Chapter 63 Building an Outpatient Intervention Suite

Samuel S. Ahn, Hwa Kho

Technological advances in minimally invasive treatments for vascular diseases in the past decade have made it clinically acceptable to perform many peripheral endovascular interventional procedures on an outpatient basis. In recognition of that development, Centers for Medicare and Medicaid Services (CMS) has, since 2006, steadily increased the types of interventional procedures it allowed physicians to perform on an outpatient basis in the physician office setting, thus making it potentially viable economically for vascular surgeons to operate their own intervention suites in their offices.

Incentives

There are three powerful incentives for vascular surgeons to consider building their own intervention suite. The first is quality of the patient experience. The vascular surgeon has much more control over the patient experience, from scheduling of the procedure time, to the environment, to the amount of time with the patient before and after the procedure. By doing the intervention in the office, the vascular surgeon can make the environment much more comfortable and less intimidating to the patient. The surgeon can schedule treatments quickly without having to compete for room time with other physicians at the hospital.

The second incentive is productivity. Without having to travel to and from the hospital and having to wait for the operating room or catheterization room to be ready, the vascular surgeon can make much more efficient use of their time. The typical vascular surgeon wastes a lot of time waiting for procedures scheduled ahead of them to finish and for rooms to be cleaned before they can begin their procedures at the hospital. With an intervention suite in their office, the surgeon can see many more patients in a day.

Finally, in the face of declining professional fees, office-based procedures offer vascular surgeons an opportunity to increase their revenues by capturing the higher global fees that CMS and many other insurance companies pay for office-based procedures. A global fee is the fee that CMS and other payers pay to the physician for providing a service in the physician’s office. The fee reimburses the physician for professional services and the technical expenses of providing that service. The latter is equivalent to the technical fees that hospitals and ambulatory surgery centers receive for procedures performed in those facilities. The global fee can be substantially, higher than the professional fee, sometimes tenfold higher. The physician will incur more expenses for procedures performed in the office, which will have to be paid from this global fee. However, by managing the intervention suite well, the vascular surgeon has the opportunity to generate a higher income.

Considerations

Financial

Appealing as the incentives are, the vascular practice needs to carefully analyze whether the fixed and incremental expenses of having an intervention suite in the physician office makes financial sense before deciding to build one.

The first question is whether the office has a sufficient number of cases that could be handled in an outpatient setting. How many cases are currently handled elsewhere, such as in hospitals and surgery centers, that can be transferred to the office intervention suite? What are these cases and how much would they reimburse? What is the payer mix? Will the payers reimburse at the global fee rate? Medicare and most commercial payers will reimburse a global fee. However, Medicaid would only pay the professional fees for many interventional procedures in the office setting. Some health management organizations may also refuse to pay a global fee.

Although an interventional procedure in the physician’s office may reimburse much more than the professional fee that the vascular surgeon would get in a hospital for doing the same procedure, it is important to remember that the physician’s office has to pay for supplies, which can be expensive, for staffing (including nurses, scrub technicians, and x-ray technicians), for equipment, and for other variable and fixed expenses.

Unless the practice has sufficient volume and the right type of cases and payer mix to cover the overheads, and is able to manage its supplies and other expenses efficiently, the intervention suite could easily become an untenable financial burden. It is important to make a careful and realistic financial projection before proceeding with the implementation.

Location

The intervention suite should be within 5 miles of, and ideally adjacent to, a major hospital in the event that a patient needs to be admitted. Such events should be rare, but as with any intervention, the physician needs to have a contingency plan for possible complications. This is usually not an issue because most vascular practices are located near a hospital.

Space

The more space the practice can allocate to the intervention suite, the easier it will be to configure the space to work efficiently for the physicians and patients. At a minimum, the intervention suite needs:

• An angiography room with at least 600 ft², but ideally about 1000 ft² (Lead-lined walls may be needed depending on the radiation pattern of the fluoroscopy machine, the size of the room, the adjacent spaces, and use of the fluoroscopy machine. The practice needs to consult a medical physicist on the actual requirements.)

• One or more recovery rooms measuring at least 100 ft²

• One or more pre-op rooms measuring at least 100 ft²

• Storage area for supplies (This area should ideally be inside the intervention room, or easily accessible from it. At least 100 ft² will be required.)

In addition, spaces for reception area and work areas or offices for staff and physicians are necessary if the practice does not already have them.

The practice needs to consider how the patients flow through the facility and plan for adequate clearance in regard to doors and corridors, bearing in mind that patients may be moved on stretchers from the pre-op room to the intervention room and from the intervention room to the recovery room. The practice also needs to plan for nonambulatory patients arriving and departing the facility, and in particular access for emergency vehicles.

If a practice already has existing space that could be converted into an intervention suite, the build-out cost could be minimal. On the other hand, building a whole new facility could easily cost hundreds of thousands of dollars.

Equipment

The basic equipment for the intervention suite includes the following:

• Fluoroscopy unit

• Imaging table

• Backup power supply

• Defibrillator

• Crash cart

• Anesthesia cart

• Ultrasound scanner

• Patient monitors

• Stretchers

• Sterilizer

• IV stands

• Stainless steel tables

• Lead aprons

• Bovie

• Power injector

• Operating room lights

The most expensive and important piece of equipment is the fluoroscopy unit and imaging table. A portable C-ARM is usually sufficient. It should have the appropriate vascular software package, and ideally, a 15-inch image intensifier. Because the physicians will be using this critical piece of equipment for many years, it is better to acquire one that provides superior clinical functions and user experience than to let price be the driving factor in deciding on a model. By buying some refurbished equipment when possible, the practice could equip the entire intervention suite for approximately $500,000 or less.

Supplies

The practice will want to stock 1 to 2 weeks worth of supplies (e.g., guidewires, catheters, balloons, stents, pharmaceuticals, disposables). Most of the more expensive devices such as balloons and stents may be obtained from the suppliers on consignment. The practice does not have to pay for a consigned item until it is used; therefore the practice should try to get as many items on consignment as possible.

The decision on which devices to get depends on the types of cases the practice plans to perform as well as the physicians’ personal preferences. It is important for the physicians to be involved in making these decisions because they know best what they need and are most comfortable using.

Managing and keeping track of the supplies is a time-consuming yet critical function. A working intervention suite stocks more than 1000 unique devices. A single balloon could come in six different permutations of sizes. Just one missing device could compromise the outcome of a case. It is important to be able to discover quickly what is in the inventory at any time and be able to track all the supplies used in each case. There are inventory management systems that provide for utilization tracking through use of barcode readers. The practice should invest in one to help manage its inventory. Initial cash outlay for supplies will typically be $50,000 to $100,000, assuming that most of the expensive devices can be obtained on consignment.

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