Cardiovascular at ASCs–The Next Frontier

Opinion

The trend of surgeries migrating from in-patient hospital settings to free-standing Ambulatory Surgery Centers (ASCs) continue to accelerate with cardiovascular procedures being the latest in the growing list of surgeries approved by CMS (Center for Medicare & Medicaid Services) and followed by most commercial insurers. The reasons are technology, cost savings and payers’ willingness to reimburse. Advanced and complicated cases can be done at ASCs because of significant improvements in technology and surgical techniques, superior instrumentation and patient monitoring. Examples include total knee replacement to spinal fusion. It is, therefore, only natural that low-risk cardiovascular cases would follow. Cost management is currently a driving factor in all aspects of healthcare and surgeries are an important cost and revenue source for healthcare providers. Most empirical studies show that the cost differential between surgeries done at in-patient settings and ASC settings are more than 50%. Large commercial payers like Blue Cross Blue Shield (BCBS) and United Healthcare have begun to influence and encourage the shift to lower cost ASC settings. Lower costs enable the insurance companies to be competitive and keep the insurance premium low for their clients/employers. In some locations, it is not unusual for commercial insurance carriers like United Healthcare to co-own ASCs in partnership with surgeons or even hospitals. Cardiovascular procedures which are currently being done or being considered by pioneering ASCs include-coronary interventions, heart catheterizations, peripheral vascular interventions as well as defibrillator and pacemaker implants.

It should be also noted that accreditation entities like Joint Commission and State Licensing authorities are developing new standards and closely monitoring cardiovascular surgeries at ASCs. Transfer agreements with hospitals and their proximity to ASCs are also becoming important factors. ASCs offer an important incentive for surgeons. Surgeons, under “safe harbor” provisions, can become shareholders at ASCs and thereby participate in profit distribution. This opportunity for doctors translates into the migration of surgeries, revenue and profits from hospitals to ASCs. Hospitals are left with high-risk patients with more complications and in many cases with limited or no insurance. However, hospitals have leverage over the doctors. An increasing number of doctors are employed by hospitals and the employer-hospital can dictate where they perform surgeries. Independent cardiovascular surgeons or groups need hospital privileges and access to in-patient hospital operating rooms with more comprehensive support services.

From the patient perspective ASCs are ideal locations. They are usually located in easily accessible locations and patient processing is fast with less paperwork. Surgeons usually operate on time and have no fear of being bumped from their schedules to accommodate emergencies. The infection rate at ASCs is also significantly lower than hospitals. The ideal model for successful ASCs which accommodate the needs of all constituents is a three-way partnership among physician-surgeons, hospitals and management companies who specialize in surgery center management. In such a model physicians have significant input in selection of equipment and supplies, hospitals continue to be aligned with new healthcare delivery paradigm and management companies can act without being encumbered by the less efficient hospital management process. An example of specialty management companies is National Car diovascular Partners, who co-own and operate 25 ASCs throughout the United States. As healthcare progresses towards more evidence- based, data driven metrics, it is guaranteed that CMS will continue to broaden the list of approved procedures to include stent procedures, vein bypass grafts or even heart valve repairs or replacements.

Keywords:

Ambulatory Surgery Center Association (ASCA), Office of Inspector General (OIC) and Center for Disease Control (CDC)

Acknowledgements

None.

Conflict of Interest

None