Trend to Watch: Cardiology Cases on the Move to ASCs


The shift of procedures to the outpatient setting is increasing access to cost-effective and high-quality care.

When Woodrow Moore needed a balloon angioplasty and single stent implant, he chose to have the procedures performed at the Texas Ambulatory Surgery Center in Katy. Fixes like these are routine for the cardiovascular outpatient center, with each surgery lasting about an hour. There was nothing particularly unusual about the experience except that Mr. Moore is the founder of the center and a well-known ASC developer who has long championed the benefits of migrating interventional cardiac procedures into the outpatient realm.

“My 30-plus years of experience in developing surgeon partnerships and licensed facilities gave me confidence in the well-documented level of care I would receive at an ASC,” says Mr. Moore. “The recent move of CMS adding many ASC-approved cardiovascular procedures is rapidly transforming the space.”

CMS recently added several types of procedures to the ASC Covered Procedure List (CPL), including diagnostic and interventional coronary procedures, peripheral vascular interventions and placement of pacemakers and defibrillators. More procedures are expected to be added to the CPL moving forward. It’s clear the reimbursement landscape is shifting to benefit same-day cardiology care and will help push more cases to the outpatient setting. 

FOLLOW THE MONEY CMS now reimburses for diagnostic and interventional coronary cases performed in ASCs, a development that is contributing to the shift of cases from inpatient hospitals to ambulatory settings.

Mr. Moore says moving cardiovascular procedures to ASCs provides many advantages for patients, including convenience and quality of care. “Based on ASC quality benchmarks alone, I had less of a concern of infection as opposed to the hospital setting,” he adds.

The overall patient experience was overwhelmingly positive for Mr. Moore. “My cardiovascular surgeon and the ASC personnel were safe, communicative and efficient throughout my short procedure, brief recovery period and discharge,” he says. “I was very pleased, yet not surprised.”

Mr. Moore has spent decades advocating for changes in outpatient care, and he admits that there can be challenges to establishing a cardiovascular ASC that is ultimately successful. “The ever-increasing regulatory compliance requirements and receiving fair reimbursement are heavy burdens,” he admits.

Gregory J. Dehmer, MD, medical director for quality and outcomes at the Cardiovascular Institute at the Carilion Clinic in Roanoke, Va., says cardiac surgery centers are able to focus on enhancing patient care. “Patients facing heart catheterizations used to be admitted to the hospital the day before they had the procedures done and remained until a day or two after,” he says. “Those days are long gone. Now, patients are likely ready for discharge four to five hours after procedures. Patients would rather go home than be hospitalized.”

Outpatient centers offer efficient scheduling that enhances the patient experience and leads to cost savings, points out Dr. Dehmer. “You don’t have the same overhead at an ASC that you do in a hospital,” he says. 

As a professor of medicine at the Virginia Tech Carilion School of Medicine, Dr. Dehmer spends a lot of time discussing the newest advances in cardiology with medical students. While much of the focus is on improving technology, he says there are other considerations about when and where certain treatments are pursued.

Some caution is advised as more cardiology cases move to ASCs, says Dr. Dehmer, such as overzealous physicians who might try to treat at-risk patients in an outpatient setting. “A significant difference between performing procedures in a freestanding facility versus a hospital,” he explains, “is that you have to transport patients who are having complications to an emergency department.”

Dr. Dehmer would like to see more data about the safety of cardiac care performed in outpatient facilities as opposed to hospital settings. “You have to follow the rules and be conservative about the patients you treat,” he explains.

ASCs are well known as quality, low-cost options for patients, physicians and payers alike. Freestanding ASCs were first developed by independent surgeons who wanted more control over when and how they could treat patients. But they faced some challenges, such as being able to sustain these outpatient centers without a connection to a major hospital network, and being able to easily work with insurers and advisory groups.

Mr. Moore, who is doing very well after undergoing his cardiac procedure, says the patient experience, convenience and cost benefits still make outpatient centers a smart investment. “There are many advantages to being able to treat patients safely in surgery centers,” he says. “Cardiology physicians in general are now realizing that.”

Meeting increased demand

HANDS IN Physicians, patients and insurers prefer the cost-effective and convenient care available at ASCs and will continue to push more cases to the outpatient setting.

The Little Rock-based Arkansas Heart Hospital is expanding into Texas with a 21,000-square-foot facility that will include a full cardiac clinic and an ambulatory surgery center. The center will feature fully equipped hybrid cauterization labs and pre- and post-operative rooms with a focus on general and interventional cardiology, as well as electrophysiology, cardiac imaging, and vein and vascular services.

Similarly, Spectrum Health invested more than $23 million in a new outpatient surgical center in Grand Rapids, Mich., that handles non-emergent diagnostic cardiac catheterizations, stenting and other percutaneous coronary interventions. Medical societies, including the American Heart Association and the Society of Cardiac Angiography and Intervention, have come on board with support for outpatient cardiac treatments.

In 2021, Banner Health partnered with ASC development firm Atlas Healthcare Partners and physicians group Cardiac Solutions to open a freestanding cardiac ambulatory surgery center serving the greater Phoenix area. Banner Cardiovascular Center, which was built in Sun City, Ariz., is the first of its kind to offer outpatient cardio-specific care in the region. The facility has three cath labs and the ability to conduct diagnostic heart cauterizations and heart stenting, and place electrophysiology stent implants and pacemakers.

Joan Thiel, vice president of ambulatory services at Banner Health, says, “The decision to open a freestanding cardiac ASC is part of our overall strategy to offer value-based care for patients.” The system is interested in aligning with independent physicians while facilitating the recruitment and retention of Banner’s own cardiologists.

Some of the most common procedures being performed at the Banner Cardiovascular Center include placement of pacemakers, loop recorders and AICD implants, heart catheterizations and stenting. In fact, instead of inserting a catheter in the groin, new stenting can be done by inserting the catheter into the wrist, allowing for fewer complications, faster recovery and earlier discharge.

“The time savings for a cardiac patient on the day of the procedure can usually be measured in fewer hours compared with the same procedure performed in a hospital,” says Ms. Thiel. “The ASC doesn’t treat emergent cases, which often cause procedural delays and cancellations in the hospital setting, so procedures typically start and end on time.”

Since the Banner Cardio-vascular Center opened last year, more than 400 patients have been treated. Banner Health also has plans to open a second location. “Cardio-vascular ASCs provide tremendous benefits to patients, providers and payers,” says Ms. Thiel. “Patients receive care from their physicians in a convenient and comfortable center, often with a dramatically lower co-pay. They also enjoy a more personal touch in a pleasant environment and are treated and discharged the same day.”

She says cardiovascular providers also have the option of choosing the setting best suited for each patient’s condition. For example, a more at-risk individual will be treated in the hospital while lower-risk patients are sent to the ASC. Payers also benefit by having a value-based site-of-service option for their patients. 

Cardiovascular ASCs provide tremendous benefits to patients, providers and payers.
— Joan Thiel

Future expansion

Outpatient cardiac care generally costs 30% to 40% less than in the hospital setting, savings that are shared by the payer and the patient. As more cardiac ASCs open, Ms. Thiel expects payers and patients to benefit from even more cost savings. “Medicare’s addition of heart stenting to the ASC CPL in 2020 was a watershed moment in the outmigration of cardiac care,” she says. “We expect Medicare to continue to add cardiac cases to the CPL and the rapid growth of cardiovascular ASCs, both by health system and independent cardiology groups, will continue.”

More professionals within the industry are seeing the value of outpatient cardiology. “Despite the challenges,” says Ms. Thiel, “it appears there is a bright future for cardiovascular care in ASCs.” OSM

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