Looking Ahead: 6 Thoughts from Physicians on the Future of ASCs

Last year, average case volume, revenue per case and staff and physician salaries increased, according to VMG Health's Multi-Specialty ASC Intellimarker 2011 when compared to 2010. However, the number of procedures performed in the ASC setting remained the same. The year 2012 brings an uncertain regulatory environment, decreasing reimbursements and an increase in minimally invasive techniques and technology. ASC physicians share their thoughts for 2012 and beyond.

1. An aging population means increased procedures in many ASC specialties. As the baby-boomer generation ages, the demand for age-related procedures will increase. For example, an Ophthalmic Market Perspectives report estimated the volume of cataracts grew from 2.4 million in 2000 to 3.2 million in 2010, and Larry E. Patterson, MD, medical director of Eye Centers of Tennessee and the Cataract and Laser Center, Crossville, Tenn., and past president of the Outpatient Ophthalmic Surgery Society, has already seen an increase in his cataract surgery volume.

"My cataract surgery volume is significantly up compared to the last few years," he says. "There are just more older people who are getting cataracts. This current generation is a little more aggressive. They are not as tolerant of visual loss. They want their cataracts out earlier."

Physicians predict that other specialties, such as urology and gynecology, will see an increase in demand for procedures as well.

"I think that the practice of urology has benefits because there are relatively few urologists relative to the population of patients that we treat," says Herb Riemenschneider, MD, staff urologist and founder of the Knightsbridge Surgery Center in Columbus, Ohio. "There are demand issues, and if we can address them appropriately, the patients and we can benefit. Urology is actually in a good position relative to the other specialties because of this supply and demand."

Amy E. Rosenman, MD, urogynecologist, clinical assistant professor at the UCLA School of Medicine and in private practice at Saint Johns Health Center in Santa Monica, Calif., says gynecological problems such as prolapse, a condition where the uterus falls into the vagina, increase with age.

"Since the demographics are going to be more incontinence and prolapse, it would behoove us all to figure out how to package that in an ASC setting," she says.

2. Scope of practice debates threaten certain specialties.
Certain procedures are becoming more feasible for the outpatient setting as physicians adopt minimally invasive techniques. However, for certain specialties — such as ophthalmology and pain management — this change has driven non specialists to perform procedures.

Optometrists have long been fighting for the right to perform certain laser surgical procedures in their offices. Earlier this year, Kentucky passed the "Better Access to Quality Eye Care Act," which expanded the scope of practice for optometrists to include certain surgical procedures. The use of laser technology has in some ways made surgical procedures easier, but the misconception that they are simple or minor surgeries is wrong, Dr. Patterson says.

"It's only minor as long as there are no complications," he says.

He calls the law "an embarrassing mark on Kentucky" and is afraid the trend may spread to other states.   

"Because of that success, there are going to be attempts all over the country," he says. "I don't think they'll be quite as successful elsewhere."

A similar battle is going on in the pain management specialty. Demand is increasing at a natural rate, but other factors, such as non-certified pain management physician performing pain management procedures, are leading to an inflated utilization rate.

"As the baby boomers are getting older, there is — based on demographic trends — a natural tendency for the demand to be rising," says Francis Riegler, MD, co-founder of Universal Pain Management in Victorville, Calif. "One of the other things you've got going on is that there are a whole lot more of these procedures being done across the board."

These procedures aren't always done by specialized pain management physicians, he says.

"If you're a physician who's not a trained pain management physician, you can go out and do these procedures and get paid the same amount of money as a legitimate, fellowship-trained pain management physician," he says. "One of the things is that the utilization rate [of pain management procedures] has been rising more than the natural rate of increase."

3. Cost will be the deciding factor on whether certain procedures can be done in the ASC. In the current atmosphere of declining reimbursements, some procedures that are feasible in the outpatient setting are not financially viable in an ASC. In addition to shrinking reimbursements, the equipment that allows many procedures to be performed in the ASC is often cost-prohibitive.

"The one thing we always run into has to do with equipment and cost issues," T.K. Miller, MD, of Carilion Clinic Orthopaedics and Medical Director of the Roanoke Ambulatory Surgery Center, says. "That to me becomes the limiting factor. There are procedures that we could do, but [they are] cost-prohibitive to do."

Orthopedic procedures at-risk for being cost-prohibitive include rotator cuff repair with acromioplasty and ACL repair with allograft. Dr. Miller says acromioplasty, which increases the space for the rotator cuff in the shoulder, is being bundled with the reimbursement code for rotator cuff surgery. So even though the procedure takes more time and equipment, the reimbursement is the same. Allograft materials — donor tendon or ligament implanted during an ACL reconstruction — are not always covered by payors. Because of a lack of reimbursement, this "bread and butter" procedure can become unprofitable and has to be moved back to the hospital setting.

In the pain management specialty, Standiford Helm II, MD, medical director of Pacific Coast Pain Management Center in Laguna Hills, Calif., and president of the American Society of Interventional Pain Physicians, thinks there will be an increased emphasis on "good value" procedures.

"Pain procedures that are going to thrive are those which add value," he says. "A good example is the MILD procedure, which treats stenosis at a cost far below surgery. In a fixed budget world, that difference will be definitive as to what therapy, if any, is provided. While patients will be interested in increased function, the insurers or ACOs will be more likely to respond to decreased utilization of resources."

4. Increased patient demand for same-day surgery will drive volume. As minimally invasive techniques become more prevalent, many younger surgeons — and even knowledgeable patients — are pushing for procedures to move from the inpatient to outpatient setting.

"Almost any surgeon that we hire with fellowship training is going to look at what they can do in an ASC setting," says Dr. Miller. "We've gone from patient comments of 'I can't believe you can do that in an outpatient setting' to 'Why do I have to stay in the hospital?'"

This demand by patients has also increased the traditional ASC patient population. Dr. Miller recently performed a revision rotator cuff repair on a woman over the age of 70. In the past, he might not have considered doing that case in an ASC, but the woman expressed her desire to have surgery in an ASC rather than hospital setting. Dr. Miller reviewed the perioperative expectations with the patient and her family, consulted with her primary care physician to make sure she had few co-morbidities, and the surgery was performed successfully in the ASC.

5. Minimally invasive procedures continue to increase.
Minimally invasive surgical techniques are increasing and allowing more procedures to move to the outpatient setting. This trend is expected to continue.

Dr. Miller says that minimally invasive hip procedures such as arthroscopic hip reconstructive procedures are transitioning to the ASC environment. This transition will continue over the next few years.

"Hips are where shoulders were 10 years ago," he says. "We start with diagnostic capabilities, evolve to debridement and clean up and, as instrumentation evolves, are moving to consistently reliable reconstructive techniques."

As with most sports-based surgeons, Dr. Miller now does almost all of his shoulder reconstructions with arthroscopic techniques and says this trend will be seen with other joints. He says hip is next on the list.

Another procedure increasingly done in the ASC setting is hysterectomy — specifically laparoscopic and vaginal hysterectomies. Dr. Rosenman thinks there will be an increase in laparoscopic and vaginal hysterectomies performed on an outpatient basis. She sees the change depending on a good post-operative care program.

"We've gotten there with midurethral slings," she says. "We can get there with hysterectomies."

The Advisory Board, a research, consulting and technology firm, predicted laparoscopic hysterectomy procedures would increase starting in 2010 and that by the end of 2010, 44 percent of all hysterectomies performed in the United States will be done laparoscopically. By 2017, this figure is expected to jump to 55 percent.

6. Reimbursement continues to be up in the air. With the population aging, more patients will fall under Medicare reimbursement, and private payors are increasingly looking a Medicare rates to set their own. An uncertain healthcare reform environment means many physicians are unaware of what exactly reimbursement will look like in the future.

"One of the insidious ways that the Medicare program pulls down the payment for physicians is by changes in the codes," Dr. Riegler says.

Medicare can reduce the cost of reimbursements by bundling codes. Next year, Dr. Riegler says the code for fluoroscopic guidance will be bundled into the procedure codes. This has been done in other specialties, such as orthopedic and spine, as well.

However, Dr. Rosenman says Medicare has begun to reimburse more gynecological procedures done as an outpatient.

"Over the years, Medicare has gotten smarter," she says. "They sometimes miss the forest for the trees, but when they get it, they get it."

Dr. Rosenman says certain private payors are now telling her that a hysterectomy procedure is going to be done as an outpatient. They better understand the cost-benefit to doing appropriate procedures in an ASC setting.

"Outpatient reimbursement for private insurance companies is usually ahead of Medicare," she says. "They have pretty good reimbursement for outpatient surgery. Clearly it's cheaper in an outpatient setting. Good surgery centers have very clear criteria as to who is safely done there and who isn't. This helps to avoid disasters and keep your cost predictable."

Related Articles on 2012 Predictions:
5 Changes for Outpatient Anesthesia in 2012: Thoughts From Dr. Gilbert Drozdow
10 Top Concerns for Surgery Center Administrators in 2012
Gastroenterology in 2012: Q&A With Dr. Glenn Littenberg of ASGE

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