St. Louis-based Ascension has become the third-largest ASC operator after its $3.9 billion acquisition of AmSurg expanded its footprint to more than 300 surgery centers. The health system now trails only Tenet Healthcare’s USPI, which operates more than 535 ASCs and surgical hospitals, and Optum’s SCA Health, which operates more than 370 ASCs.
But while the scale is similar to the dominant for-profit players in the ASC space, Ascension’s strategy is fundamentally different. In addition to viewing ASCs as a growth vehicle, the Catholic system sees them as the foundation for a broader shift toward community-based care, virtual care and “health hubs” designed to move services closer to patients.
Thomas Aloia, MD, executive vice president and chief clinical officer at Ascension, spoke with Becker’s about what the deal means from a clinical perspective, how the system plans to leverage AmSurg expertise to build a hub-and-spoke ambulatory network across nine markets and why he thinks “ASC” is the wrong term for what these centers are becoming.
Editor’s note: Responses were lightly edited for length and clarity.
Question: Ascension is now the third-largest ASC operator nationally, behind Tenet/USPI and Optum/SCA Health. Given that Ascension is a faith-based nonprofit system as opposed to a for-profit entity like the other big players in this space, how do you see the future looking from a clinical and growth standpoint? I assume acquiring and building de novo ASCs in existing and new markets remains a key part of your strategy?
Dr. Thomas Aloia: Absolutely. One thing worth noting is that we already were partnered with 60 existing ASCs, so we have bones in running and managing ASCs and in recruiting surgical talent for co-ownership arrangements. AmSurg is at a completely different scale, and we think they’re going to step up that entire platform for us.
This equation becomes straightforward if we recruit the right talent and keep our ear to the ground and listen to what patients need. Our mission calls us to treat all, so it really simplifies the equation for us. We just have to find creative ways to make it work. For example, we are pairing ambulatory care with a virtual platform. We’re now moving into remote patient monitoring and patient-reported outcomes. Many other health systems are in those spaces, but we think we have a coherent model, and AmSurg is coming in at the perfect time to help us leverage those asynchronous, non-face-to-face capabilities.
Every American health system is called to reinvent how we deliver care, and I give all the credit to our President and CEO, Eduardo Conrado, for challenging us to do it differently: Can we do it better and less expensively for our patients, and serve more people? In that context, AmSurg — which has historically operated in a more for-profit setting — fits quite nicely with Ascension.
Q: CEO Eduardo Conrado said the AmSurg acquisition positions Ascension’s hospitals to focus on “highly specialized acute care.” What does that mean from a clinical perspective? Which service lines are you actively shifting to the ASC setting?
TA: AmSurg gives us an incredible foundation to explore what’s possible in the ambulatory space. I’d take it in two directions. One is we see this as a major accelerant to build more hub and spoke around our existing hospital system network in our nine markets. I’m not sure the term will catch on, but I really think these should be called APCs — ambulatory procedural centers. The idea that these are surgery-only is a thing of the past. That framing opens the art of the possible for eye, GI, and other procedures, but also interventional radiology and cardiac cath: things we see as procedural but not necessarily surgical.
Once you’re at an APC, you can think about the health hub concept, with rehab, pharmacy, and imaging. You can pivot that into various service lines. If you have cardiac imaging, a pharmacy, and cardiac rehab, and you’re doing heart caths, now it’s not an ASC or an APC. It’s a health hub, and that model becomes deployable — rural, urban, in between, at a hospital, at a distance from a hospital, etc. We’re excited about exploring a wider view of these health hubs and leveraging the expertise that AmSurg has in the ASC/APC space.
Q: Can you elaborate on the benefits that a larger hub-and-spoke model will offer Ascension across those nine markets?
TA: Building that brick-and-mortar inpatient footprint just doesn’t have the reach we need. We have to get pretty sophisticated to triage what can be handled remotely over video, what can be handled in an urgent care environment, what could come to a health hub and be covered completely, and what finally needs to hit a traditional acute care environment.
It’s been floated over the past five years that acute care will look more like specialized EDs and ICUs. There will always be a role for the med-surg inpatient floor, but we have to acknowledge that with remote monitoring and access to different health hubs in a city, we could start decanting some of the generic med-surg census to a home or home-adjacent environment.
That makes it more convenient for the patient and increases their access, and it reshapes this traditional, highly expensive, brick-and-mortar-centric model into something more compatible with the future — both in terms of hospital reimbursement and financing and in terms of where patients need us to be.
Q: How will Ascension standardize clinical quality and patient safety standards across 300+ ASCs without dismantling the physician autonomy that made those centers successful in the first place? Where do you draw that line?
TA: Safety is a given, and quality is what we strive for every day. I’m proud of the ASC and APC industry for setting benchmarks. The vast majority of activity in these centers is done extremely safely. The need for acute care after an ambulatory procedure is roughly one in 1,000, which is a real credit to the ASC/APC industry’s KPIs and standards. AmSurg has lived into that and been an industry leader within that ecosystem. We’re inheriting a group with a focus on safety, culture and high reliability, with a proven track record of hitting industry-standard KPIs above benchmark.
The number one thing we want to do is be data-driven. We bring an aptitude for looking at large volumes of healthcare data and identifying early trends and early signals, and for striking the right balance between initiatives and culture building, which is one area where Ascension can support AmSurg. But AmSurg has an amazing track record and a committed group of administrators, surgeons, nurses and anesthetists dedicated to safety and quality. Perhaps we can give it a little air beneath its wings, but in the quality space it’s a pretty solid flying model to begin with.
Q: How is Ascension’s leadership team planning to balance growth in ambulatory surgery with the need to maintain financially sustainable inpatient operations? Do you see the AmSurg arm driving the lion’s share of revenue in the future, similar to what USPI is increasingly doing for Tenet?
TA: I think it’s about right care, right time — and there’s plenty of work to go around. We see this as enlarging the pie, not stealing from one pocket to put into another. Our mission calls us to treat those experiencing poverty and vulnerability, and our doors are open to all.
Historically, ASCs have largely been a commercial and Medicare-based environment, but we want to give all of our patients access to procedures in the right place. Convenience, efficiency, and safety call us to put patients into the ASC framework. As for the traditional hospital system, the reimbursement patterns and economics almost take care of themselves. There will always be a place for doing highly technical, high-complexity work that justifies that level of reimbursement at a cost basis consistent with a hospital.
We constantly try to balance things, and we know there’s a decant opportunity that benefits both patients and the system. It’s a matter of having those procedural rooms available. We want that movement, we’re seeking it, and we’re confident — especially in our large flagship hospitals — that our service lines are among the best and that we can grow the number of patients who can be treated in acute care environments that truly need acute care.
Q: Anesthesia staffing challenges came up repeatedly at Becker’s recent ASC conference. How are you thinking about staffing models, the role of CRNAs versus physician anesthesiologists, and what happens to the network’s capacity if that workforce tightens further?
TA: It’s a question we deal with every day. The real physician staffing crisis I once thought would come after I retired is here now. You have to have everyday rigor around it. We lean on AmSurg, which has managed this problem well, and we want to learn from them what staffing models, the right mix of CRNAs versus MD/DO anesthesiologists, work best for safety, quality and performance.
We also need to understand the pipeline. This is a renewable resource, and you have to be cultivating talent and supporting people through the licensure journey. We have dynamic plans within our nursing ecosystem, and HR teams that support people in laddering up through their careers. Those programs are paying real dividends. We’ve had techs take the next step and become licensed professionals, all the way up to supporting an anesthesiologist in getting pediatric training to further differentiate. The key — and probably where Ascension and AmSurg can synergize — is understanding state-by-state differences. Scope of practice for RNs and CRNAs varies significantly at the state level, and you have to be cognizant and compliant. Both Ascension and AmSurg live that every day.
But I think there’s a unique opportunity here: imagine Ascension, AmSurg, and a training facility or set of facilities, essentially an academy. We think we’re an attractive place to work, and if we pair a training program with financial support, we secure our future and help people advance their careers. We have a good head start on that, and we’re hoping AmSurg adds fuel to the fire.
I keep coming back to the people. I’m a surgeon by training and very cognizant of the stressors that proceduralists are under. If we provide the best, most professional workplace for them, they’re going to give the best, most professional care. ASCs are in their second generation of the physician-owner model, and it’s been highly successful. The question is how we maintain the best parts of it while looking to a future where a workforce might want more shift work or more collaborative models. We’re going to have to be creative on the proceduralist, nursing and anesthesia front to make sure this remains a rewarding environment where people feel they’re fulfilling their vocation.
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.