CMS reinstating the inpatient-only list and President Joe Biden's healthcare vaccination mandate were two of the most prominent events in a year of massive flux in the ASC industry.
Thirteen ASC leaders shared their hard grade of Biden and CMS' 2021 performance:
Editor's note: This piece was edited lightly for brevity and clarity.
Amar Setty, MD. CEO of Patient Premier (Baltimore): In general, presidents have less impact on policy than most people believe. In the setting of a global pandemic, however, President Biden has had policies that have both supported and hindered the growth of ASC volume. In sum, there is increasing volume, increasing cost and greater payment uncertainty.
Peter Young. President of HealthCare Strategic Issues (Fort Myers, Fla.): It's important to recognize the CMS agenda has been an evolving, best-practice, triple-aim and value-based care agenda prior to both the current and previous administration. Since Biden took office, CMS issued, in essence, a restatement of triple-aim best practices and appropriate value-based care, as well as a willingness to be open and flexible in carrying out the CMS mandate. CMS is hosting an increased number of stakeholder "listening" sessions to encourage the transition to value-based care. The Biden administration appears to be greenlighting CMS efforts, and that deserves a positive grading of "B."
Earl Andersen. CEO of Tennessee Orthopaedic Clinics (Knoxville): One of the primary issues we've had to deal with under the current administration is the complexity around COVID-19 regulations. Various government agencies have sometimes been either confusing or in conflict over vaccine mandates, testing requirements and other regulations. As a result, frustration has created real stress on healthcare workers, and many have left the industry. Staffing is not optimal to meet the demands of healthcare consumers, and it will be interesting to see how various entities recover from these shortages. I do think ASCs and physician practices are better positioned to recover than entities such as hospitals.
Pavan Chada. CEO of Synergy Spine and Pain Center/Synergy Surgery Center (Glenn Dale, Md.): I'd give CMS a "B." Its worst handling was physician fee reductions and ASC facility fee reductions, on top of the already increased overhead costs to medical practices for providing medical services and medical supplies/equipment.
James Stidham. President of Healthcare Management Associates (Birmingham, Ala.): "B-minus." CMS was indecisive in how they handled the inpatient-only list. It appears on the surface they responded to pressures from outside sources. CMS' own data indicates they must move procedures to the lowest cost facilities to be able to continue to provide the best service to the ever-increasing number of Medicare recipients.
Catherine Retzbach, BSN, RN. Director of ASC Operations for Virtua Health (Marlton, N.J.): I would give them a "C." I know they have many items on their plate, but they are overlooking a great opportunity to save money by not embracing a high-quality, safe-environment site of service. The worst thing CMS did was remove already approved procedures from the ASC-approved procedure list. The procedures had been performed safely in surgery centers. There were no studies showing they could not be performed safely in them. CMS did acknowledge in a small way that hospital outpatient departments and ASCs should be paid the same. They seem to have decided to bring HOPD reimbursement down to the ASC level instead of bringing ASCs closer to HOPD rates.
Sylvia T. Folkins, BSN, RN. ASC Nurse Supervisor at the Rockwood Eye Surgery Center (Spokane, Wash.): I'd give CMS an "F." The worst thing they did was the vaccine mandate for healthcare workers.
Chhaya Patel. Medical Director of Ambulatory Anesthesia and Assistant Professor at Emory School of Medicine (Atlanta): I would give CMS a "B" for its handling of 2021. The last two years in the healthcare industry have been the most challenging in recent memory. We are still recovering from a pandemic that has led to burnout among frontline workers, workforce shortage, higher labor cost and supply chain issues that have negatively impacted patient care. Despite these challenges, ASCs have been steadfast during this crisis in providing lower-cost procedures without compromising patient outcomes or quality of care.
CMS penalized the healthcare industry by shifting procedures safely formed at ASCs to the hospital without much clinical evidence or outcome data. Another gut punch to the physicians was the physician payment cuts in the midst of this pandemic at a time when physician practices are still recovering the personal and financial impacts of the COVID-19 public health emergency. We must continue to advocate for our patients to provide safe, accessible and cost-efficient care.
Ashlie Cramer, MSN, RN. Clinical Administrator of Lakewood Ranch Surgical Suites (Sarasota, Fla.): Variations of the ASC-approved procedure list is one area that I believe CMS could improve on in 2022. We have seen the overall shift of patient preferences and surgeons' necessity to move cases to ASCs, and CMS has not ignored this. We would like to see even more cases included as we move forward. Inclusion of facilities in this determination would be a great opportunity! CMS should pilot facilities to test and track outpatient results for higher-acuity patients.
Carole Guinane, RN. Executive Director of ASC Operations at Cedars-Sinai (Beverly Hills, Calif.): "A-minus." Here's why:
- CMS moved swiftly to offer assistance.
- Its financial programs for the surgery centers were a positive.
- CMS allowed surgery centers to function as hospitals without walls, which was instrumental in keeping elective surgeries going.
- CMS removed telemedicine barriers.
- A focus on COVID-19 infection and prevention strategy and tools was quite useful.
Andy Ball. CEO, Beverly Hills (Calif.) ASC Venture: "B-minus." I think enough has been written about the uncertainty created by CMS' abrupt decision to halt the elimination of the inpatient-only list and to add back the vast majority of procedures removed from the list in 2021. However, the ASC quality reporting measures are also lacking and fail to account for the shifting acuity and complexity of cases being performed in our surgery centers. We are collecting a lot more data than we have ever before, but we need to make sure it is smart data. We are constantly dialing in best practices that result in better patient care and better outcomes, and it's easy to believe that the more data you gather, the better you will perform.
However, in order for the measures to be useful, they need to be appropriate and specific and not just an exercise in data collection. We need to be able to act on the data. Our focus over the last couple of years has been toward patient-reported outcomes: Do we see better outcomes for patients using one implant over another? Do patients undergoing robotic procedures do better in the long term? Can we reduce or eliminate the use of narcotics in surgery and postoperatively, while ensuring patients can recover in comfort and be discharged home? The quality reporting measures currently lack imagination and are of limited use in driving real improvements in quality and outcomes.
Curtis Collins. COO of Palmetto Surgery Center (Columbia, S.C.): "F." CMS caved in to big hospital systems in regards to:
- The orthopedic procedures that could be safely performed at surgery centers with a significant taxpayer savings.
- The mandate for all team members to be vaccinated at CMS-accredited facilities.
Trudy Wiig, RN. Administrator and Managing Officer of Kerlan-Jobe Surgery Center (Los Angeles): The single thing that CMS waffled and fell on, in deference to their alleged mission of saving money, was giving in to the hospital lobbyists related to the types of procedures that can be performed safely in an ASC setting. Hospitals continue to hang on to the final vestiges of surgical procedures that should be performed, for most, in an ASC setting. Taxpayers, CMS and upcoming CMS recipients cry foul. They are or will be adversely affected by laborious admission processes, subjected to excessive hospital-acquired infection rates, minimal registered nurse care post-procedure and greater dollars spent per recipient, among a few factors that differentiate ambulatory surgical settings.
These are some reasons why ASC patient satisfaction rates far exceed the hospital rate. ASCs do ambulatory/outpatient surgery or procedures best, more efficiently and at a lower cost than hospitals or hospital outpatient departments, who receive three times the reimbursement of ASCs for the same procedure. If CMS is going to cater to hospitals on the strongholds, fine — let there be parity for the same procedure regardless of the setting, be it the hospital outpatient department or the ASC.