look at her case within Interqual. So the first thing we'll do is go ahead and look up that code.
That we had for her. So it's 58550. She is a CMS beneficiary. So we can see that this is not on the inpatient only list. It is a CMS ASE eligible procedure, but it's being requested inpatient following the procedure.
So because we're not looking at prior authorization here, we can go ahead and look at doing an inpatient admission for her in our general surgical subset. So it's operative day for her day of procedure. We'll go ahead and look at the requested level of care, which is the acute.
Level of care. We do not see that the surgery has been designated as inpatient either on the CMS list, the Interqual benchmark setting report or we do not have a prior authorization. So that's really not the appropriate selection for us here.
We do have an ambulatory procedure with higher risk for complications requiring inpatient management based on the documentation that we got with our request for an inpatient setting for this procedure. Physician is documentation is supporting the need for post procedure management for at least two days.
And let's look at sort of her complications. She does have an ASA score of three. Let's see, what else did she have in her case? She also had uncontrolled diabetes.
Really indicating that she is of a higher list of complications. She also had some diabetes, some COPD issues that were uncontrolled. So really utilizing this section of the criteria we can help support.
You know her clinical risk for needing an inpatient setting based on her clinical specific findings that might differ from sort of everyone else, right? You might have had another patient who was appropriate to have this procedure in the outpatient setting, but for her based on her clinical documentation.
Her increased risk physician documentation supporting the need for at least two days of postoperative management. She is appropriate at the inpatient setting of care.
So we talked through a couple of examples here and really there's a huge amount of opportunity as we think about this ambulatory shift. This data here comes from a study done by McKenzie evaluating the opportunity in the rise of ambulatory care. As you can see here, the majority of codes.
fall into clear inpatient or outpatient buckets. So in both of these groups, benchmarking data shows that a high percentage of cases are being done either inpatient or outpatient. Nearly 30% of procedures, though, have notable variation in site of care choice, and this represents
$132 billion of opportunity. So you can see here in the CPT code, the inpatient CPT code bucket is much smaller, right? We're looking at 676 codes versus 5300 codes in the mixed or all outpatient grouping. So that's pretty significant.
Things are, it's late in the shifting from inpatient to outpatient, right? The majority of what's being shifted has shifted. In their analysis, though, Mackenzie set out to analyze what was the source of the variation and what is the opportunity in reducing that variation.
Found was that in the mixed group of codes, it really represents that bucket really represents a number of procedures that are being done in the ambulatory setting safely and that the approach, technology and clinical protocols exist to support in doing them in that setting.
And so then you look at maybe some financial aspects at play here, you can see that there is a cost savings of between of $21,000 between inpatient and ambulatory settings for the same procedure. They really defined low hanging fruit opportunities as those were 65.
To 95% of encounters are already being done at the outpatient setting. And you can think back, this is a great example of our pacemaker example where we saw 71% of pacemaker insertions were being done in the outpatient setting. And so the data here is the key, you know in order to.
Capitalize on the opportunity.
So what is driving the variation? When they looked at it, what they found was a couple of key things, the variation across how different specialties and specific procedures are shifting. So specialty was a great example. Joint replacement is one of the procedures that experienced the greatest shift.
Due to aligning regulatory physician and hospital incentives, spinal surgeries, prostatectomy and appendectomy are also starting to shift due to the advance of minimally invasive operating techniques, making them more likely to be performed laparoscopically in the hospital outpatient department.
Cardiac procedures are starting to shift, albeit slowly. CMS has approved ambulatory care for procedures like diagnostic cath, ICD implants, pacemaker implants and PCI. But change can start to happen quickly when the regulatory changes push folks in the new direction and so.
With the proposed OPPS rule, things could start happening very quickly and so we all want to make sure that we are on track to to be able to react to that change. Patient risk is another factor contributing to variation.
Either related to comorbidities or other risk factors like the need for more complex anesthesia or increased clinical backup. Generally the younger and low risk commercial population is more suitable for outpatient procedures than the Medicare population, so that can contribute to the risk to the variation.
And geography is also another area where we see impact. Change does not happen everywhere all at once. It varies across different healthcare systems and geographic locations and typically can be driven by local market conditions and incentives. So things like local regulations, physician independence, health plan policies.
and patient volume for a given procedure can really influence the variability across different areas of the country.
So having a data-driven determination for where the service should be performed tied with a way to evaluate unique patient characteristics is going to be key to help ensure that the patients are being treated in the safest and most cost-effective setting for them.
Focusing on finding the right setting where that variation exists will help to reduce cost, denials and administrative burden, decrease the need for second level review, enhance efficiency, and really most importantly, improve patient safety and overall outcomes.
Thank you for joining me today. I hope you're walking away from this session more informed about the shift in ambulatory care so that you can take this back to your organization and determine the most cost-effective and and use data-driven and cost-effective strategies to identify the safest.
And most cost effective setting for each patient based on their specific clinical scenario. At the end of the day, this is all about providing patients with the safest and most efficient cost effective care. So as a system we can partner together and use some new tools, some new data to help achieve that outcome.
If you're interested in learning more about the Interqual site of service functionality that we reviewed today, please reach out to your account manager or your sales executive for more information. We'd be happy to talk to you about it and show it to you in more detail. Thank you, everyone.