It's been a few weeks since 2020 ended.
I think it's safe to say that we're all still processing what happened — and will likely be doing so for quite some time. What we do know already is that events from last year will forever reshape healthcare while also having significant short- and long-term effects on the ASC industry.
While we experienced severe challenges as a result of the pandemic, the ability to pivot in times of crises displayed the resilience and fortitude of the country's healthcare workers and the entire ambulatory surgery community. In this retrospective, I will begin by looking back at some of the greatest challenges affecting the ASC industry in 2020 but will then focus on and celebrate the many positive developments that occurred last year.
COVID-19 pandemic
Is there any other development that could have led this list? It's been roughly a year since the first confirmed case of the 2019 novel coronavirus in the United States. In March, the World Health Organization declared COVID-19 a pandemic. Around the same time, COVID-19 was declared a national emergency in the United States.
Delaying of elective surgeries
On March 18, the Centers for Medicare & Medicaid Services (CMS) announced that all elective surgeries should be delayed. As CMS stated in a press release, "This will not only preserve equipment but also free up our healthcare workforce to care for the patients who are most in need."
The following day, the Ambulatory Surgery Center Association (ASCA) provided guidance to ASCs concerning what cases and surgeries should and should not be postponed and how to reduce safety risks, among other issues of significance.
In the coming days and weeks, ASCs nationwide either shutdown or significantly scaled back operations.
Elective surgeries resume
In mid-April, with the first wave of the pandemic seemingly over, guidance was issued concerning how ASCs and other surgical providers could safely resume performing elective surgery. Included in the guidance were a number of safety recommendations intended to help keep patients, staff and communities safe. Which brings us to our next development…
PPE and other supply shortages
The pandemic created immense demand for personal protective equipment (PPE) and other supplies critical to helping ensure safety. This demand was fueled not just by the healthcare industry but essentially all other industries, consumers and countries. Competition was fierce for face masks, eye protection, medical gloves, respirators, gowns, goggles, cleaning and disinfection supplies, thermometers and many other supplies.
ASCs answer the call
To help their communities, ASCs nationwide shared PPE, other supplies and equipment and even staff with the hospital, health systems and frontline providers caring for COVID-19 patients. Some surgery centers — including clients of ours — enrolled in the Hospitals Without Walls program. This allowed them to provide hospital services and perform procedures typically done in a hospital that should not be delayed, such as cancer procedures and trauma surgeries, while receiving temporary billing privileges as a hospital.
Within ASCs, as well as many other provider organizations, healthcare workers stepped up and risked their own health and wellbeing to help protect and provide care for their patients. Physicians, nurses, and all other healthcare workers were truly 2020's heroes.
Revamping ASC operations
Safety has always been a cornerstone and defining quality of ASCs, which undoubtedly played a role in helping surgery centers quickly and effectively adapt their operations to the challenges presented by the novel coronavirus. Changes that occurred — many of which remain in place today — included pre-screening patients, screening staff, requiring patients to undergo a COVID-19 test prior to surgery, face mask requirements, enhanced sanitation protocols and barring care partners (i.e., visitors) from entering the facility, unless their presence is necessary for patient safety.
Development of COVID-19 vaccines
Before 2020 ended, we got some very good news. On December 11 — roughly one year after SARS-CoV-2 was discovered in China — the U.S. Food and Drug Administration (FDA) issued the first emergency use authorization (EUA) to the Pfizer/BioNTech COVID-19 vaccine. A few days later, the first American received the coronavirus vaccine outside a clinical trial. And a few days after that, the FDA issued its second EUA to the Moderna COVID-19 vaccine.
I hope that my look back at 2021 leads with the ending of the pandemic and achieving of "herd immunity."
ASC-covered procedures list grows significantly
If not for COVID-19, 2020 would likely be considered one of the best years for ASCs. The 2021 final payment rule for ASCs and hospital outpatient departments, which was released in early December, finalized the addition of nearly 270 codes to the ASC covered procedures list (ASC-CPL) for 2021. In addition, the finalizing of a proposed revision to ASC-CPL criteria resulted in 256 additional codes being added to the ASC-CPL.
Total hip arthroplasty added to list
Perhaps the most significant procedure added to the ASC-CPL for 2021 is total hip arthroplasty (THA). My 2019 ASC industry roundup led with the addition of total knee arthroplasty (TKA) to the list and included a note near the end of the piece wondering whether THA would be added in 2020. The answer was "yes."
Becker's ASC Review recently identified more than 500 ASCs with total joint replacement programs. We can expect that figure to increase going forward, especially if — or, more likely, when — additional total joint replacement procedures are added to the ASC-CPL.
Elimination of the inpatient-only list
Also included in the final rule was CMS finalizing its plan to begin eliminating the inpatient-only list by 2024. CMS began this transition by removing roughly 300 primarily musculoskeletal-related services in 2021. By 2024, the full list of 1,700 procedures will be phased out and approved for payment in the outpatient setting, when clinically appropriate. This will hopefully encourage further additions of procedures to the ASC-CPL.
Analysis shows ASCs save Medicare billions
An analysis published in September further demonstrated the value that ASCs deliver — in this case, the financial value. Analysis performed by KNG Health Consulting revealed that ASCs now reduce Medicare costs by more than $4 billion annually, with a projected annual savings of $12 billion by 2028.
Medicare beneficiary cost sharing for colorectal cancer to be phased out
Near the end of 2020, the "Consolidated Appropriations Act, 2021" was signed into law. The law brings good news for gastroenterology patients, as ASCA notes: Under the bill, Medicare beneficiary cost sharing for colorectal cancer screening will be phased out between January 2022 and January 2030. This would ensure that if scheduled screening colonoscopies become therapeutic, Medicare beneficiaries will not face copayments.
2020 election brings a new administration
With 306 electoral votes, Joe Biden defeated Donald Trump and will serve as the country's 46th president, with Kamala Harris serving as the vice president. The Democratic Party maintained control of the U.S. House of Representatives and took narrow control of the Senate in early January after winning two runoff elections in Georgia. This is obviously significant news. What we don't know yet is how the change in administration and control of Congress will affect ASCs.
Hospital pricing transparency goes into effect
While this is technically a 2021 development as it took effect on Jan. 1, 2021, hospital pricing transparency was a matter of significant discussion, debate and lawsuits throughout 2020 (which have continued into 2021). Under the hospital price transparency rule, which was finalized and released in November 2019, all U.S. hospitals are now required to provide clear, accessible pricing information online about the items and services they provide via a comprehensive machine-readable file and in a display of shoppable services in a consumer-friendly format. CMS has announced its plans to audit hospitals for compliance in addition to investigating complaints and reviewing analyses of noncompliance. Hospitals may face civil penalties for noncompliance.
As I noted in previous columns, the availability of such data can only help ASCs support the argument that they usually represent a lower-cost option — and one that is typically higher-quality — for surgery compared to hospitals.
Meetings go virtual
Essentially all national and state meetings hosted in 2020 were virtual — a trend that is continuing into 2021, as ASCA has announced its annual meeting will once again be entirely virtual. As ASCA states, "The uncertainty around the length of the pandemic, along with our priority on protecting the health of every attendee, prevents us from hosting a live event the size and scope of our in-person annual conference."
Meeting organizers deserve significant praise and appreciation for working to host engaging educational events virtually in these unusual, difficult times. I am confident, though, that they, like most of us, eagerly look forward to the return of live events and the in-person experiences that cannot be effectively replicated in a virtual manner.
ASC celebrates 50 years
On February 12, the ASC industry celebrated its 50th anniversary. It was on this date in 1970 that the first ASC was reportedly established by Wallace Reed, MD, and John Ford, MD, in Phoenix, Ariz. Fifty years is quite an achievement!
Looking into the crystal ball…
I like concluding these pieces with a list of questions that I think may be answered in the year ahead. Considering the year that we just finished, which no one could have imagined, I'm sure I will look back on this list a year from now and recognize that I omitted what will turn out to be some important questions. Even still, here goes:
● Will we be able to declare the pandemic over in 2021?
● How will the first year of a new administration and Democrat-controlled Congress affect ASCs? Will there be many changes with so much focus on the pandemic and economy?
● What will happen with the Affordable Care Act? While we're not likely to see a move toward the Medicare-for-all single-payer system, will we see expansion of Medicare Advantage plans?
● Will we see the likes of total shoulders and/or other total joint replacement procedures added to the ASC-CPL?
● How will reduced case volumes in 2020 caused by the pandemic impact capital investments?
● We know cases will continue to migrate out of the inpatient setting and into the outpatient setting. Will the pandemic and/or new administration further accelerate that migration?
● How much more aggressive will we see the likes of hospitals, health systems and possibly payers in acquiring and/or building ASCs?
● Will new development (de novo) activity pick up? What about consolidation?
● Will the migration incentivize more private equity activity in the space?
● How will the pandemic affect safety requirements/standards and surveys (e.g., Medicare, accreditation, OSHA)?
You can continue to count on Surgical Notes to closely watch and share these and any other development that will or may impact the ASC industry. Doing so ensures we are able to respond efficiently and effectively to activities affecting our clients and the delivery of 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 (rbishop@surgicalnotes.com) is president and chief executive officer for Surgical Notes. Surgical Notes is a nationwide provider of revenue cycle solutions, including, transcription, coding, revenue cycle management (RCM), and document management applications for the ASC and surgical hospital markets.