So the the issues that I'd really brought up and was asked to speak to was some of the financial and regulatory issues surrounding an ambulatory surgery center because I think that's one issue that those who in interventional cardiology when this first became an option when CMS basically said we're going to pay for PCI in an ambulatory surgery center everyone really based it on what they had seen or heard about endovascular intervention in office-based labs. So it's important to realize that those even though interestingly they can take place in the same building they are two different sites of service and are reimbursed differently. So one of the important things that oh yeah great to be aware of is the difference in payment for a heart catheterization and especially a percutaneous cornea intervention in an ASC is going to be significantly different than it is in a hospital setting even though both are outpatient procedures and in this slide here just illustrates that point. So basically if you do let's just one quick example a PCI outpatient medicare in a hospital setting the hospital gets paid ten thousand dollars. If you do that in your ASC you get paid six thousand dollars. Now a lot of people that have never done this and I actually am one of those I had to full disclosure but if you're not familiar with this world I can tell you that's a tight margin. So as a result that this gets into the issue of the case selection if you are sitting listening this webinar and you're thinking I can't wait to open my ASC and start doing PCIs you need to really be aware of the fact that your volume if you're only going to be doing coronaries it's got to be exceptionally high that you're going to need to have a high percentage of private pay patients and that realizing also that all of the cases you do in the hospital I mean if we think back over the you know past month that all of us have been working how many PCIs have you done that you would feel safe and comfortable doing an ambulatory surgery center. So because you can't do acute coronary syndrome one it's a bad idea and two it's not covered so that's off the books so all your ACS cases are out then you're looking at your stable disease patients and those that you feel are safe and comfortable to do in an ASC and there was a question about you know well what are the characteristics those patients and there is some guidance about that in the document but I think the bottom line is is that you know the physician interventional cardiologist needs to be very aware that in ASC you're operating without a very big safety net so you don't have anesthesia to call you don't have you know the critical care guys to come down you don't have anybody but you and your team so that's one thing just to keep in mind when you're looking at that and so go to the next slide where that really oh backup sorry I wasn't ready for this I had one more point the issue that also people need to think about is that I mentioned the different payments for an OBL versus an ASC you should think about the fact that if you're really going to be successful a lot of these programs have other procedures that are being done there besides coronary so whether that's going to be peripheral vascular there are some EP procedures that can be done so those are things that it's very important to just have that in mind that either you have those in your skill set or you're going to partner with somebody and then be aware of the fact that some of the political developments which is how I became involved in this space that are affecting the OBL space OBL setting that are not directly related to ASC because of this interdependence are going to be very important to you as an ASC owner so for instance there is a issue that we are fighting very hard in SCI about the payment of what's called the clinical labor index so it involves all outpatient office based procedures and a certain amount of the payment is coming from almost 20-30 percent of the payment comes from this clinical labor index so that's being cut that's a long discussion but the point of that is the fact that if that critically impacts the procedures that are done office base that's going to greatly impact you as an ASC owner so you need to be more aware of kind of the bigger picture of what's happening in the outpatient setting if you're looking financially going into an ASC so the the big issue that we talked about a lot when we were doing both the ASC paper as well as this paper was the fact that really we feel like good intervention involves the use of IVAS imaging and IFR and FFR however they were not covered in the ASC setting so as I mentioned the cost of you know your margins were very small so it's quite a an altruistic ask to tell people you should do IVAS on every PCI in your ASC and you're going to lose money every time you do that so your ASC is not going to stay open very long so it was a obvious conflict there a lot of effort went into this but ultimately CMS does now provide coverage for IVAS, FFR, OCT in the ASC setting so that it is now financially viable to do those which really further supports what we said in the document was that regardless of where you are doing your PCI you still need to do this in a high quality way and use imaging to guide your intervention so now that that payment is available there's really no excuse for not doing that in your ASC so that's it I'll open it to discussion. Thank you very much Linda we had a question specifically for the ASC so maybe Jeff and you and perhaps Adir can answer this question you know how do you have third-party oversight of an ASC or any hospital I mean do you need accreditation to start a program do you need external case review or quality outcome reviews I know our document had at least you know we should have case reviews preferably with the cardiac surgeon as well as part of a heart team approach but maybe you can describe how you do that Jeff and then maybe Adir you could talk about external case reviews whether that's necessary. Yeah so right now everyone should know there's no requirement for OBLs or ASCs to have accreditation peer review processes credentialing is state-by-state there are higher regulatory issues with the ASC so if you're going to establish an ASC you know the regulations are really up here compared to the OBL and it's state-by-state so that's really want to emphasize that you need if you're going to get into this you need to go to your state to understand it of what's required but for the ASCs it's really there's most of them are very similar across the nation we have adopted is right now it's voluntary and it's highly recommended strongly recommended there's a QI process in all of these centers OEIS was built and started for that purpose to create those standards and accreditation is voluntary and we highly recommend that that shows that there's safety in the processes but also a peer review credentialing processes and you know really focused peer review for any QI issues with poor outcomes are are strongly recommended at this point so we do that on a in my lab we've been doing it from day one and we've been in existence for 14 years doing PCIs for 14 years in an OBL setting and now with the ASC we've been doing that and we are we track every single patient within three days after the the intervention and within 30 days as well so three and 30 day follow-ups on all of our patients for all interventions that are done. Nadir you're chair of the quality committee can you describe how you would ensure quality at ASCs or out non-hospital settings or even in hospital settings? I'll actually I'm going to let Mladen do this is he he actually has a lot of involvement at least at our VA site with doing external case review and so I really follow his lead there but thank you. You know thank you for shifting the question over to me it's like you know so VA does something done things really well and the thing that it does really well it has a national major event events committee so essentially all VA cath labs are one big happy family and there is one committee that looks at all bad cases and it actually works exceptionally well because you have an independent reviewer of your buddies colleagues peers who look at complications and it's it's probably one of the highest qualities committees that I sit on because you actually have pretty smart experienced people looking at cases from all over the country and giving you opinion what's happening somewhere else and didn't have any particular interest in your particular life they have no political interest or whatsoever and they're mainly interested in quality and it actually would be very interesting if let's say and I think I've bounced this off with Arnold is this a role of accreditation if this an external peer review would sky provide some service to its members of that level again it's somewhat easier to do in an insular galapagos environment that the VA operates in then maybe in a free range environment again some things may not be transferable to the you know again let's say free economy environment but again a peer review is quite important and actually would be very interesting if sky could develop this further so again thanks for bringing this up.

ASCs

interventional cardiology procedures

payment difference

safe environment

accreditation