CMS’ decision to phase out the inpatient-only list could reshape how surgery itself is approached. However, according to two orthopedic and spine surgeons who have built their careers around the shift to outpatient surgery, eliminating the list does not have to compromise patient safety or eliminate inpatient procedures — as long as physicians, rather than administrators or private equity firms, decide which cases are appropriate for each setting.
Benjamin Stein, MD, an orthopedic surgeon who owns an ASC company in the Washington, D.C., area, said that although technological advances have expanded what can be performed in an outpatient setting, they have not eliminated the need for inpatient care.
“Every single type of surgery, doesn’t matter what it is, theoretically can go to a surgery center,” he said. “Does that mean that everything should go to the surgery center? Absolutely not.”
He and John Peloza, MD, founder and owner of Peloza Spine who owns a physician-controlled ASC-based practice in Chesterfield, Mo., emphasized that broader eligibility is not the same as universal appropriateness. The deciding factor, they said, must remain the individual patient.
“There are always patients who will have degrees of illness, degrees of complexity that are simply not as safely served in an ambulatory environment as they are in a hospital setting,” Dr. Stein said, pointing to transplant surgery, complex cardiothoracic procedures, cancer care and severe trauma as cases he does not expect to leave hospitals.
Dr. Peloza said deformity cases, multilevel fusions in medically complex patients and overnight trauma cases will continue to require hospitals because patients with high comorbidity burdens will remain inappropriate candidates for outpatient surgery, regardless of technological advances.
“There’ll be an evolution,” he said, but not extinction.
The physicians were also aligned on what will determine whether that evolution remains safe: who decides which procedures belong in an outpatient setting and which should remain inpatient.
“The most important thing is making sure the clinicians are the ones deciding that, and that it’s not somebody who’s a non-clinician looking at a P&L sheet deciding all of this needs to go to the surgery center,” Dr. Stein said. “It needs to be the doctors, based on their Hippocratic oath, doing what’s correct for the patient.”
Dr. Peloza raised a similar concern from a different perspective. He pointed to regulatory policies and private equity ownership structures that can shift decision-making away from physicians. He criticized private equity’s typical four- to six-year investment timelines, saying they can create pressure to “flog the physicians in cases to generate revenue that may not be the best.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
