Use Research to Drive ASC Advocacy

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Use Research to Drive ASC Advocacy

Several studies find that patient outcomes at surgery centers are equal to or better than other sites of service

Facts- and data-based studies that show ASCs provide high-quality and low-cost care make for a powerful tool to educate legislators.

For example, in September, 60 ASCA members from 15 different states participated in ASCA’s National Advocacy Day. Participants met with representatives from 164 US Congressional offices, educating legislators and their staffs about the ASC community and securing support for ASC-focused legislation. Research can be instrumental in meetings such as these, giving legislators academic and clinical support for ASCs as a high-quality, low-cost site of service.

The studies below back up ASCA’s claims. ASCA’s Advancing Surgical Care site also offers a fact sheet on common procedures in your state and savings due to ASCs, as well as a list of regularly updated ASC-focused research.

Procedure-Focused Study

The most common form of research examines at a single procedure or type of procedure and reviews its outcomes, such as safety, efficacy and patient satisfaction. This can allow the research to glean information about patient selection protocols, site of service recommendations or general procedure quality metrics.

Outpatient and Inpatient Single-level Cervical Total Disc Replacement: A Comparison of 30-day Outcomes

Published in SPINE, January 2019

This study from a research team at the Emory University Department of Orthopedic Surgery looked at patients who underwent one kind of surgery: single-level cervical total disc replacement (TDR) surgery. The study authors then compared 30-day postoperative outcomes such as complication rate and reoperation rate between those patients who were treated as outpatients and those who were treated on an inpatient basis. The authors found no difference in any of the 30-day measures and offered the study as support that TDR can be performed safely in outpatient settings.

How it impacts ASC advocacy: As technology and surgical technique advance, complex procedures will shift from the inpatient to outpatient space. In regard to spine procedures specifically, evidence suggests that the volume of spinal procedures has grown drastically since 1990, likely the result of an aging population overall. The proportion of such surgeries performed as outpatient has grown significantly as well due to the development of better, minimally invasive surgical techniques. While this migration is encouraging for the outpatient surgery sector, patient safety must remain paramount. The proliferation of research showing safe performance of outpatient spine procedures has directly translated to the Centers for Medicare & Medicaid Services (CMS) reimbursing for more of these procedures in hospital outpatient departments (HOPD) and ASCs.

Site-of-Service-Focused Study

A less common but more useful category of study examines outcomes at ASCs specifically in an effort to reach conclusions about the ASC as a site of service rather than the procedure itself. The following example is especially pertinent, with CMS proposing to take total hip arthroplasty (THA) off the Medicare Inpatient-Only (IPO) list in the CY 2020 OPPS/ASC Proposed Payment Rule:

Outpatient Total Hip Arthroplasty Performed at an Ambulatory Surgery Center versus Hospital Outpatient Setting: Complications, Revisions, and Readmissions

Published in The Journal of Arthroplasty, July 2019

This study looked at almost 1,000 outpatient THA episodes performed by two surgeons from 2013 to 2018, with more than 300 THAs performed in an ASC and the remaining 600 performed in the HOPD. The authors state that to their knowledge it is the first study to directly compare safety profiles of patients undergoing outpatient THA in a freestanding ASC versus HOPD. However, it is important to note that the authors did not match underlying patient comorbidities and even acknowledge that ASC patients were younger and healthier (possibly due to patients over 65 being ineligible due to lack of Medicare reimbursement). The authors found no difference in 90-day complications, revisions, reoperation, readmission or emergency department (ED) visits and conclude that with appropriate patient selection protocols, THA can be safely performed on an outpatient basis at ASCs.

How it impacts ASC advocacy: As previously mentioned, CMS proposed that THA be removed from Medicare’s IPO payment list in 2020. Although this will not make the procedure eligible for reimbursement for Medicare patients in ASCs, it is the first step on that path by allowing for reimbursement in other outpatient sites of service. Although many ASCs have been performing total joint replacements and similar complex orthopedic procedures for years, CMS still does not pay for it in the ASC setting. Advocacy to CMS in support of moving complex surgical procedures to the ASC space must definitively show patient outcomes at ASCs are equal to or better than other sites of service. A study such as this one shows that surgeons are already performing THA in ASCs with no adverse outcomes, and that proper patient selection protocols make the procedure a good candidate for ASC payment by Medicare.

Cost-Focused Study

The final type of research study that can be instrumental as an advocacy tool looks at cost rather than clinical outcomes.

Medicare Cost Savings Tied to Ambulatory Surgery Centers

University of California-Berkeley, September 2013

This study, commissioned by ASCA and performed by researchers at the University of California-Berkeley’s Nicholas C. Petris Center on Health Care Markets and Consumer Welfare, examined ASCs cost-saving effects on the Medicare program. Researchers focused on the 120 procedures most commonly performed in ASCs, which represented almost three quarters of total procedure volume in 2011. They found significant single year savings for a number of high-volume procedures, including $829 million saved by Medicare on cataract surgery alone in 2011. In total, from 2008 to 2011, the lower reimbursement for procedures performed at ASCs as compared to HOPDs and physician offices saved Medicare and its beneficiaries $7.5 billion. However, these savings could be greater if not for the growing disparity between ASC and HOPD payments and the slowed migration of even the most common, safe outpatient procedures. At the time, the authors projected that possible Medicare savings due to ASCs could exceed $50 billion over 10 years, a goal that has likely not been achieved due to federal payment policies.

How it impacts ASC advocacy: Research such as this study show that ASCs have an incredibly strong case to make as preferred sites of service for eligible outpatient surgeries in the Medicare program. ASCs should have seen greater migration of baseline procedures such as cataract surgery and colonoscopies, procedures that have been proven many times over to be very safe and very cost-effective to perform in an ASC. Leveraging cost research might be the most powerful tool to show lawmakers and regulators the untapped savings potential of ASCs for public payers.

For more information on accumulated research on ASCs write Alex Taira, ASCA’s regulatory policy and research manager.