The Rise of Ambulatory Surgery Centers

By Joseph Pawlikowski

For minor surgical procedures, patients are discovering that Ambulatory Surgery Centers (ASCs) are convenient and safe alternatives to hospitals. Simply put, an ASC is a health care facility that performs surgeries in an outpatient setting. A patient arrives at a given time before the procedure and is discharged within hours of completion. For the most part, these are elective procedures.

“ASCs play a very important role in creating a modern, innovative health care system by providing care at a lower cost with better patient satisfaction,” says Mark McClellan, an administrator at the Centers for Medicare and Medicaid Services. “With the challenge of rising health care costs, it is clear to me that innovation and creativity in ASCs can make a big difference in the quality and costs of health care.”

The rise in ASCs is evident in the numbers. In 1997, there were 4,976 hospitals nationally, 81 percent of which offered outpatient surgery. There were 2,644 ASCs that year, 34 percent fewer than hospital outpatient programs. Those numbers took a sharp change by 2003. ASCs had skyrocketed, as 3,877 centers were open nationwide, a 47 percent increase. The number of hospitals dropped to 4,079, though there was a response to the ASC rise, as 94 percent offered outpatient surgery. However, the raw numbers show that those 3,834 hospitals equipped for outpatient surgery did not match the number of ASCs nationwide.

Medicare began reimbursing ASCs in 1980 for 400 different procedures. In 1983, surgeries were performed at 400 ASCs in the US. Through slow and steady growth in the 80s and a surge in the mid-90s, over 4,000 ASCs are now in operation from coast to coast, and Medicare covers over 2,400 procedures.

As recently as 1990, there were 2.3 million surgeries performed annually in ASCs. That number increased nearly 300 percent, to 6.7 million, by the end of the decade. The 00s have been ripe with growth as well, though much more normal and steady. The number of procedures performed annually now exceeds eight million, or a 19 percent increase from 2000.

The scope of procedures available at ASCs has evolved over the years. When ASCs began popping up in the early 1980s, they were mainly centers for plastic surgery. With advances in medical technology and minimally invasive surgery procedures, the proportions changed. Ophthalmologic procedures are now the most common, at 27 percent. Other common surgeries include gastroenterological, orthopedic, and gynecologic procedures. Plastic surgery is still among the most performed, though it has dropped to six percent.

While there are many factors behind the rise in ASCs, three basic elements have contributed most to the growth of ASCs: safety, cost, and patient care.

SAFETY
When undergoing even a simple procedure, patient safety is the ultimate consideration. Hospitals may convey a greater sense of security than a specialized surgery center, but taxing regulations exist for Ambulatory Surgery Centers. “Every requirement of a hospital is present at an ASC,” says Dawn Spencer, administrator at the Center for Ambulatory Surgery in Mountainside.

Forty-three states now regulate ASCs through licensure, and 85 percent of centers are certified by Medicare. There are also four organizations that independently accredit ASCs. “They hold you to a standard a little higher than the next guy,” says Linda Schultz, director of surgical services at the Ambulatory Surgical Center of Union County in Union Township. In addition to government-issued regulatory surveys, accredited ASCs are subject to on-site inspections by their providers.

Doctors have more control over surgical safety in an ASC, whereas a manager oversees such issues in a hospital. The staff and postoperative care measures can be customized to fit the needs of each patient. ASCs are also required to have an active transfer plan with a local hospital should an unforeseen complication arise.

COST
Perhaps the most appealing aspect of ASCs is the financial relief. Because the centers maintain lower overhead costs than hospitals, they are able to offer the same procedures for less money. According to the Federated Ambulatory Surgery Association (FASA), the average procedure costs 47 percent less at an ASC, though there are a few procedures, such as endoscopies and biopsies, that sometimes bear a greater cost. This, however, is more the exception than the norm.

Costs are further controlled due to the highly efficient nature of ASCs. At a specialized center, there is much less set-up and breakdown for surgery than at a general hospital. This allows for more procedures to be performed daily.

The savings are intensified for Medicare beneficiaries; co-payment is 20 percent of the cost of the procedure at an ASC, compared to 40 percent at a hospital. This means the out-of-pocket cost is more intensely magnified. Procedures performed at ASCs are also less burdensome to Medicare, as they pay out an average of $320 less than one performed at a hospital outpatient center.

This cost differential has caused much tension between hospitals and ASCs. Since hospitals often treat patients who have no means to pay, they rely on the income from elective surgeries to replenish the losses. ASCs themselves have been facing competition as well. The same advancements in technology that allow for procedures to be performed in an outpatient setting now extend to office-based surgeries. They are mainly simple procedures for the time being, hernias and arthroscopic joint surgery. But like ASCs, this looks to be an expanding field.

PATIENT CARE
The satisfactory safety and deflated cost of an ASC visit may be practical reasons to choose an ASC, but most ASCs pride themselves most on phenomenal patient care. “Beyond the regulatory stuff that we make sure happens, it’s all about patient satisfaction,” says Schultz. “We’re doing what they can’t do at hospitals.”

According FASA, 98 percent of beneficiaries were satisfied with their ASC experience compared to a 94 percent hospital satisfaction rate. This can be attributed to shorter waiting times, less paperwork, and the ability to spend recovery time with friends and family.

“Surgery is a very apprehensive time,” says Nancy Vick of the Ambulatory Surgical Center of Union County. “No matter what the procedure, it’s not minor to the patient. We offer them the very best in treatment.”

The ASC of Union County offers other services to ensure the satisfaction and comfort of their patients. Since they are not allowed to drive due to the anesthesia, a transportation service is offered to and from the facility. “It is difficult sometimes to find a friend or family member available to drive to and from the surgery,” says Schultz.

Nurses and staff also make pre- and post-op calls to check up on their patients. They offer a friendly voice, speaking to patients about their experience and their recovery, both physically and emotionally.

The Ambulatory Surgical Center of Union County has a unique patient care story. “I first came to the ASC as a patient and I was so impressed with the staff, the warmth of the facility and the care I received, I applied for a job,” says former patient Maciel Gonzalez, who is now scheduling coordinator at the Center. “It’s been more than a year now and I am so glad I became part of the ASC team.”

Ambulatory Surgery Centers are poised for even further growth in the near future. “The more patients that come in, the more patients that will return and spread our message via word of mouth,” says Spencer.

If you are thinking about elective surgery, ask a doctor if an ASC is the right choice for you.