November 17, 2021

U.S. lawmakers believe surgery centers are increasingly essential components of the nation's healthcare infrastructure.

AFFORDABLE OPTION Medicare beneficiaries should be able to have procedures done in facilities that save the U.S. health system billions of dollars.

The Outpatient Surgery Quality and Access Act of 2021, which was introduced on Nov. 2 by Reps. John Larson and Devin Nunes in the House of Representatives and Senators Richard Blumenthal and Bill Cassidy in the Senate, aims to improve access to lower-cost outpatient surgical care for Medicare beneficiaries.

The bipartisan legislation would close the gap between reimbursement rates for identical procedures performed at ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs), provide patients with transparent quality comparison data across sites of service, align the inflation and budget neutrality updates for ASCs and HOPDs, and institute a copay cap for procedures performed in ASCs.

CMS would also need to reveal the criteria it uses to include or exclude procedures from the list of procedures it covers in surgery centers and add an ASC representative to the Advisory Panel on Hospital Outpatient Payment, which decides on reimbursement rates at HOPDs and ASCs as well as eligible procedures for each site of service.

"This legislation expands access to quality, more affordable outpatient surgical care offered at ASCs across the country," says Sen. Blumenthal. "As an often more affordable and convenient alternative, these centers offer Medicare beneficiaries procedures and services essential to their well-being and health."

Surgery centers saved Medicare $28.7 billion between 2011 and 2018 and are expected to save CMS an additional $73 billion between 2019 and 2028, according to the Ambulatory Surgery Center Association (ASCA). The lawmakers who introduced the act acknowledge current reimbursement policies limit access to surgical care in ASCs, which could cost the government billions of dollars in the coming years.

"We want to thank the sponsors of the act for their efforts to reduce Medicare beneficiaries' out-of-pocket costs and put the program on more stable footing," says ASCA CEO Bill Prentice. "Increasing access to care in ASCs can play an important role in reducing Medicare expenses, freeing up dollars for other priorities."

Surgeons are beginning to perform the advanced procedures at freestanding facilities.

CREDIT: Urology of Virginia
NEW HORIZONS The team at Chesapeake Regional Surgery Center at Virginia Beach performed one of the few robotic prostatectomies done in a surgery center.

Robotic surgery has evolved into the gold standard surgical treatment for prostate cancer, although controversy persists regarding its use when open and laparoscopic techniques are effective and less expensive options.

In a commentary published in JAMA Network Open, Jeffrey Howard, MD, PhD, says large studies performed in Australia and Sweden demonstrated robotic prostatectomy reduced blood loss and led to shorter post-op lengths of stay compared with open procedures. He also references a recent study conducted in Taiwan that showed robotic assistance led to improved immediate outcomes, including less severe post-op pain and better long-term function in patients.

Critics of robotic-assisted prostatectomy say the technology's adoption is based more on marketing than proven clinical results, according to Dr. Howard, an assistant instructor in the department of urology at the University of Texas Southwestern Medical Center in Dallas. "These criticisms notwithstanding," he writes, "the adoption of robotic assistance as the standard of care is now a fait accompli, with robotic prostatectomies likely representing more than 90% of prostatectomies performed in the United States."

Now the procedures are migrating to surgery centers. The Robotic Surgery Institute at Central Ohio Urology Surgery Center in Gahanna is one of a handful of freestanding outpatient facilities in the nation offering robotic urologic procedures. "Allowing our patients to have their cancer surgery at a surgery center and then go home the same day removes most of the anxiety they feel," says Ronney Abaza, MD, FACS, who performs robotic surgery for prostate, kidney and bladder cancers.

In October, Chesapeake Regional Surgery Center at Virginia Beach became the first freestanding ASC in Virginia to perform a robotic-assisted prostatectomy. Michael Fabrizio, MD, FACS, who completed the procedure in about three hours, says using robotic assistance in the ambulatory setting allows patients to recover in the comfort of their homes, experience less pain and benefit from improved mobility.

"Our patient had the initiative and trust to have this procedure in a freestanding ASC," he says. "The surgical and anesthesia team, as well as our nurses, operating room techs and our surgical assistant were exceptional."

The critical partnership that led to the successful transition of inpatient total joint surgeries at the Lighthouse Surgery Center.

CREDIT: Lighthouse Surgery Center

Three years ago, Michael Joyce, MD, noticed total joint replacement patients were mobilizing more quickly than in the past. Advanced surgical technology and new pain management techniques meant patients had shorter recovery times and hospital stays. Dr. Joyce and his colleagues began to perform some of their total joints as outpatient procedures at the hospital to develop an efficient process for patient selection, surgical flow and postoperative discharge.

The surgeons also collaborated with anesthesiologists to use long-acting local anesthetics and limit narcotic use, so patients would be discharged home in relative comfort. The last step was having patients undergo their initial physical therapy shortly after surgery.

The process worked, and after successfully performing outpatient total joints for several years at the hospital, the surgeons decided it was time to take their cases to an ASC.

Dr. Joyce and his partners collaborated with St. Francis Hospital to develop a Lighthouse Surgery Center in Hartford, Conn., with assistance from outside vendors, including Stryker. Dr. Joyce had used Stryker implants for more than 25 years, but as he worked to develop the new ASC, Stryker was much more than a pure implant vendor. They became a true partner, providing guidance for inventory management and design advice based on best practices. "I think of Stryker now as a company that provides both products and services to help make your ASC a reality," says Dr. Joyce. "Having Stryker come to the table with so many different ideas gave us a higher degree of expertise."

Steps to success

Over the past three years, the surgeons saw the volume of outpatient cases grow from dozens to hundreds annually. Then, COVID-19 accelerated the migration of total joints to the ASC. "Patients didn't want to be in the hospital," says Dr. Joyce. "We were COVID-free and became a safe alternative."

To move a high volume of total joints from the inpatient hospital to the outpatient ASC setting, organizations need strong leadership to build a collaborative culture, says Dr. Joyce. Surgeons must have the ability to discuss challenges with each other and the larger surgical team, especially if they are coming from separate independent clinical practices.

The sterile processing department at the ASC plays a critical role in the success of a total joint program. "Sterile processing has to be robust," says Dr. Joyce. So CJRI built a sterile processing department that was similar to the hospital's department, with the same policies, procedures and standards of care. Among the first 300 TJA's patients at the surgery center, there were no hospital admissions, and the current infection rate is well below 1 percent.

The stellar outcomes and low infection rate at Lighthouse Surgery Center aren't an accident. Dr. Joyce and his partners put in 18 months of planning and careful research to develop the surgery center. "This isn't something you can do shooting from the hip," he says, "You can't avoid the long-term planning."

Dr. Joyce said Stryker was helpful in planning out the sterile processing workflow and inventory management system at the ASC. Inventory management is different at an ASC because centers can't keep as many instrument trays on hand as hospitals do.

"Stryker has a breadth of experience working with centers across the country, and as we started to face some of the development challenges of building an ASC, they were a point of contact for us to collaborate with other centers that faced similar issues," says Dr. Joyce. "We created a culture of collaboration where they helped us meet some of our design, billing and operational challenges. Stryker was instrumental in all phases of developing the ASC."

A promising future

When Dr. Joyce first began performing outpatient total joints, patients were skeptical. Now, patients are asking for surgery in the ASC. They are motivated to recover from surgery quickly and return to normal activity. "You can't deter a motivated patient," he says. "People now come in and tell us they are exactly the right person for an outpatient total joint."

The motivated patients bode well for continued ASC industry growth. Dr. Joyce and his partners see the value in performing more total joints in a physician-owned setting.

"Health organizations are getting very large," he says. "I think surgeons, who are ultimately face-to-face with patients and care for the patients, feel that our ability to dictate important elements of their care is being diluted by larger bureaucracy of the big organizations. With our ASC, we have operational control."

"There are a lot of avenues where innovation is found and brought to us, and we don't have a barrier to entry," says Dr. Joyce. "That's something we all believe in strongly, and if the technology is reasonably priced, we work with surgeons to bring it to the center and evaluate it. Our goal is to make surgeons' lives easier, and we can do that."

Note: Dr. Joyce is a paid consultant of Stryker's ASC business. The opinions expressed by Dr. Joyce are those of Dr. Joyce and not necessarily those of Stryker. Individual experiences may vary.

Note: For more information about Stryker's ASC business, please go here.

Experts point to ASCs as providers of safe, efficient and cost-effective care.

Hospital and health systems are building new surgery centers and converting hospital outpatient departments to ambulatory surgery centers (ASCs) to capitalize on low-cost, high-quality outpatient surgical care, according to an industry report published by healthcare strategy firm Avanza Strategies.

The report says 76% of larger hospital systems across the country are increasing their investments in ASCs. Last year, 75% of hospitals with 200-plus beds owned more than one ASC, a trend that highlights the collaborative stance hospitals have toward surgery centers. The pandemic has also highlighted the importance of providing surgical care outside of hospitals when appropriate, and further reinforced the importance of hospitals adding ASCs to their portfolios, according to Avanza Strategies.

Another industry report issued by Global Market Insights (GMI) says the compound annual growth rate (CAGR) of the ASC market is expected to increase by 6.1% through 2027. The growth is due in part to a geriatric patient population that is prone to chronic disease states and a rising overall demand for minimally invasive surgery that leads to improved patient care.

GMI says hospitals are tapping into new technologies and advancing surgical techniques that allow for faster recoveries to move more procedures to ASCs, a factor that is contributing to the expansion and value of the surgery center market. Hospital-owned ASCs were valued at $3.5 billion in 2020, notes the report, which says single-specialty ASCs are also increasing in value, passing $45 billion last year.

The top reasons hospitals own or are affiliated with ASCs include interest in increasing their outpatient surgery capacity, a response to increased patient demand for same-day care and efforts to enhance relationships with local surgeons, according to GMI.

"Gone are the days when hospitals formed joint ventures under pressure from surgeons," notes Avanza Strategies. "They now do it proactively because it's good business."

The move signals the tremendous growth potential of same-day surgery.

Tenet Healthcare Corporation and its subsidiary United Surgical Partners International (USPI) acquired ownership of 92 surgery centers through the purchase of SurgCenter Development (SCD), a national developer of physician-owned ASCs. The $1.2 billion deal provides USPI with ownership interests in more than 440 facilities in 35 states.

The acquired surgery centers are located in high-growth markets in Arizona, Florida and Texas, and in newer markets in Ohio, Indiana, Wisconsin and Maryland. Of the newly acquired centers, 65 are established facilities, while 27 have opened in the past year or will begin operating in 2022. As part of the agreement, USPI and SCD will form a five-year partnership to provide continuity for the physician-owners of the acquired facilities and collaborate on new ASC development projects.

"We are extremely pleased to announce this transformative transaction and partnership, which builds upon USPI's position as a premier growth partner and SCD's track record of developing high-quality centers with leading physicians," says Saum Sutaria, MD, CEO of Tenet Healthcare. "By welcoming these centers into our company, USPI will maintain its reach as the largest ambulatory platform for musculoskeletal services, a high-growth service line. We are also creating a pathway for further expansion through a partnership that pairs the expert development and operational capabilities of our two organizations."

In December 2020, USPI paid SCD $1.1 billion for 60% ownership interests in 45 physician-owned ASCs. Last month, USPI announced it had bought nine ASCs from Compass Surgical Partners located in Florida, North Carolina and Texas. The deal gave USPI 20% ownership stakes in the facilities, and at the time USPI said the transaction was part of a larger strategy to purchase established facilities and accelerate the growth of new facilities.

"We look forward to adding another portfolio of high-quality, well-established SCD centers, as well as those in various stages of development," says Brett Brodnax, president and CEO of USPI. "We're excited to continue our longstanding relationship in partnership with the SCD principals, who have an extremely effective development engine to expand our network of care."