How to Establish an Effective EUS Practice

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A patient with unexplained, chronic abdominal pain has struggled for months to find the cause of his discomfort. His physicians suspect something serious, and order an endoscopic ultrasound for further examination.

Without a local option for care, the man is stuck waiting months for an appointment and must travel hours for the advanced endoscopic procedure. While most patients prefer to be seen in ambulatory surgical centers (ASCs) due to convenience and, often, lower costs, EUS is not always readily available in ASCs.

Unfortunately, barriers to bringing EUS to ASCs or outpatient clinics include limited training opportunities for physicians – especially post-fellowship – and equipment costs for ASCs and outpatient centers. But, bringing the procedure to your practice can drive revenue and significantly help patients in the community.

There are always questions about if a group should start an EUS program, but once that decision is “Yes”, the new set of questions becomes “How”.  So, if a physician who is already trained in EUS is thinking about starting in another setting, then here is an outline of how to get it done:

Explore:

Take stock and determine if EUS is the right fit for your practice and community.

A team of representatives from gastroenterology, nursing, materials management, pathology, radiology, procurement and medical device reprocessing should collaborate to determine goals of an EUS program, the target patient population and the overall implementation plan. The team will also need to analyze the current availability of adequate resources (budget, equipment, trained personnel, reprocessing facilities, etc.) to implement an advanced procedure like EUS in your practice, and/or what will need further investment.

Plan:

Develop an implementation timeline complete with short-, medium- and long-term goals and measures for success.

The implementation plan should include how your team will meet training requirements, acquire equipment and market the new offering to the community. Post-fellowship training fellowships are available for endoscopists seeking to gain competency in EUS. Reprocessing personnel also require training on proper handling and cleaning of specialized endoscopes. All credentialling requirements must be met as well.

Implement: 

Install equipment and train appropriate staff to cover all aspects of procedure, from preparation, to anesthesia, to performance, to reprocessing of endoscopes to follow-up care.

An advanced endoscopic procedure such as EUS requires a large amount of institutional support to be performed successfully. Facilities may choose to engage with medical device manufacturer clinical support teams, especially with using new equipment and setting up brand-new services. The needs of additional stakeholders, like anesthesia and radiology, should also be factored into implementation timelines and plans.

Review:

After successfully launching EUS as part of your practice, take time to review what went well and what could be improved for both team members and patients.

No new program implementation will ever be perfect, and this is a good time to review all procedures and protocols to ensure all patient and department needs are met. Additionally, the implementation team described above can determine future clinical needs for continued operation and expansion of a successful EUS program.

“EUS program leaders and healthcare administrators must work collaboratively to measure preestablished metrics of success, operationalize identified opportunities for improvement, and regularly evaluate the overall clinical care system,” according to an article in the January 2022 edition of Endoscopic Ultrasound about establishing EUS in practice. “[EUS] programs require a comprehensive and interprofessional approach to strategic planning, goal setting, implementation, training, and program maintenance.”

ASCs--the-Benefits-of-Physician-Ownership-

ASCs, the Benefits of Physician Ownership

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Two physicians opened the first ambulatory surgical center (ASC) in 1970 in Phoenix, Arizona to create a workplace where they could call the shots. For the first time, physicians were in control of everything from scheduling to the types of medical equipment purchased.

While many ASCs remain independent (100 percent physician-owned) like the very first one, the intense market demand for care outside of the hospital setting has led to an influx in corporate investment and co-ownership of practices. Still, today, more than 5,800 ASCs exist all over the country, providing economic and convenience benefits to providers and patients alike for same-day surgical procedures.

“Over the last several years, it’s become apparent that the hospital setting just isn’t the most appropriate for a lot of surgical and procedural care,” according to Dr. Michael Owens, a gastroenterologist in Portland, Oregon. “Patients, health systems, and payers are all looking to the ASC now for mutual benefit.”

ASCs offer a plethora of procedures today, ranging from orthopedic surgery to endoscopy. According to March 2022 data from the U.S. Centers for Medicare & Medicaid Services (CMS), 32 percent of single specialty ASCs, or EASCs, perform endoscopies – upper endoscopy, colonoscopy, etc. – and 37 percent of multispecialty centers offer endoscopy services.

“EASCs fit well for everyone in this healthcare scenario,” according to a study in Clinics and Colon and Rectal Surgery. “They are more efficient than hospital-based procedures, they are less costly to payers than hospital-based procedures, and they provide an additional source of revenue to healthcare providers.”

Pros and Cons of Physician Ownership

For providers with a full or partial stake in ASC ownership, the benefits extend beyond those offered owners of any profitable business, according to Owens. Physicians also have the chance to offer greater value-based care, he said.

For physicians with any stake in outpatient service ownership, benefits for them and their patients include:

  • Eliminating the need for negotiations over types of medical equipment used.
  • Having the opportunity to specialize in certain specialties of care.
  • Controlling scheduling and offering greater flexibility for patients.

“ASCs are typically nimbler, faster to react to change and may therefore have the ability to embrace new methods, technology and policies,” Owens said. “But this is not always the case, a poorly run ASC might be more disadvantaged than other sites of service.”

Having a good business partner can be crucial to success, Owens said, but it is not imperative for physicians to have a business administrative background to put the needs of their patients first and run a successful practice.

“We are professionals who do understand the delivery of health care as experts, and I’d encourage my colleagues to want more seats at the table,” he said.

The Role Payors Play in Where Patients Seek Care

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There are many factors to consider when deciding where to seek care for patients needing a routine or advanced endoscopic procedure. Perhaps it’s urgency for diagnostic or therapeutic care, the ability to travel, a desired physician to see, the convenience of available appointment times, or simply going to the first place found on Google.

But one influence is increasingly difficult to ignore: the bill.

Depending on type of coverage and whether benefits are from private or public sources, patients may unknowingly be directed to select certain locations for care. Increasingly, payors are favoring ambulatory service centers (ASCs) as a cost-effective alternative to hospitals.

“The ASC is usually more efficient, and the patient will benefit by having specialized care in a more efficient manner,” according to Dr. Adam Goodman, a gastroenterologist and professor at NYU Langone Hospital-Brooklyn. “The system benefits by less administrative costs, greater efficiency, and more procedures getting done in a similar amount of time.”

Ultimately, patients receive the same quality of care, but at a much-reduced cost, Goodman said.

It is estimated today that 90 percent of colonoscopies are performed in ASCs, hospital outpatient clinics, or in physician’s offices. Up to 32 percent of the ASC’s in the U.S. specialize in endoscopy alone, while 37 percent of the multi-specialty centers offer endoscopy services, including upper GI endoscopy, sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS).

Since ASCs typically offer specialized care, procedures can usually be performed more efficiently and quickly than at hospitals, resulting in lower costs. Patients seeking care at ASCs are likely also to have fewer complex conditions, requiring fewer resources for care. A recent study in California found colonoscopies cost an average $2,300 less when performed at an ASC rather than a hospital.

In fact, large payors have increasingly created policies that favor ASC care and may put continued pressure on physicians to perform non-urgent procedures in these settings. In some instances, insurance companies won’t pay for a routine colonoscopy in the hospital anymore. For example, United Healthcare now restricts sites available for non-emergent surgeries and Empire Blue Cross Blue Shield in New York began requiring proof of medical necessity for certain procedures to be performed outside of an ASC in 2021. The New York-based company argued procedures they were pushing to ASCs have been safely provided in such settings for many years. This is particularly true for GI endoscopy.

Studies have shown how care provided at ASCs is significantly cheaper than hospitals – with one report from Regent Surgical Health estimating healthcare cost savings up to $38 billion annually. Additionally, combined out-of-pocket expenses for patients could be reduced by roughly $5 million annually, according to the report. Even for advanced GI endoscopy procedures like ERCP or EUS, ASCs can offer a cost-effective alternative to a hospital.

ASCs are becoming increasingly popular throughout the country, and there are more than 5,000 operating nationwide today. If payors continue to drive future care to the centers, that number will only grow.

Reducing Medicare Costs by Migrating Volume from Hospital Outpatient Departments to Ambulatory Surgery Centers

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From Advancing Surgical Care (Download PDF)

More than 5,800 Medicare-certified ambulatory surgery centers (ASC) provide outpatient services to Medicare beneficiaries. On average, Medicare pays ASCs one-half of hospital outpatient department (HOPD) rates for the same procedures, meaning that every time a procedure for a Medicare beneficiary is performed in an ASC instead of an HOPD, the Medicare program saves money. This report seeks to update estimates of those savings to the Medicare program for the period 2011 to 2018 and project those savings for 2019 through 2028.

Surgeons Migrate to ASCs as Surgeries Move to Ambulatory Settings

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From OutpatientSurgery

OSD Staff –  

It’s no secret that the ongoing coronavirus pandemic has challenged American health systems in ways that they are not used to being challenged. Many have had to adjust rapidly to best meet the needs of their patient population, while doing what they can to stay afloat financially. Among the most attractive solutions to this problem is the migration of procedures to ambulatory surgical centers (ASCs)

10 Big Challenges for ASCs

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One year ago, many ASCs were closed or at limited case volume to divert resources to hospitals treating COVID-19 patients.A year later, the pandemic has had some silver lining in driving more cases outpatient, but there are several challenges ahead. ASC owners and operators will have to navigate their organizations through a new healthcare ecosystem emerging in the next 12 to 24 months.
From Becker’s ASC:

Laura Dyrda –  

Ten challenges:

1. Boosting case volume. The COVID-19 pandemic, and other natural disasters last year, depressed ASC volume because centers temporarily shut their doors. While many ASCs have resumed operations, other factors are keeping them from reaching 100 percent capacity. Social distancing measures and lack of supplies force centers to lower their daily case volume. Unemployment in some areas will continue to challenge surgery centers, as patients don’t have access to insurance or necessary funds to undergo elective surgery. ASCs will need to find new ways to boost case volume, through facility expansion, adding services, employer partnerships or accepting alternative payment plans. Read more