Looking back at 2021: Another wild, challenging ride for ASCs

For the past few years, I've written a column that looks back on the previous year and highlights the challenges that faced ASCs and positive developments for the industry. I conclude the column by listing questions I believe may be answered during the upcoming year. For last year's column, the first topic covered and question asked concerned the biggest news of 2020: the COVID-19 pandemic.

The pandemic was one of several significant challenges for ASCs last year, many of which continue today. But there was also good news for ASCs. I remain as optimistic as ever about the future of the industry and our ability to be resilient in the face of substantial obstacles and disruption.

Below are my thoughts on the year that was.

The variants
2020 was the year of COVID broadly. 2021 was the year of two of its variants: delta and omicron. Just as the country seemed to be entering the final stages of the pandemic, delta hit. Then came omicron, which accounted for most cases by Christmas. As I write this, it appears that omicron cases have peaked overall for the country.

Staffing shortages
There may have been no bigger challenge for ASCs in 2021 than staffing shortages, particularly on the clinical side. A confluence of factors strained efforts to recruit and retain staff. There was already a nursing shortage going into 2021. Then came trends like increased burnout, workers leaving the profession because of health concerns, the "Great Resignation," and the explosion in the demand for travel nursing.

These and other factors have contributed to the loss of staff in ASCs nationwide and inability for many centers to easily add new staff. Short- and long-term staffing shortages have caused many ASCs to scale back their operations and caseload, further straining margins already under pressure.

Vaccines and boosters
In 2021, we saw widespread distribution of COVID vaccines and boosters. ASCs had significant decisions to make concerning vaccinations, such as whether to require them for staff and patients, what exemptions were acceptable, and whether testing would occur for those with and without vaccination.

In September, the Biden-Harris administration announced it would require COVID vaccination of staff within all Medicare- and Medicaid-certified facilities. The U.S. Supreme Court upheld the mandate in January. During the September to January period, there was much uncertainty among ASCs that had chosen not to mandate vaccination prior to September. CMS has established multiple sets of compliance deadlines.

Supply chain disruption
ASCs are struggling to obtain a wide range of equipment and supplies. Factors contributing to this challenge include everything from surge in product demand to companies like manufacturers, distributors and warehousing struggling to attract and retain workers to the global semiconductor chip shortage to the backup of container ships at ports. ASCs have needed to wait longer for orders to arrive or change vendors to get what they require while often paying higher prices for goods.

ASC-covered procedures list shrinks significantly
Now let's look at some ASC-specific developments, starting with perhaps the most disappointing of 2021. The 2021 final payment rule for ASCs and hospital outpatient departments finalized the addition of 258 codes to the ASC-covered procedures list for 2021. Most of those additions were short-lived, with CMS removing 255 of the codes as per its 2022 final payment rule. As ASCA reported, the three CPT codes that remain are:

  • 0499T (Cysto f/urtl strix/stenosis)
  • 54650 (Orchiopexy (fowler-stephens))
  • 60512 (Autotransplant parathyroid)

For ASCs that had begun performing any of the removed codes, this announcement was frustrating and forced them to reevaluate their plans.

Return of the inpatient-only list
Let's look at another positive 2020 development that was reversed in 2021. In the 2021 final payment rule, CMS seemingly finalized its plan to begin eliminating the inpatient-only list. The hope was that this should encourage additions of procedures to the ASC covered procedures list. CMS backtracked. In its 2022 final payment rule, the agency announced it was halting elimination of the inpatient-only list. On a positive note, as ASCA reported, several CPT codes were not reverted to the inpatient-only list, including:

  • 22630 (Lumbar spine fusion)
  • 23472 (Reconstruct shoulder joint)
  • 27702 (Reconstruct ankle joint)

OAS-CAHPS returns
Another noteworthy development in the 2021 final payment rule was the announcement that CMS plans to make ASC participation in the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey mandatory beginning in 2025.

New ASC legislation introduced
In November, new federal ASC legislation — the Outpatient Surgery Quality and Access Act of 2021 — was introduced. It concerns several issues, including publication of quality data, copay penalties, ASC representation on a key CMS advisory panel, and alignment of ASC and HOPD reimbursement update factors. Read ASCA's summary of the law here.

ASCs step up to fill surgery gaps
Throughout the pandemic, hospitals have been forced to postpone elective/nonurgent surgeries when COVID cases increased and clinical staffing was further strained. ASCs have worked through the various challenges that came their way and taken on some cases that could not be performed at hospitals. This has helped ensure more patients could receive the surgical care they need in as timely a manner as possible and given ASCs a case volume and revenue boost.

No Surprises Act becomes law
In December, Congress passed the No Surprises Act. The legislation concerns surprise medical bills and has short-term requirements and potential long-term ramifications for ASCs in areas including disclosure of balance billing protections, provision of "good faith" estimates, patient consent and dispute resolution. Helpful guides to the law can be found here and here.

Recommended colorectal screening age lowered from 50 to 45
In May, the U.S. Preventive Services Task Force announced it was recommending that screening for colorectal cancer in adults begin at age 45 — down from 50. While it will take some time to educate referral sources and patients about the revised recommendations and expanded coverage, the lowered age should help detect more cancers early while they are still treatable. For surgery centers that perform colonoscopies — one of the most common ASC procedures — this will help expand patient and case volume.

Cardiology and total joints on the rise
Two types of ASC programs seeing significant growth in the industry are cardiology and total joints. Both have received a boost in recent years thanks to the addition of CPT codes to the ASC covered procedures list and increases in Medicare reimbursement.

Outpatient migration of cases continues
Surgical cases in general continued their migration out of the inpatient setting and into the outpatient setting, with many ending up at surgery centers. ASCs and their surgeons, supported by advances in surgical technique, equipment and IT, are safely tackling more complex cases. Payers are also increasingly looking to steer cases away from the higher-cost, higher-risk hospital setting to surgery centers.

Hospitals continue to pursue ASCs
Hospitals and health systems are increasingly working to add ASCs to their portfolio. A survey by Avanza Healthcare Strategies of senior healthcare executives and clinical leaders found that about two-thirds of hospitals and health systems were planning to increase their ASC investments, with more than three-quarters of larger hospitals reporting increases in their investments.

Cybercriminals remain a substantial threat
Cybercrime has accelerated during the pandemic, with cybercriminals looking for opportunities to take advantage of healthcare organizations that let their guard down as they scrambled to respond to the challenges brought on by COVID. ASCs must be especially careful of recent changes to their operations that may present an opening to cybercriminals, such as increased staff turnover, moving to a partial remote workforce, and investments in new information technology and "smart" equipment.

Looking into the crystal ball…
Now comes my list of questions for the year ahead. While I expect 2022 will throw new challenges at us as we continue to try to tackle challenges that have carried over from years past, I am confident that this year will be a good one for the industry.

  • Will we finally be able to declare the pandemic over?
  • Will there be another significant COVID variant? If there is, how will it compare to previous variants?
  • What surprises will CMS include in its 2023 payment rule?
  • What new supply chain disruptions will we experience?
  • Will demand for travel nurses subside?
  • Will commercial payers push for more value-based care in ASCs?
  • Will we see robotics making their way into more ASCs?
  • How will efforts by hospitals and health systems to expand their ASC portfolios affect their various markets?
  • Will we see any significant revisions to certificate of need laws?

I hope you found this summary informative. Throughout the year, the Surgical Notes team closely watches and shares information on developments that will or may impact the ASC industry. Doing so better ensures we can best support our clients and their efforts to deliver high-quality, cost-effective surgical care. For the latest company and industry news, visit www.surgicalnotes.com and follow Surgical Notes on LinkedIn.

Randy Bishop (randy.bishop@surgicalnotes.com) is president and chief executive officer for Surgical Notes. Surgical Notes is a nationwide provider of ASC billing solutions, including transcription, coding, revenue cycle management (RCM), and document management applications for the ASC and surgical hospital markets.

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