Acute Care Surgery Practice Boosted Hospital Income

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.