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ASCs + CMS: The good, the bad and the ugly

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ASCs are known as the high quality, low cost setting for surgical care, and CMS has taken notice.

The agency, along with commercial payers, have made some moves to direct more surgeries to ASCs, but have also developed new policies making it more difficult to perform certain procedures there.

At the Becker's Orthopedic, Spine + ASC Virtual Event Aug. 12, a panel discussed the payer landscape and what to expect in the future. Below is an excerpt from that conversation, edited lightly for clarity and length.

The good

Anthony Romeo, MD. Executive Vice President of the Musculoskeletal Institute of DuPage Medical Group (Downers Grove, Ill.): The good of the ambulatory surgery center is that it really asked us to focus directly on patient care for a specific set of diagnoses. The challenge in the hospitals is you have to be prepared to take care of everything. With the ambulatory surgery center, we have processes and identify indications and proper patients for the setting. We can really focus on delivering the highest level of care since we have the desire to let them go home. We have to make sure their perioperative status is in the best place.

Alok Sharan, MD. Director of Spine and Orthopedics at NJ Spine and Wellness (East Brunswick, N.J.): There is no doubt in my mind that ASCs are the future of medicine, but not quite in the shape that we're seeing it right now. The focus of the ASC is to take care of the patient and perhaps discharge them home the same day. But I think what you're going to see is a morphing of ASCs to more 23 or perhaps 40 hour stays. The reason I believe the ASC is the future is this: Regina Rosenberg wrote about the notion of focused factories. I'm a big believer in specialization. The orthopedic hospitals tend to be better than general hospitals. What we're seeing now is that there's a disaggregation where cases that were being done in orthopedic hospitals are now being done in hyper-focused ASCs.

We're seeing ASCs devoted just to joint replacement and sports medicine. In cardiology you're seeing a trend toward having just cardiac ASCs, and that is the same for kidney disease also. What you're going to see now are these focus factory ASCs where we'll have hyper-focused ASCs on doing total joints, spine and pain, and there will be one or two-room ASCs. They won't be big, but they're going to be more efficient because they're specialized and the team's experience will be better.

The Bad

Dr. Sharan: The bad, unfortunately, is like everything else. The pendulum never swings in the middle. There's always going to be an issue of safety going to the outpatient ASC. It's not as simple as a change of the site of service. At NJ Spine and Wellness, our motto is to get our patients better faster. When I'm bringing a patient to an outpatient procedure, it's not just deciding that we're going to do the case in the ASC versus the hospital, but it's getting the patients to do pre-hab, making sure their nutrition is optimized and looking at all the other factors so when the patient's arrive at the ASC, there's no question that they'll be able to go home the same day.

For me, the safety issue is not just simply steering the case in the best way, but really trying to optimize patients for an outpatient result.

Dr. Romeo: The real issue we have is developing an ecosystem of care between the hospital and the ASC. We need to have the hospital, which has a different environment than the physician-owned ASC. At the ASC, there is a personal level of care and a different process. We'd really like to standardize our care across the entire surgical ecosystem, which sometimes means a comanagement agreement.

The Ugly

Dr. Romeo: We're watching what the government is doing. Everybody is so excited about moving all these cases out of the hospital and into the ASC. Everyone knows the cost will be less, but because they know the costs are less, all of a sudden, our payers have dramatically reduced our reimbursement in the ASCs to the point where a Medicare joint replacement may not even be cost-neutral; you may actually lose money on that procedure if you don't do everything perfectly efficiently. The hospital still has an opportunity to generate a reasonable margin to continue their business [with Medicare total joint reimbursement]. The ugly is that we don't have proper alignment yet.

Dr. Sharan: The ugly part of ASCs is what's going on with the government right now in that there was a big shift in moving cases from the inpatient list to the outpatient list, and now many cases are going back on the inpatient list. When the government does this, it's really hard to plan. Reading the regulations makes you confused as well. At some point, what we have to do is decide which cases can be done safely outpatient.

Let's work on an iterative process to make that decision better, and not just say in two years that you can't do a procedure any longer, like ACDF in ASCs. The ugly part is that we haven't come to a reasonable business model in terms of government regulation on what should be considered outpatient cases.

Dr. Romeo: It's challenging when these factors from the government are changing, or they are alluding to significant changes back and forth. These are dramatic changes that are not affecting just a few cases, but hundreds of cases taken off the inpatient-only list that could go back on.

It's very hard to plan and you have to be able to understand what your caseload is going to be and your ability to grow. The practice is going to grow based on the eligibility within your market place, and when these kinds of shifts take place, it gets very hard to plan for the future.




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