Cardiology has been at the center of the most recent wave of procedures approved for the outpatient setting by CMS – but the widespread adoption of these procedures in ASCs hinges on affordability and feasibility.
Supply and device costs — especially for disposables — can make margins especially thin for these procedures.
“In the peripheral vascular and EP space, the revenue numbers can look high, but the costs are substantial,” Amanda Ryan, DO, an interventional cardiologist and CEO of Advanced Heart and Vascular Center of New Mexico, told Becker’s. “You can find yourself in the negative on a case very quickly if anything goes beyond routine. Even with standard equipment, you’re looking at profit margins around 15% — which is workable, but slim.”
Ian Woollett, MD, an electrophysiologist with Norfolk, Va.-based Sentara Medical Group told Becker’s that has been building a workflow he expects the rest of cardiology will eventually need: a way to perform atrial fibrillation ablations without intracardiac echocardiography, or ICE, the imaging catheter that has been the U.S. standard for nearly 20 years.
ICE catheters are disposable, single-use devices that typically cost $2,000 to $3,500 per case. In most of Europe and much of the rest of the world, cost-constrained health systems have avoided ICE altogether, relying on fluoroscopy instead — an approach many U.S. physicians, Dr. Woollett included, are not comfortable with. His workflow instead replaces the disposable catheter with a reusable form of echo imaging. In the U.S., Dr. Woollett said hospital margins on EP procedures have historically been wide enough that physicians rarely had to think about the cost of the tools they were using.
“We’ve kind of been sheltered from the direct effects of costs, because a lot of us work in hospital systems, and the margins for EP procedures have been so big, they’ve kind of been willing to eat the cost, and we’ve been blind to it,” Dr. Woollett said.
That blindness is what led him to build and test a workflow that swaps ICE for transesophageal echocardiography, or TEE, a reusable probe that is cleaned and reused for three to five years rather than discarded after a single case.
“The per case cost comes down to dollars, as opposed to four figures,” Dr. Woollett said.
A recent feasibility study he contributed to included 128 consecutive procedures undergoing afib ablation — a mix of redo and first-time procedures, some with concomitant Watchman/LAAO implants — performed entirely under real-time TEE guidance without opening a single ICE catheter. (A small number of patients underwent more than one procedure and appear twice in that count.) The study recorded a 100% acute success rate, defined as completing the intended lesion set, and a 95% (18 of 19) Watchman/LAAO implant success rate, with no major complications, including vascular, esophageal or stroke-related events.
Dr. Woollett said fluoroscopy times in the initial rollout were comparable to those in published ICE literature, though not remarkable. Since then, with roughly 230 cases now done clinically, his fluoroscopy time typically runs one to two minutes, reflecting a steep learning curve in how to visualize the pulmonary veins with an imaging tool that lacks much published guidance for that purpose.
The workflow also appears to reduce the field’s most common complication. Vascular access issues — not stroke or other rarer events — are the leading cause of complications in afib ablation, Dr. Woollett said, and ICE requires its own dedicated vascular access separate from the ablation catheters. About 80% of the TEE-guided procedures in the study were completed with a single access sheath instead of two, three or four.
“We didn’t have any vascular complications in that, but just mechanistically, if you stick less sheaths in the veins, you’re likely to have less vascular access complications as well,” Dr. Woollett said.
CMS approved afib ablation for the ASC setting in January, and Medicare’s average ASC payment for the procedure runs around $20,250 — meaning a single ICE catheter can account for 10% to 12% of the Medicare facility payment before any other expense, Dr. Woollett said. He noted that math becomes unavoidable once a physician is the one signing the check.
“Everything you’re using now in the hospital, and that the hospital is paying the bills for — if you had to take out your checkbook and write a personal check for that piece of equipment every day for every case, would you still consider it essential, or would you not?” Dr. Woollett said. “For some things the answer is clearly yes, and for some things the answer is maybe there’s other ways to do it.”
He put the savings in daily terms: “If you’re doing five afib ablations a day and you’re saving $2,000 on each of them, that adds up pretty quickly.”
Dr. Woollett is not currently practicing in an ASC — he described himself as “ASC aspirational,” hopeful his hospital system will move in that direction. That timing, he said, was deliberate. Building and validating the ICE-free workflow now, while he is still a salaried hospital employee with no financial stake in the outcome, was the only way he felt he could adopt it without the change looking self-interested later.
“I don’t want to move to an ASC and suddenly start changing how I’m practicing because suddenly I have skin in the game. That’s a hard thing for me personally to defend ethically — and probably legally,” Dr. Woollett said.
“It’s important to consider using the hospital as where you experiment with new workflows, so that you can legitimately say you’re doing this because you think it’s equivalent or better patient care, regardless of whether you have any personal skin in the game,” he said.
The workflow requires a second set of hands to drive the TEE probe — in Dr. Woollett’s case, a physician assistant he trained and works under his direct supervision, a model he compared to a surgical assistant operating a laparoscopic camera at a surgeon’s direction. He was careful to frame it as one option among several, noting that imaging cardiologists, cardiac anesthesiologists and trained echo technicians have filled the same role elsewhere, and that scope-of-practice rules vary by state.
Dr. Woollett’s timing also lands alongside a broader shift in Medicare payment policy. CMS’s 2026 outpatient payment rule continued expanding the ASC covered procedures list and extending site-neutral payment policies between hospital outpatient departments and other settings, part of a multiyear push to move more procedures out of hospitals altogether. A 2027 proposed rule would extend site-neutral rates further. For EP specifically, Dr. Woollett said the arrival of ASC-eligible ablations makes the underlying cost structure of the procedure — ICE included — a live question for the first time.
“Again, I’m an employee model. I don’t get paid any differently right now whether I spend $10,000 or $15,000 on a case,” Dr. Woollett said. “But I think it’s important to set that precedent that what you’re doing, you’re doing it before you have skin in the game, so it’s defensible afterwards.”
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