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2 6 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • F E B R U A R Y 2 0 2 1 The specialized, collaborative nature of providing cardiac services requires high levels of knowledge, training and experience. As such, it's not the type of discipline you can simply assign to existing staff. "It doesn't really translate," says Ms. Bemis. "You can't cross train OR nurses and make them cardiology nurses. There is an extensive amount of added training required, and you want someone with a good deal of experience." And, of course, you'll need physicians. "You want to work with committed cardiologists who are will- ing to bring appropriate outpatient cases to your facility," says Ms. Bemis. Her ASCs attract cardiolo- gists by providing familiar environments that give them confidence they can do their work in an out- patient setting. "We set up our ASCs to look exactly like a cath lab in a hospital — the same emergency equipment, the same supplies," she says. "We want- ed to make sure our physicians knew they had everything they needed." Which model will you use? For regulatory reasons, starting a cardiac ASC in most states requires choosing one of two less-than- palatable models: co-management or hybrid. Under the co-management model, an ASC contracts with a cardiovascular medical group to develop, imple- ment and manage a program within the facility. Under the hybrid model, an office-based laboratory (OBL) — essentially an office-based ver- sion of cath labs found in hospitals — is co-located within the ASC facility. In the mid-2000s, CMS allowed peripher- al artery disease (PAD) procedures, which had been restricted to hospitals, to be per- formed in doctors' offices, resulting in a sig- nificant shift of these procedures to OBLs. Essentially, OBLs can perform and be reim- bursed for certain procedures that ASCs can't. "They're two different facilities oper- ating in the same space, but on different days of the week," says Ms. Bemis. "This model allows patients to have access to any of the outpatient procedures in a safe, high- quality and convenient outpatient setting." Most current discussion is focused on the hybrid model, but it's a highly complex proposi- tion. A hybrid facility must alternate as an OBL or an ASC on different days, or at different times of the same day provided all OBL patients have exited the building before it's used as an ASC. Each must main- tain separate tax IDs and National Provider Identification (NPI) numbers, medical records can't be accessed by the other and each bill at different rates for the same procedures. The ASC receives facility fees and only performs CMS-approved proce- dures, while the OBL receives enhanced professional fees for the physician and the expense of doing the procedure in the OBL. That's not all: The two entities must remain dis- tinct within the shared space. "In some states, you can operate as co-located providers sharing space at the same time," says Mr. Yood. "Patients for both would walk in the front door and, depending upon the services provided, go to one space or the other. Some states might allow the two providers to share common areas, but not clinical areas." Rules vary in terms of how patients and staff can physically move between the entities. "It can get as detailed as a requirement that a nurse helping with the provision of cardiac catheterization services has to wear a name badge that indicates the name of the OBL, but if they go to help out in the surgery center, they need to change their name badge so it reflects the name of the ASC," says Mr. Yood. "It's just this whole morass. Maintaining that separation is really hard." HEARTS AND MINDS Cardiac ORs are highly specialized environments that require collaboration among teams of skilled doctors, nurses and radiologists.