This Week in Surgery Centers: Opening a Cardiovascular ASC

Ep. 94: Align Health – Opening a Cardiovascular ASC

Here’s what to expect on this week’s episode. 🎙️

Cardiovascular is one of the most discussed specialties right now, especially with reimbursement per case ranking second only to orthopedics. But with great opportunity comes unique challenges—feasibility, construction, staffing, technology, and so much more.

Three experts from Align – Chuck Brown, Nathan Martin, and Marc Toth – join us this week to discuss the nuances.

📈 Reimbursement Trends

• Cardiovascular procedures are seeing steady or increasing rates in ASCs, while office-based labs face reductions.

• Implants like pacemakers and ablation procedures are the revenue drivers, covering 75-80% of ASC income.

⚙️️ Unique Setup Requirements

• Specialized equipment such as fixed C-arms, hemodynamics systems, and mapping devices make CV tough to integrate with other specialties.

• Staffing needs are also unique – ICU or cath lab-trained nurses for high acuity post-op care is ideal.

💰 Cost Considerations

• Upfront CapEx can exceed $1M per room, but vendor agreements (e.g., capital lease programs) can help offset costs.

• Personal guarantees for financing are often required—something for physician partners to carefully consider.

💡 Feasibility is Critical

• Conduct thorough feasibility studies to align case types, volume, and costs.

• Location matters: Cardiovascular ASCs should prioritize proximity to hospitals for patient safety.

Listen to the full conversation on YouTube or your favorite podcast platform!

#ASC #SurgeryCenters #TWISC #Cardiovascular

Episode Transcript

[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.

We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.

Erica: Hi everyone. Here’s what you can expect on today’s episode. We’ve explored a lot of topics about opening an ASC, but today’s episode takes a deeper dive into something a little more specific, but very exciting. Joining us are three experts from Align ASC to talk about what it takes to open an ASC with a cardiovascular focus.

Erica: CV is one of the hottest specialties right now with reimbursement per case ranking second only to orthopedics. But with great opportunity comes unique challenges for sure. [00:01:00] Feasibility, construction, staffing, tech, and so much more. This was a really interesting conversation and I learned a ton myself, so I hope you all enjoy it.

Erica: In our news recap, we’ll cover ASCA’s latest survey regarding access to anesthesia, how AI models are being publicly ranked by health systems, the critical role of surgery centers during national emergencies, and of course, end the news segment with a positive story about a nurse who went above and beyond to help a family in need.

Erica: Hope everyone enjoys the episode and here’s what’s going on This Week in Surgery Centers.

Nick: Nathan, mark and Chuck, welcome to the show. Excited to have you guys on this week.

Marc: Thanks for having us.

Nick: As we jump in here, I was hoping to ask you a little bit about Align Health and your role in this ASC space. Can you tell us a little bit about Align and where you focus?

Chuck: Sure.

Chuck: We developed Align a couple years ago and we created the [00:02:00] company and the name Align to better align with the physicians in the market. We have a unique offering. We do not take equity. And we have a kind of a fixed fee approach to how we develop and manage surgery centers.

Nick: Fantastic. And within the cardio specialty area, there’s a ton of buzz right now.

Nick: I know you guys follow that closely. What’s going on right now with cardio in the ASC space and why is there so much? Interest and buzz around it.

Marc: Yeah, this is Mark. I can speak to that. I’ve been part of this cardio out migration trend for about the last 10 years. And if we rewind the clock and look at 2009, that’s when Medicare approved peripheral arterial disease or PAD cases in the office space setting.

Marc: Then around 2015, Medicare added pacemaker and device implants on the covered procedure list for surgery centers. And then really the watershed moment was 2020 when Medicare added a PCI, which is heart stenting. On the covered [00:03:00] procedure list for surgery centers. That was really the trigger to get us to this point today, where there’s this flurry of activity in CON states in non CON states.

Marc: With health system joint ventures with independent cardiology group with a bunch of private equity folks now buying cardiology Practices and then opening surgery centers for all their cardiology platforms. So really the buzz has been going on since 2009 I also work as an advocate and we pushed hard to get EP ablations Added to the covered procedure list for 2025.

Marc: Unfortunately we didn’t, but we have societal support from HRS, the heart rhythm society. So everyone is very optimistic that we’ll see that added to the covered procedure list in 2026. We’re also advocating for some structural heart procedures. One’s called the Watchman. It’s a left atrial appendage occlusion device and TAVRs, which are trans aortic valve replacement procedures.

Marc: To be added into the covered procedure list over the next three to five years. So we really think that [00:04:00] moment in 2020 with PCI changed the dynamics. And now, as I mentioned, from health systems to independence, we’re seeing a lot of activity.

Nick: Got it. And so that you hit on there, some great points on the covered procedure list and in case volume, what do you see is going on the reimbursement side of the house as it relates to these procedures and reimbursement rates and ASCs versus other settings?

Marc: I can talk a little bit about CV and then Chuck and Nate can dive in about other multi specialty centers. We’re seeing the rates in office based labs. Decline and the rates in surgery centers increase. For example, this PAD, these cases I mentioned that shifted in 2009, they’ve taken a consistent single, sometimes double digit reduction over the last few years.

Marc: While in surgery centers, we’ve seen the rates increase. We got about a 5 percent increase for 2020, 2025. So we really see Medicare is shifting cases. I don’t want to say away from the [00:05:00] outpatient center, but shifting them to the surgery center, whereas we all know they’re regulated. And accredited and they’re different than the office space lab.

Marc: So in that specific scenario, we’re seeing rates hold and maintain in the surgery center space. And I think we all know when cases first get approved, there’s usually that honeymoon period where rates stay the same, hopefully for five or six or eight years. We’re seeing not only maintaining, but growth in, in pacemaker implants.

Marc: In this in PCI and in those PAD cases. So things look good right now that can always change, but there are a couple of advocacy groups that are really active in in the lobby work for cardiovascular procedures in the surgery center. Fantastic.

Nick: And there’s a lot of discussion around cardio right now in the ASC world.

Nick: But when we zoom out and look at overall procedure volume within the ASC setting, cardio is still relatively low. Are there other procedures? You mentioned ablations earlier. Are there other procedures that you foresee, when they do get added to [00:06:00] the procedure list have the potential to really shift and drive?

Nick: Even more case volume.

Marc: So one thing to understand with cardiology is we’re at an inflection point right now where we’re losing cardiologists, they’re aging out. And yet the demand of patients is exploding.

Marc: So we’re really in a funky spot here in the next five to 10 years with access to care, just because of that dynamic, not enough doctors, too many patients. So how and where do we treat them? For ablations, for example, have about a six to eight week lead time to get a patient in. So we need, the health system needs some system to decant these hospital cath labs from their just continued explosive growth, and we can decant them to an efficient, easy to run, value based site of care, like a surgery center.

Marc: So that’s where I see the next five to 10 years being so optimistic and so positive for the cardiology space. Not enough doctors, too many patients. And cath labs are, [00:07:00] most of them are busting at the seams.

Nick: So there’s busting at the seams, there’s volumes that need to be absorbed elsewhere in an outpatient setting.

Nick: Do you see most of this volume or demand being absorbed by existing ASCs that may add on cardio as an area of focus? Or do you see more cardio specific ASCs being developed?

Marc: Yeah, it’s definitely the latter and for kind of three main reasons we believe and align and I know a lot of folks are aligned with us, no pun intended, that mixing cardio with other specialties has its issues, specifically net revenue per case.

Marc: Our net revenue per case is nearly 8000. And when we add ablations and watchmans, our net revenue per case is going to be north of 10, 000. So a big difference between a GI center. Secondly, staffing is different. Cath labs are unique. We have unique staff. We have unique recovery. We have unique equipment.

Marc: We need to equip each room with about a million dollars worth of imaging and software. So the other [00:08:00] specialties may not want to pay for that capital cost.

Nick: So you hit on, started to hit on some of the differences there with cardio and the requirements versus other specialties, talk a little bit about staffing, talked a little bit about equipment.

Nick: Can you expand on equipment? Cause that’s such a big one, right? And you mentioned it can be a million dollars to add some of this equipment that needs to go into a cardio focused ASCs. Tell me more about that and some of the equipment differences versus other specialty areas.

Nathan: I think from an IT perspective alone there’s so many different systems to weave together into a coherent Charred document. There’s the hemodynamics system is the key piece within the cardiovascular ASC getting all of that to tick and tie together with the electronic health record Is a trick and it requires a great deal of expertise.

Chuck: In the surgery centers like to say they are surgery centers, but they are nuanced and one of the big nuances in a surgery [00:09:00] Cardiovascular center is that fixed C arm and they can be for ceiling mounted. So you have to have engineering look at your weight support and your ceiling heights, et cetera.

Chuck: We’ll have a control room for each of those fix the arm rooms and uninterrupted power system. A few nuances that are different from a typical surgery center. We have a higher number of pre and post bays due to the higher utilization of radial access. You have higher turnover. And then we don’t have a huge need for sterile processing department in cardiovascular centers yet.

Nick: Great. Can you tell me more about staffing and the types of experience that you’re looking for when you’re looking to staff up? I would love to

Nathan: take this one. So my background comes in registered nursing, and one of the best types of nurses to have here is a great critical care nurse. This can come from the emergency department, ICU, cath lab.

Nathan: Someone who’s used to [00:10:00] managing these types of patients post procedure because If it would be equivalent to an ICU nurse versus a med surge nurse, they have different skill sets and different focuses. And so what we need is the ICU skill set to where if there’s a nine beat run of ventricular tachycardia in the PACU that the nurses don’t panic.

Nathan: They realize this is comes with the territory of interventional heart stuff, and let’s not all freak out. So staffing, like you said is critically important and hiring the right staff, I think is the most important thing.

Nick: Great. Do you look for people that have worked in a cath lab before?

Nathan: Absolutely. I think that’s the number one precursor for experience that we need to build on. And then in the pre op and recovery areas, the lab experience is important, but I think also intensive care and emergency department nurses can handle the groins, access sites.

Nathan: And then postoperative care needs from a hemodynamic standpoint, understanding what’s pre what [00:11:00] pressures are concerning, understanding what rhythms are concerning and which ones are par for the course after an ablation and which ones are somewhat normal.

Nick: What about implants with stinting procedures and types of procedures that are going on here?

Nick: How important do implants purchasing of implants? The tracking of the expense and the profitability impact of those implants. How did, how does that may be different than other specialty areas?

Marc: I don’t think logistically from a procurement standpoint, it’s much different We typically consign all of our implants and when we talk about implants, we talk about pacemakers AICDs and loop recorders So they’re consigned first of all and secondly just to illustrate they will drive those implant procedures We’ll drive 75 to 80 percent of the revenue in the surgery center.

Marc: So those are the Holy grail in a cardiovascular surgery center. We can do left heart [00:12:00] catheterizations all day long and a stent here and there. But really what pays the bills are those EP, those electrophysiology implants.

Nick: So let’s talk about purchasing differences that we should consider for cardio versus other specialty types. We’ve talked about upfront equipment charges and CapEx that go into these facilities.

Nick: How can Cardio Focus Centers think about purchasing an upfront CapEx that goes into this?

Nathan: Sure. One of the main things we look for are opportunities with these equipment vendors at the front end of the development project to see if there’s a way that they can Partner with the surgery center to really bring in the equipment on a capital lease program.

Nathan: And really the physicians work that off over time through use of a partnered implant company, say Abbott or Medtronic or. Any of them really Mark, do you care to elaborate on this as well? Any additional perspectives?

Marc: [00:13:00] No, that’s a good point. Reducing your capital spend with an agreement with one of these vendors makes a lot of sense.

Marc: And they’re all competing with each other. They all have a preferred imaging vendor. And what I’ve learned through the years is the imaging vendor is really not highly important to the physicians. Driving the best deal is so whether the imaging vendor is vendor a B or C, it doesn’t matter. It’s what does that contract look like?

Marc: They’re usually market share agreements. Or their total spend agreements and those companies that Nate mentioned earlier is cover the whole sphere of what we do. They cover the PAV cases. They cover the implant cases and they cover the cardiology cases for stents. So they’re making it really easy for us to to get capital equipment at no charge.

Nick: That’s good. So it sounds like you don’t find those agreements to be too limiting in terms of supplies you have access to.

Marc: Yeah, not at all. We would never sign. I think everybody on this listening to this podcast would agree. We wouldn’t sign 100 percent contract with any one vendor, but market share agreements are fine.

Marc: And as we look forward [00:14:00] to ablations, there’s a large capital expenditure for ablation procedures, more than a half a million dollars for mapping equipment. And the vendors that make the catheters for the ablation cases will also offer a no cap or a volume based agreement. As I said a second ago they’re making it pretty easy for us to save capital if we align with them.

Nick: So continue along the line of differences for cardio cardio procedures versus other procedures.

Nick: Want to touch on revenue cycle management and billing in particular, are there considerations for cardio facilities around how they do billing and revenue cycle that are maybe different than some other specialty areas.

Chuck: Yeah, I think, the reimbursement is larger. The expenses are higher.

Chuck: So there’s a lot at stake here. And I think the answer is find a partner that has the expertise that has done this before. That would be our best recommendation.

Nick: Great. Can you shift over here and talk about specifically, if that’s okay, you guys work with cardio centers. Tell me [00:15:00] some of the areas, cause we’ve just gone through all these differences and all these considerations for cardio facilities that are out there, the wave of cardio facilities that we anticipate in the years ahead from an aligned health perspective, where are the areas that you feel like you can.

Nick: work with cardio facilities and add the most value to everything that they’re working through and considering.

Chuck: I’ll start. I think the first thing that we do well is developing a feasibility study. We want to make sure that we’re doing all the right things, that we understand all the pretty big expenses.

Chuck: The lease, the facility, the equipment, all of those things have to really come together into a business plan that makes sense given the volume and the case types that we’re working with the physicians that are going to come work at the center.

Nathan: I think another, an additional area that, that is a hot, a bit of a hot topic right now is the personal guarantee. I think when, at least when. Chuck started developing centers. This was [00:16:00] not even a requirement for a lot of a lot of surgery centers. They would be guaranteed by the property itself at this point, any one of these centers is going to require a personal guarantee on the financing for the center.

Nathan: So that’s a big part of the feasibility study is helping. Helping the doctors really understand this. If they’re entering the market without a hospital partner, this is really going to be probably eight or 10 million of guarantee that they’re going to have to sign up for. And that’s oftentimes really important in the first first discussions is to have everyone get around that, rallied around that and understand what’s going to be required because without that, the project.

Chuck: And part of the feasibility study includes these are new cases, new new surgery centers, I should say, with physicians are moving cases to an outpatient setting that they haven’t done that before. And so really looking at, safety proximity to the hospital. These aren’t, GI cases where if you have a [00:17:00] perforation, you can take a case to the hospital and, time isn’t of the essence necessarily, but in the cardiovascular setting you’re working around the heart.

Chuck: And so you really need to do these a little bit differently, put a lot of effort into looking at, centers that are on or near hospital campuses. There are some states that require the ASC to be on the hospital campus for safety purposes. So I think that’s a really big of note to, I don’t know how to say it, to make sure that your ASC has safety first, especially when it comes to a cardiovascular ASC.

Nick: Great. Final question for you guys. We do this every week with our guests.

Nick: What’s one thing our listeners can do this week to improve their surgery centers?

Chuck: Yeah, I think a lot of surgery centers. In fact, most of it we evaluate do not have a line of sight into their accounting, tying their accounting to revenue, to volume, to really their patient accounting system. And we’re talking about budgeting properly, estimating revenue properly, accruing so that you can really see your expenses and revenue in the period.

Chuck: And you can [00:18:00] understand your business and how it reacts to the different levers that you pull. And so only then, if you’ve got all that tied together, can you truly know if you’re being efficient and optimizing your ROI.

Nathan: Great. Thank you guys so much for joining this week.

Chuck: Appreciate it. Thanks

Nathan: for having us.

 As always, it has been a busy week in healthcare, so let’s jump right in. In a recent 60 second survey by ASCA, surgery centers are seeing improvements in access to anesthesia services. The survey, which was conducted in October of 2024, gathered responses from 320 ASCs across 46 states. And here’s what stood out.

Erica: 70 percent of respondents reported adequate access to anesthesia providers. That’s an increase from 64 percent in 2023 and 56 percent in 2022. However, access did vary by facility size. So smaller surgery centers that had one to two [00:19:00] ORs fared better, with 81 percent reporting adequate access, while only 61 percent of larger facilities reported adequate access, and that was considered surgery centers with five or more ORs.

Erica: And when asked what the biggest challenges are, low supply of providers is no surprise the number one issue, while competition and low reimbursement rates also played major roles. What I found super interesting though is how the shift we’re seeing in smaller ASCs being able to bring their anesthesia services in house.

Erica: The majority of ASCs do still rely on contracted anesthesia providers 82 percent reported contracting this year, although that is slightly down from 86 percent last year. And there is, again, this trend toward in house staffing or smaller centers and physician owned facilities being able to bring everybody in house.

Erica: So for instance, 18 percent of small centers employed in house anesthesia providers in 2024 [00:20:00] compared to only 10 percent in 2023. And when it comes to financial incentives, only 30 percent of centers are currently offering assistance to attract anesthesia providers, which was down from 41 percent in 2023, which I think is a really great trend.

Erica: I know a lot of usually bringing services in house or kind of offering these. That was something that only large facilities or maybe JV facilities were previously able to do, but it seems like that tide is changing a little bit. And I know that finding reliable and fairly priced anesthesia services has been a growing concern.

Erica: So I think it’s really great and really, giving me some hope. And we’re seeing some positive shifts here where maybe, the effects after COVID, we’re starting to get back to that equilibrium. Yeah. And if you’re not familiar with ask a 60 second survey, they do them quarterly and they’re intended to obviously take under 60 seconds to complete.

Erica: And they’re only 10 questions. And personally, I [00:21:00] love the insight that they give us into the industry. So if you are able to participate in, it comes across your desk, please do. We really appreciate it. All right. Next story, Mass General Brigham, Emory Healthcare and other major health systems are teaming up to tackle a big question in healthcare, which AI tools are actually worth using.

Erica: Since chat GPTs debut in 2022 companies like Google, Microsoft, Amazon, and open AI have been flooding the market with generative AI tools. But for healthcare providers, figuring out which tools fit their needs has been pretty tricky. There’s really no standardized way to compare them. In an attempt to fix that, Mass General Brigham launched the Healthcare AI Challenge Collaborative.

Erica: This new initiative lets clinicians test and compare the latest AI models in simulated clinical settings. So think of it as, head to head competition with a public ranking or what they’re considered What they’re calling a [00:22:00] leaderboard and that public ranking should come out soon. It’s not public yet.

Erica: But the program is starting with nine models, including products from big players like Microsoft, Google, and Amazon. Clinicians will evaluate them on tasks like report generation, accuracy, and even how readable the output would be for patients. While accuracy is key, other factors like usability and style will weigh in depending on the tool’s purpose.

Erica: And what’s exciting is the potential for this leaderboard to level the playing field. So smaller health systems just may not have the resources to extensively vet tools, but they’ll be able to use these rankings to help them make informed decisions. And it’s really a great win. And if you think of it in terms of health equity, this will give everyone access to some of the best AI tech out there.

Erica: With heavyweights like the University of Washington and the American College of Radiology involved, this collaborative could set a new standard for evaluating AI in healthcare and we’ll [00:23:00] all benefit from that transparency. So I know I will certainly be keeping an eye on when these leaderboard results become public and I’ll be sure to share them with all of you as soon as they are.

Erica: Okay, let’s talk about national emergencies. So this is not a fun topic, but it is a necessary topic. So ASCs are stepping up as critical players in times of crisis. So as we know, during COVID 19, ASCs played a vital role relieving overwhelmed hospitals and handling essential procedures. This really highlighted ASCs as being a key part of a public health response, which pre COVID really wasn’t the case in every community.

Erica: So Jeffrey Flynn, who is the president of the New York State ASC Association, amongst many other impressive things, noted that during the pandemic, ASCs initially weren’t classified as essential facilities. However, advocacy efforts did help to redefine the surgery center’s role, allowing [00:24:00] them to perform stent replacements, cases that, if delayed, could have led to serious complications for patients. And as a natural extension of what shifted during COVID, disaster preparedness has become a growing focus. So ASCs have long supported health health systems and hospitals during hurricanes and supply shortages, but these crises have really exposed a bunch of vulnerabilities.

Erica: For example, Hurricane Helene caused an IV fluid shortage, forcing ASCs to postpone certain procedures. Operators like Scott Bergman emphasize the need for a national strategy that integrates ASCs into broader emergency responses. So what’s the takeaway? ASCs are more than just elective surgery centers.

Erica: They are a vital resource during emergencies. So make sure you connect with your local officials, fire departments, police departments, and other first responders. And make sure that you proactively have a plan in place and are part of a solution to help your community and just the broader healthcare [00:25:00] ecosystem when there is a time of need.

Erica: And to end our new segment on a positive note, This week’s nurse of the week is Heather Braden, an RN at Atrium Health Floyd Medical Center in Rome, Georgia. Heather stepped up when a single mother and her special needs daughter faced unimaginable challenges. After their home burned down, they were forced to leave a hotel and move into a mobile home, but they desperately needed a wheelchair ramp to make the transition possible.

Erica: Recognizing this urgent need, Heather and her husband Dana, who is a firefighter, work together to move the ramp to the family’s new home. This small but powerful act ensured the family could regain some sense of normalcy and dignity during an incredibly difficult time. For her selfless actions, Heather was honored with the Daisy Award, which celebrates extraordinary nurses who go above and beyond in patient care.

Erica: Sheila Bennett, a senior leader at Floyd, summed it up best.

Erica: Heather’s kindness didn’t just provide practical [00:26:00] help, it offered emotional support and hope. And Heather’s story is just a beautiful reminder of the profound impact nurses have on their communities, so a huge thank you to Heather and her husband Dana for helping out this family when they needed it most.

Erica: And that officially wraps up this week’s podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from. I hope you have a great day and we will see you again next week.