When the Centers for Medicare and Medicaid Services (CMS) proposed a new fire safety code for ASCs and other health care facilities, the agency most likely did not anticipate a firestorm of criticism and concern. All the major ambulatory surgery organizations are urging CMS to change the proposal, joining more than 100 provider groups that have filed comments.
Ambulatory surgery groups say the proposed change would cost the typical ASC $30,000 to $50,000 per operating room, just to meet one part of the Natonal Fire Protection Association's 2000 Life Safety Code. Experts say the costs to the ambulatory surgery industry could exceed $450 million.
"The effect of these costs could be devastating [to ASCs]? Because of the cost savings that ASCs offer the Medicare program and its beneficiaries, driving ASCs out of business due to onerous, costly and unnecessary government mandates will cost the government and our nation's elderly money," said Kathy Bryant, Executive Director of the Federated Ambulatory Surgery Association (FASA), in comments submitted to CMS.
Currently, CMS is reviewing comments submitted by provider groups prior to publishing the final rule. While some ASC experts expect the final rule to be handed down this spring, CMS officials indicate they are taking provider protests seriously.
"We expect to have a published rule by the end of 2002," says one CMS official, adding that the compliance timetable will most likely be extended beyond the usual 60 days from the effective date.
The problem relates to a long lapse in updating the Life Safety Code required for Medicare certification. All ASCs and health care facilities built before 1997 were required to comply with the 1985 Life Safety Code or earlier versions. Surgery centers built since 1997 complied with the 1997 Life Safety Code. Now, CMS wants all ASCs to comply with the 2000 Life Safety Code and does not offer to "grandfather" existing centers that comply with a much earlier code.
"?Grandfathering' facilities that are already Medicare-certified may be necessary, because we believe that many ASCs, particularly smaller ones, could not fully comply with the 2000 LSC no matter how much money they spent," noted Lawrence Pinkner, MD, President of the American Association of Ambulatory Surgery Centers (AAASC), in comments to CMS.
The most costly retrofit would involve converting from a Type 2 or 3 Essential Electrical System (EES) to a Type 1 EES. Hospitals are required to have a Type 1 EES, which incorporates powerful generators and compatible wiring to provide continued electrical service during a power outage. The Type 2 or 3 EES followed by most ASCs relies on a small generator or batteries as power back-ups.
ASC organizations contend that a Type 2 or 3 EES is adequate for ambulatory surgery because procedures generally don't exceed 90 minutes, patient recovery doesn't exceed four hours, and the non-life-threatening procedures don't result in extensive blood loss.
"Given there are no examples of patient harm under existing [fire safety] rules, we believe it is unwarranted to impose these kinds of costs," says Ms. Bryant. A survey conducted by FASA shows that only 15 percent of existing ASCs have a Type 1 EES; more than eight out of 10 surgery centers would need to purchase expensive generators and retrofit.
"This is unfortunate for smaller, single-specialty ASCs. They already have safety procedures in place, and it's a real hardship for them to retrofit," notes Yvonne Bley, administrator for the Wills Eye Hospital surgery centers in Pennsylvania and New Jersey (they all comply with the 1997 Life Safety Code).
Meeting the 2000 Life Safety Code also would require ASCs to install emergency lighting that illuminates escape routes for 1.5 hours, protect stairwells so fire and toxic gases can't spread from one level to another, and install alarm systems that notify local fire and emergency departments. ASCs in buildings without sprinkler systems would be required to separate areas with fire-rated corridor walls.
CMS officials point out that the proposed 2000 Life Safety Code does allow waivers for "undue hardship" on a case-by-case basis. But many say this would be a bureaucratic nightmare for individual ASCs and CMS.
"We expect that CMS will receive a large number of applications for case-by-case waivers from specific provisions of the Life Safety Code due to undue hardship. Responding to the high volume of waiver requests on a timely and efficient basis will have a significant impact on the agency's resources," warns C. William Hanke, MD, President of the Accreditation Association for Ambulatory Health Care (AAAHC). "Therefore, we urge CMS to include in the final rule a provision allowing ASCs currently in compliance with the 1985 edition of the LSC to maintain their compliance."
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