The ASC industry has functioned as a high quality, low cost setting of outpatient care for around 50 years. Over the past two decades, the number of ASCs in the U.S. has dramatically increased, and the industry is poised to play a crucial role in value-based care going forward.
On Friday, March 2, Kaiser Health News and USA Today published an exposé that was months in the making, examining the stories of patients and families who underwent procedures at outpatient centers and either experienced major complications or died afterward. The report cites 260 patients who died after surgery in an ASC since 2013 but failed to contextualize these events; over the same time period, more than 200 million procedures were performed safely in the ASC setting.
"By the article's reliance on a small number of tragic adverse events, which are rare in ASCs and outpatient surgery, the article helps make the case of what we know is true: the ASC setting is extremely safe and well regulated," says William Prentice, CEO of ASCA. "Any informed person in healthcare would know the same types of adverse events that happened in these stories occur in every healthcare setting."
The investigative piece raises concerns about performing complex procedures in the ASC setting. More procedures continue to move to the outpatient setting for several reasons, including the advancement of technology, making the procedures safe for appropriately selected patients in the ASC setting. Insurance companies are also seeing their patients do well in ASCs and approving more cases in the setting.
"The whole ASC model is based on the idea of using patient selection to ensure patients are seen in the right setting," says Mr. Prentice. "There isn't a definitive way of making that determination, but the best solution is to rely on the physicians' judgment in coordination with the patient's needs. Our surgeons stay current with medical thinking and clinical techniques, which adjust over time."
As the KHN/USA Today article notes, increasingly complex procedures are moving to the outpatient setting, including total joint replacements and spinal surgeries. The movement of procedures from inpatient to outpatient typically occurs in the hospital setting first; surgeons do outpatient cases in the hospital setting, discharging patients from the hospital within 23 hours of the procedure. When they have a successful track record of outpatient procedures in the inpatient setting, they move those cases to the hospital outpatient department and then the ASC.
"Physicians rely on the outcomes they see in the inpatient setting to feel comfortable in the new setting," says Mr. Prentice. "What was lost in the reference to CMS approving spine procedures in the ASC space is that it occurred only after those procedures had already moved from the inpatient setting to the hospital outpatient department years prior. If there is a procedure that moves from the inpatient setting, it first moves to the hospital outpatient department, and only after years of experience and data does Medicare make the decision to allow it in the ASC setting."
Mr. Prentice and ASCA leadership are considering how to proceed after this article; while Mr. Prentice was interviewed for the article, KHN and USA Today did not include most of the contextual information ASCA provided them. "Surgery centers are extremely diligent about abiding by the regulations that apply to the industry," says Mr. Prentice. "These stories are the exception and not the rule.
Finally, the article alleges ASC owners perform more procedures than surgeons in the hospital because of ownership in the ASC, without directly citing any evidence. "Financial considerations do not play a role in the decisions they make about surgeries; it's too important of a decision for the surgeon," says Mr. Prentice. "This is a baseless accusation. I would argue that if ASC owners are able to perform more procedures in the ASC setting, it's because the ASC is more efficient."
Mr. Prentice doesn't believe the investigative article will affect ASCA's ability to work with lawmakers and advocate for policy on behalf of the ASC industry; it hasn't changed ASCA's focus for 2018. However, the article does underscore the need for a more centralized quality reporting mechanism for all settings, which Mr. Prentice indicates the ASC community would welcome.
"Adverse event reporting systems are arcane and hard to access and use; we would be pleased to help with their improvement," he says. "We need more data available to patients and centers about quality, outcomes and adverse events, and we don't have it. There is much work to be done to build that framework so we have more useful information available to consumers. One of the most rewarding things about my experience at ASCA has been the community's willingness to accept more regulation if that regulation leads to better outcomes. We are willing to work on developing a system of more transparency in healthcare because we believe a more transparent healthcare system where patients can find out about quality, safety and pricing of their data will be beneficial to them and the ASC industry."
The ASC Quality Collaboration collects quarterly quality data for ASCs; in the most recent report for the third quarter of 2017, the 1,484 ASCs reported a wrong site, side, patient, procedure and implant rate of 0.955 per 1,000 admissions; the patient transfer and admission rate was 0.955 per 1,000 admissions. The rate of unplanned hospital admissions within one day of discharge from the ASC was 0.36 per 1,000 admissions.