Pediatric Specialty Care in ASCs Today: A Conversation with Michael Powers (July 5, 2022)




In this episode of the Advancing Surgical Care Podcast, ASCA Chief Executive Officer Bill Prentice talks with Michael Powers, administrator of Children’s West Surgery Center in Knoxville, Tennessee, about pediatric surgical care in the ASC setting. This highly informative discussion takes place in Dallas, Texas, following Powers’s presentation to attendees at ASCA 2022 and covers a wide range of clinical and operational issues. Topics Powers and Prentice consider include protocols for creating a child- and family-friendly clinical environment, the most common procedures performed for young children, strategies for successfully negotiating reimbursement rates and present and future trends in pediatric outpatient surgery.

Narrator: 0:06
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice: 0:37
Hello, and welcome to the Advancing Surgical Care Podcast brought to you by the Ambulatory Surgery Center Association, or ASCA. My name is Bill Prentice, I’m ASCA’s CEO and the host of this episode. My guest today is Michael Powers, the administrator of Children’s West Surgery Center, a pediatric ambulatory surgery center located in Knoxville, Tennessee. Michael has more than 35 years of healthcare experience with a strong focus on pediatric ambulatory surgery care. He’s also the president of the Tennessee Ambulatory Surgery Center Association Board of Directors and the author of several studies and professional publications relating to pediatric surgery center administration. Michael and I are recording the podcast today at the ASCA conference and expo in Dallas, Texas, where he was a presenter on the opportunities and challenges of performing outpatient surgeries and procedures on pediatric patients. We’ve covered a lot of topics on this podcast over the past three years, but Michael is our first guest to join us for a conversation focused on pediatric ambulatory care and we’re pleased to have him with us. Michael, welcome to the ASC podcast.

Michael Powers: 1:38
Thank you so much. I’m excited to be here.

Bill Prentice: 1:40
Great. Over the last couple of years, we’ve had a lot of guests on to talk about the most common adult outpatient procedures, but this is our first one that focuses exclusively on pediatric procedures, as I mentioned. So in addition to thanking you for participating in our annual meeting here in Dallas this week, I’m especially grateful to have you with us to introduce the topic of pediatric surgeries and procedures in the ambulatory surgery center setting. As a starting place, can you take me and our listeners through some of the most fundamental differences between preparing, admitting and treating an outpatient pediatric patient, as opposed to an adult who might be seen for similar or comparable procedures?

Michael Powers: 2:17
A lot of the initial things are going to be the same, if you think about registration, prepping, medical screening. But I think the distinct difference is going to be when you’re medical screening a child, there are a lot of other things that you’re looking for. We have a very involved anesthesia group that has prepared anesthesia guidelines for us and looking at reasons of why a patient would or would not be a good admission for an ambulatory surgery center. One of the things that’s unique about us is that we’re 16 miles from the closest hospital. So, a lot of pediatric ASCs or outpatient departments are actually on hospital campuses, and we’re not, so we’re very careful in that selection. And I think the other thing, too, is we have engaged our physician referrals. We prepared a very detailed, little trifold brochure that sort of talks about what to expect, what to bring, let them know it’s okay to bring their favorite stuffed toy or their favorite stuffed blanket and give them an idea. And we even encourage and offer tours, especially prepandemic, that they can come and they can actually walk through our facility and see what it’s going to be like to try to lessen the fear.

Bill Prentice: 3:31
And I imagine that process has to be kind of twofold. You have to do it for the child, obviously, to make sure he or she is comfortable, but also the parents. I mean, they probably have their own concerns about where they’re bringing their child. So, I guess you have to communicate to both those audiences to make sure that they’re comfortable.

Michael Powers: 3:46
That is correct. And in fact, I think that’s another one of the very distinct differences between us is we all love our moms and dads, we all love our spouses or partners and etc., but it seems like we all have a very heavy attachment to our children or grandchildren. And so that even, we see it all the time of releasing their child to go with that nurse back through those doors into the restricted OR hallway, a lot of them have a very difficult time letting go. And so all that we can do to prepare them besides giving some medication to relax the child to help prevent so much of the separation anxiety. We have some nurses who love to sing and they’ll sing Frozen and they’ll sing other songs, and it’s really fun and we try to make it fun, but yet be very intentional in what we’re trying to accomplish.

Bill Prentice: 4:39
But no medication to calm down the parents or grandparents, right?

Michael Powers: 4:43
Unfortunately, not.

Bill Prentice: 4:44
In the presentation you gave this week, you gave a statistical overview of the most common procedures that are performed at Children’s West Surgery Center, and it was clear you perform far more ear, nose and throat surgeries and procedures than any other type of specialty. Is that because of the way your center is staffed, or is it indicative of the elective pediatric surgeries you see in general?

Michael Powers: 5:06
I think it’s more the way that we’re designed. I did a little research and looking, and I think it’s going to be from region to region how things are set up. ENT is, we have more investors that are ENT, who do pediatric only, and what we have found over the last few years is our ENT physicians have been taking more market share in our area. They love coming to an ASC and, honestly, they come for two reasons. One is they’re investors, so every case that they can bring there, not only will they get the surgical fee, but also they’ll get the profit from the bottom line. But the other thing is in an ASC, as you well know, we’re very efficient, quick turnovers, and they can do three times the amount of cases in one day than they can in a hospital setting, an outpatient setting.

Bill Prentice: 5:56
And I imagine over time, word of mouth amongst the patient population, those parents out there talk to each other and know, hey, this is the place to go to get this care, they did a great job with my child. That probably is also a factor, I would imagine.

Michael Powers: 6:08
It is a factor. And the other thing, too, is we’re surprised that they’ll have siblings, and sometimes they’ll come maybe at a one-month-old urology for a circumcision or circumcision revision. And so, urology is our second largest specialty that we have provided. But then you know, they have a three-year-old and they may need their tonsils taken out. So, they had such a great experience, we do see a lot of repeat patients coming back for different procedures.

Bill Prentice: 6:37
That’s great. Well, before we continue, I’m going to ask that we take a short pause to hear a quick word from our podcast sponsor. We’ll be right back.

Narrator: 6:48
This episode of the Advancing Surgical Care Podcast is being brought to you by National Medical Billing Services, an ASCA affiliate and leading ASC revenue cycle company that helps ASCs properly capture their revenue and maximize their cash flow in a highly compliant fashion. To learn more about National Medical Billing Services’ wide range of revenue cycle services and analytics, visit

Bill Prentice: 7:18
Michael, before the break, we were talking about your presentation this week at the ASCA conference. And another statistic that stood out for me was your overall payer mix that showed that Medicaid from several states accounted for about half of your revenue. That’s not a statistic that you typically see in a private or public healthcare facility. And now I’m curious, and I’m sure that our listeners would be as well, to learn how that came about and what, if any, special considerations are required to serve that large of a percentage of Medicaid patients? And last, but certainly not least, I’d be interested to know how your Medicaid reimbursement compares to your commercial insurance reimbursement.

Michael Powers: 7:54
Sure. First and foremost is I think you’d look at Tennessee and they began one of the earlier initiatives of TennCare, where they built a program with the actual federal Medicaid to do I think a dollar-to-dollar and trying to work through that. So, they spearheaded that many, many, many years ago. Currently, in the state of Tennessee, there are four different payers that are on the Medicaid, if you will, program: Amerigroup, TennCare Select, BlueCare, which is a BlueCross product, and United Healthcare TennCare, which is a United Healthcare product. And what we have found starting back in about 2014, there was a salient increase in our Medicaid population. But again, that sort of mirrors statistically what’s happening in the state of Tennessee when it comes to kids, and the healthcare coverage that they have. So, we are not selective or trying to prevent children who need outpatient surgery based upon what their payer mix says. But one of the things that I did early on is, since we are unique and different, is I prepared a little informational sheet, if you will, about us and why we’re different and what we do. And then I invited every one of our major payers to come into our facility to talk about who we are and what we do. I mean, honestly, when it comes to pediatrics and you’re looking at a United or a BlueCross, that’s small potatoes overall of what they do, and at the end of the day we would ask for fee increases. And across the board, I think all but one said yes. And so, we build that relationship with them. And so, every three to four years at the end of the term, we go back and we sort of negotiate, and most of the time it’s the same representative you’re working with. But if that representative changes, then we try to get them back into the door to get them familiar with us and that has been quite successful. So, even though you mentioned there are lots of different Medicaid, we do have Kentucky and Virginia but it’s like 0.1 percent of our business, the volume is very, very low and that's specifically only because of one surgeon who is a urologist, pediatric urologist, who is excellent. And he pulls some of the local, bordering states into our facility because of that. But if you look at the others, by volume, BlueCare and United TennCare are our two largest Medicaid.

Bill Prentice: 10:33
That is not what I normally hear in other states, so that’s great. And then obviously, I think you’ve kind of cracked the code on how to develop that relationship with those payers in a way that’s good for you, good for the patients and good for the payer. So, kudos.

Michael Powers: 10:49
Yes, we’ve been watching it very closely and within all that. And the other part, too, is, again, it’s a mixture of payer mix and surgical mix, right?

Bill Prentice: 10:58

Michael Powers: 10:59
And how that all works out.

Bill Prentice: 11:01
Well, let’s talk about present and future trends. On the adult level, we know with some certainty that the demand for outpatient surgeries and procedures are expected to grow across the board, simply because we are living longer and leading more active lives and wearing out our body parts. What can you tell us about the trend lines in children’s health and the incidence of disease amongst younger people and how that might affect future demand for more surgery and more procedures?

Michael Powers: 11:26
That is probably the question that I’ve looked at that’s probably the most difficult one to answer. I think it’s going to be regional specific. And I live across the country, and especially in our area of Knoxville, the birth rate is slightly down compared to previous years. And I’m not really seeing for the things that would be an outpatient procedure, a lot of incidence of that growing. And so, it’s sort of, I think, the opportunity for growth is really through taking market share.

Bill Prentice: 11:58
So, you don’t see, for example, I’ve seen reports of increases in childhood obesity, for example, over the last couple of decades. Does that have any impact, do you think, on your patient volume, or what you might be able to do in your facility?

Michael Powers: 12:10
Actually, obesity, based upon how obese a patient is, would actually make them not be a good candidate for an outpatient surgery.

Bill Prentice: 12:19
Of course, yes, because that gets back to the ASA rating.

Michael Powers: 12:22
Exactly. So, we do ones and twos, and very few threes, and a lot of those will fall into an ASA of three. And it’s safer and it’s best care for them to be in that hospital setting.

Bill Prentice: 12:32
Right. And that’s obviously the key characteristic of the ASC model is patient selection, and using that criteria to make sure that you’re only seeing the patients that really belong there. And I guess that applies just as much for children as adults.

Michael Powers: 12:44
It does. And one of the things that we’re very proud of is, prepandemic, we have three OR rooms for us, a small facility, but because of what we do and our efficiencies and turnover times, we did about 5,600 cases, and we only transferred two patients for observation.

Bill Prentice: 13:02
Yes, well, that’s a great point, because it’s one of the things that has bothered me for years in terms of our quality reporting is the idea that a hospital transfer is an adverse event measure. And it’s really not because oftentimes, it’s you finding the patients as they are walking in and in doing your preop checkup, identifying something that was a warning that maybe this patient should be seen in the emergency room or over at the hospital and not your facility.

Michael Powers: 13:27
And sometimes you catch those on the front end. Unfortunately, I mean, so much energy is spent around for our success is contract negotiations, is working every day, the OR schedule for efficiencies, removing gaps.

Bill Prentice: 13:44

Michael Powers: 13:45
Make sure block utilization that takes place. But when it comes from a safety perspective and to ensuring that we do have a good day is that patient selection and that medical screening is pivotal. And so, we have a lot of resources around that part.

Bill Prentice: 14:01
And that’s great to hear. Well, listen, Michael, this has been really interesting and informative, and I’m sure our listeners are going to really enjoy hearing about the model that you’ve created in Tennessee. And I want to thank you for being on the podcast.

Michael Powers: 14:12
It’s my pleasure. Thanks for asking me.

Bill Prentice: 14:14
Great. So before concluding, I’d also like to once again thank our podcast sponsor, National Medical, an ASCA affiliate and leading ASC revenue cycle company. To learn more, visit