This week, on Feb. 12, the ASC industry celebrates its 50th anniversary. According to the Ambulatory Surgery Center Association, the first ASC was established in 1970 by Wallace Reed, MD, and John Ford, MD, in Phoenix.
To commemorate the milestone, Becker's ASC Review asked industry leaders to reflect on how ASCs have evolved in the past 50 years, predict what the future holds and share highlights from their careers. This is the first installment of the series.
Question: 2020 marks 50 years since the nation's first freestanding ASC was established. How have ASCs evolved since then and what does the future hold?
Note: Responses were lightly edited for style and clarity.
Michael Chmell, MD. Medical director of OrthoIllinois Surgery Center (Rockford): The evolution of ASCs over this time can conservatively be described as dramatic. Orthopedic ASCs started as places where cases such as carpal tunnel releases and knee arthroscopy were performed routinely with minimal supply inventory, very predictable surgical times, and the day was usually over by midafternoon. Today, orthopedic ASCs are basically orthopedic hospitals that send their patients home on the day of surgery. The procedures performed today run the entire gamut of orthopedics, from total joints to spine fusions to the most complex arthroscopic procedures. An orthopedic ASC today has evolved into a center requiring a new infrastructure (storage, sterile processing, longer-term recovery options) and a new paradigm in terms of staffing (more labor-intensive work environment, irregular/later hours). This is why today we must see ourselves more as a hospital and be prepared to compete as such because of the changes.
Cheryl Garmon, DNP, RN. Director of Heaton Laser & Surgery Center (Tyler, Texas): In the last 50 years, ASCs have experienced rapid growth in the healthcare industry. The concept of stand-alone surgery centers started with courageous pioneers who thought outside the box in proposing that a safe level of care performed outside the hospital system could be possible. In part, the mindset was to protect patients in the event that adverse outcomes would occur, leaning on the rapid response that hospital systems could provide.
Eventually, over the years, the growth in the ASC industry largely involved a change in the mindset and restructuring of how care can be provided in other settings other than the hospital. This paradigm shift was supported by the positive clinical outcomes of surgical specialties that posed little risk for complications, fiduciary integrity and the additional ASC-specific accreditation standards by accrediting organizations. ASCs are now widely accepted in many specialty areas, and will continue to expand as quality-driven care outcomes are reported.
Vincent Laudone, MD. Chief of surgery at Memorial Sloan Kettering Cancer Center's Josie Robertson Surgery Center (New York City): A major proportion of surgery that was done only on an inpatient hospital basis has transitioned to the outpatient setting. This is a result of improved surgical techniques such as minimally invasive surgery, streamlined and standardized patient care pathways that focus on enhanced patient recovery, and a realization that patients generally recover better and prefer to be in their own home rather than a hospital. A popular notion has been that the growth of outpatient over inpatient surgery has been insurance- or cost-driven, but in reality, it is simply better patient care in most circumstances.
Yousif A-Rahim, MD, PhD. Chief medical officer for Covenant Physician Partners (Nashville, Tenn.): ASCs have become ubiquitous in the U.S. The number of Medicare-certified ASCs, currently estimated at 5,603, has steadily increased from about three in 1980. Clinical and technological advancements, including improvements in anesthesia and in analgesics for the relief of pain, and the development and expansion of minimally invasive [techniques] such as endoscopy, laser surgery and laparoscopy, have paved the way for this growth in the ASC business line. Before these advances, almost all surgery was performed in the inpatient setting.
In addition to these advances, concerns about ballooning healthcare costs in the early 1980s led to changes in the Medicare program that encouraged growth in ambulatory surgery. By expanding coverage to its beneficiaries to include surgery performed in ASCs, Medicare introduced a prospective payment system for hospitals based on diagnosis-related groups. This then created a strong financial incentive for hospitals to shift some surgery out of the hospital. Today, more than 60 percent of all U.S. outpatient surgical procedures are performed in ASCs, up from 32 percent in 2005. This trend in procedure migration from hospital to ASC is expected to continue, as population growth forecasts project [an estimated] 15 percent growth in outpatient surgery volume by 2028.
Nicholas Grosso, MD. President and orthopedic surgeon at The Centers for Advanced Orthopaedics (Bethesda, Md.): Throughout my career, I have watched ASCs increase their capabilities and become more reliable for patients undergoing surgery. Specifically, over the past 20 to 30 years, more complex surgeries have been performed in ASCs because of the advances in anesthetics as well as in equipment and technology. Many open surgeries that previously needed to be done in the inpatient setting can now be done arthroscopically in the outpatient setting. Total joint replacement is an example of a surgery that previously needed to be performed in a hospital, but now performing the surgery in an ASC is commonplace.
I see a bright future for ASCs, including an increase and expansion in the types of surgeries we can do in the outpatient setting. For example, total joint replacements can currently be done either in the inpatient or outpatient setting. I predict that a significant percentage of total joint replacements will ultimately be done in ASCs.
John Beck. Chief solutions officer for NextGen Healthcare: ASCs have evolved from outpatient procedures that were once considered not "complicated" and were deemed safe to perform outpatient, to now performing complex cases such as spine fusions and total joints in an ASC. This is a transition that is happening right now.
Scott Jackson. Senior director of Henry Schein Medical's ASC business: It's kind of interesting when you look back 50 years. The ASC industry faced significant adversity in its early days, especially from various lobbying efforts. But, if you fast forward to today, ASCs have evolved in a way that has allowed them to thrive by providing high-quality patient care, while at the same time saving our healthcare system billions of dollars a year. Better care at a lower cost has been the outcome. What more could you ask for?
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