OR Manager - December 2020 - 30

AmbulAtory
Surgery CenterS
Continued from page 29
Brianna
Motley
The story differs
considerably by service
line (sidebar, " 2019
Procedure Volume by
Service Line " ). Most
of the anticipated outpatient
growth over the
next decade will occur
in services such as orthopedics
(25%), followed by ophthalmology
(23%), GI (18%), and pain management
(10%).
Ever since CMS added total hip arthroplasty
and total knee arthroplasty to
its list of outpatient procedures, growth
in total joint arthroplasty has surged.
For 2021, CMS's Outpatient Proposed
Payment Rule includes another 266
orthopedic procedures that may be removed
from the inpatient-only list. Sg2
forecasts 78% growth in total knee and
total hip replacements over the next
decade.
For general surgery, the shift toward
antibiotic management for appendectomies
may preclude the need for emergency
general surgery in a hospital, and
minimally invasive approaches for cholecystectomy
and hernia repair may make
it more feasible to perform these procedures
in ASCs.
For OB/GYN, the outpatient shuffle
includes procedures being done in
physicians' offices. Currently about a
fifth of all hysteroscopy and endometrial
ablation occurs in the office, partly
because vendors facilitate the process
by setting up the rooms. Sg2 projects
that 98% of pelvic floor procedures will
be outpatient within the next decade
and expects to see greater interest in
urogynecologist-owned ASCs as well as
accelerated adoption of more minimally
invasive approaches.
For ENT, 55% of outpatient procedures
have shifted to physicians' offices
and only 17% to ASCs, but a large
proportion of those ASC procedures are
single commodity procedures such as
Eustachian tube placement or removal.
Sg2 anticipates that some of those procedures
and other sinus/endoscopy
procedures will shift to the office.
Many HOPDs continue to garner
higher facility fees with grandfathered
payment accommodations, which puts
strong, if temporary, financial brakes
on the continued outpatient shuffle,
according to Sg2. Perhaps the best example
of this is in GI, where about 35%
of colonoscopies are being performed
in HOPDs, yet many of those cases
are ASC-eligible. Sg2 anticipates a 23%
growth in ophthalmology and 18% in
GI/endoscopy over the next decade.
Whereas 79% of ophthalmology procedures
are for Medicare patients, 48% of
GI/endoscopy procedures are for commercial
patients.
" Follow local payment action to
predict further outpatient shuffle-the
story will be market specific and subject
to local politics, " says Guth (sidebar,
" 2019 Procedure Location Mix " ).
Sg2 says as smaller ASCs continue
to face COVID-19 headwinds, a key
strategy is physician engagement in developing
these subspecialty programs.
First, consider ownership arrangements
where physicians will practice. For example,
some cases will tend to stay in
HOPDs because some surgeons prefer
to co-locate their inpatient and outpatient
procedures. Indeed, there is still
a significant volume (10% to 20%) of
high-acuity cases. But physicians who
are well versed in minimally invasive
techniques may be more comfortable
with taking cases off campus.
As COVID-19 has limited procedural
activity across the country, emphasis
has shifted from capital expenditures
for new technological investments to
maintenance costs for upkeep of equipment
already in ASCs and offices. New
types of clean infrastructure and new
lab requirements, such as COVID-19
testing for patients and staff, will further
challenge ASCs for the foreseeable
future.
" We encourage hospitals to extend a
helping hand to ASCs in need of assistance-as
we fight the COVID-19 battle
together, we know unconventional relationships
forged in a crisis will extend
in mutually beneficial ways into the future, "
notes Motley.
Cardiovascular procedures
In 2019, CMS's inclusion of " surgerylike
procedures " added cardiac catheterization
and coronary interventional
procedures to the approved list, and
in 2020, the addition of certain angioplasty
and stenting procedures further
expanded the range of cardiovascular
services that may be performed in ASCs
or officed-based labs (OBLs).
In a recent migration risk assessment
case study, leaders from ECG
Management Consultants, Seattle,
looked at more than 2,300 cardiac
cases done in an HOPD and assessed
which ones could potentially move to an
ASC and when. They identified that 66%
of cases were ASC eligible, and it was
projected that 77% are at risk to shift
30
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