I'm going to talk about ASC. I also put in OBL, Office-Based Lab, because I think it's important to understand what's different between the two of them, as a lot of people use them interchangeably and they're not interchangeable. I have no relevant disclosures. So what is kind of on the surface? What are the differences? ASCs have much stricter facility requirements. So they're going to watch how wide your doorways are, what kind of beds you're using, what are your firewalls, do you have a backup power supply, all of these pieces. They're certainly more costly to build and there has to be more standardization in how the equipment, aside the airflow for sterility, is in place. And you can use general anesthesia in the ASCs, which you cannot do in the OBLs, and there's joint commission accreditation. In OBL, certainly more limited, as we've alluded to, you could do local unconscious sedation. A lot of people have a CRNA, do all of their anesthesia for these cases. Less expensive for a startup and there are also regulatory requirements. Every state is different, so you have to find your state requirements as well. So some of the things you can do in an ASC, pacemakers, defibrillators, anything that can be done, endoscopy, pieces like that. You can have general anesthesia, so you can do more procedures more comfortably in certain patients. And in OBLs, you can do diagnostic angiography in some states, PCI, diagnostic vascular and treatment of vascular, veins, arteries, all those pieces you can do, and local unconscious sedation. So what are the benefits? Well, there has been data to show that there can be improved patient outcomes if things are done because of decreasing variability. There's improved access to care because the patients are getting care close to their home. There's autonomy for the doctors and staff, so you have an ability to do things the way you think things should be done, what you think is best for your patients, timing, scheduling, all those pieces. And the insurers are paying for it. Why? Because it's reducing their cost. You can control the overhead much more than the hospitals can, elimination of inefficiencies. Again, you're doing contracts, so you're using one kind of stent, one kind of wire. You're really limiting what you have because you only usually have a few operators. Patient-focused environment. The patients love this. They come in a separate door. They don't have to park in a parking structure. They just walk in. They get their procedure done. It's one-on-one care with the nurse, generally, and it's not a high-volume place. And staff engagement. The staff is, you know, they're really excited about working in these places because they are really in charge and they don't have to worry about 10 other people doing things 10 different ways. You also capture both the technical and the facility fees, so it is a profitable endeavor. And having both the ASC and the OBL allows better insurer coverage. So some insurers will say, yes, you can do this SFA stent, but you can't do it in an OBL. You can only do it in an ASC. And so sometimes, not sometimes, all the time when you're scheduling a patient, you have to decide where they can be done. And there's still some insurers that will only allow it to be hospital-based, but that's becoming less and less. And you can either self-manage if you've got somebody who's really interested in the business of medicine, or you can hire a management company and they'll help you mitigate the financial risk, the regulations, build the business. They'll give you your disposable packages, all those pieces. So why do people do this? Because there's lots of inefficiencies in a hospital-based system. There's hospital schedules. There's block scheduling. So maybe you only get two, on Tuesday, between 2 and 5 to do your cases. And maybe the person who comes before you is really long, always goes over their time. So you're starting your cases at 4 o'clock. So what are you doing between 2 and 4 if you do an account for that? You're not really profitable yourself. You're not being efficient. You're late home. You're late to your family, all those pieces. Case turnover. Case turnover at some hospitals can be up to 40 minutes, sometimes even longer, depending on the efficiencies, which is terrible. Wait times. The patients have to wait. You have to wait. It's unsatisfying for everyone. Is there a room available? Did a STEMI come in and just crash your whole day? With bed availability in hospitals, you have nowhere to put the STEMI because there's not an ICU bed ready and waiting yet. So the catholic gets tied up. Unexpected delays. More variability. Again, increased variability decreases quality. I totally agree with that. Also, cost. So more variability leads, generally speaking, to more cost. The staff training you have complete control over so you know exactly how things are done every time. And you mitigate the travel. Often when you, you know, if you have an offsite office, you have to travel to your hospital for your procedures, and all that time is mitigated. You have to, I just put this on here, there's lots and lots to talk about with understanding the financials of this as you're going forward, but just understanding MACRA is like a beginning piece, and you could have 100 talks on this. Value-based care, quality, performance, and improved patient outcomes. A lot of people use the merit-based incentive payment program in order to improve their payment for themselves. Quality is a big piece of it. 50% using an EHR can give you an extra 25% of that payment. Having practice improvement and quality improvement things in place all the time, and of course, cost savings. So this is just an example of what the hospital will get for an outpatient rate for, let's say, a right heart cath, $29.58. And the ASC reimbursement is less, but your overhead is less, and you can do more because you're more efficient. So there's a push by the insurers to move some of these procedures offsite because they win, and you also can win. Things to consider. Are you going to do an OBL alone? Are you going to do an ASC alone? Are you going to do a hybrid? So lots of places have both an ASC and an OBL, and they might have the OBL open for four days a week with the staff and the ASC open one day a week, or lots of different combinations of that. You can either self-manage or you can co-manage. So there's lots of companies out there who will come in, and you just say, look, I want to have an OBL. I want to have an ASC. They look through the regulations, figure out if you can do it in your community, and then they help you from start to finish on how to get it going. There certainly are state requirements. There's a number of states or a certificate of need states, and so you have to be really mindful of all those pieces as you just start your journey. And who in your practice will be the business person? So even if you have someone manage from outside, you need someone in your group who's going to be willing to take on that piece and understand it and be able to communicate it to the partners. So in summary, and I've tried to make up a little bit of time so we have time for questions, efficient high-quality practices will really do well in this setting. You need to be very organized, and you need to have an interest in the business of medicine. If you're not interested in decreasing variability, watching the costs of the equipment that you're having in, all of those pieces, learning how to schedule properly, will not be successful. You need continued maintenance of the process for quality improvement, and you need to consistently look back. Go back every quarter initially. Go back once a year, once you're up and going, to determine what you can do to make things better. Some of the metrics are how many times you need to send someone to the main hospital from where you are. It should be pretty close to zero, but it will never be zero. The rewards of autonomy, work-life balance, and potential financial independence are tangible. We, my last practice I started in OBL, and it was wonderful. Like, I would see two patients in the morning. I'd pop over, do a couple caths, you know, come back over, finish my clinic, see the patients like literally five steps away to be able to send them home. Everything was done on my time, my schedule. There was no waiting, no scheduling issues. Everything moved very, very efficiently. Patient satisfaction is great. We did a patient satisfaction survey with every patient who went through, and they were very happy with their experience. We thought we had improved outcomes because we could control the staff. You had everybody educated to the same level, so you weren't dealing with travelers who had never worked in your hospital before, or, you know, somebody brand new at a training. You had real control over the people you were working with, and obviously staff engagement. So, when the staff is engaged and proud of what you're doing, and they can see you providing a quality outcome for the patient, they're super on board, and it makes a really happy place to work. Thank you.

Ambulatory Surgical Centers

Office-Based Labs

facility requirements

equipment standards

anesthesia options