Ambulatory Surgery Centers and Interventional Techniques: A Look at Long-Term Survival

With health care expenditures skyrocketing, coupled with pervasive quality deficits, pressures toprovide better and more proficient care continue to shape the landscape of the U.S. health caresystem. Payers, both federal and private, have laid out several initiatives designed to curtail costs,including value-based reimbursement programs, cost-shifting expenses to the consumer, reducingreimbursements for physicians, steering health care to more efficient settings, and finally affordablehealth care reform.Consequently, one of the major aspects in the expansion of health care for improving quality andreducing costs is surgical services. Nearly 57 million outpatient procedures are performed annuallyin the United States, 14 million of which occur in elderly patients. Increasing use of these minor,yet common, procedures contributes to rising health care expenditures. Once exclusive withinhospitals, more and more outpatient procedures are being performed in freestanding ambulatorysurgery centers (ASCs), physician offices, visits to which have increased over 300% during the pastdecade. Concurrent with this growing demand, the number of ASCs has more than doubled sincethe 1990s, with more than 5,000 facilities currently in operation nationwide. Further, total surgicalcenter ASC payments have increased from $1.2 billion in 1999 to $3.2 billion in 2009, a 167%increase. On the same lines, growth and expenditures for hospital outpatient department (HOPD)services and office procedures also have been evident at similar levels.Recent surveys have illustrated on overall annual growth per capita in Medicare allowed ASC servicesof pain management of 23%, with 27% growth seen in ASCs and 16% of the growth seen inHOPD. Further, the proportion of interventional pain management which was 4% of MedicareASC spending in 2000 has increased to 10% in 2007. Thus, interventional pain management as anevolving specialty is one of the most commonly performed procedures in ASC settings apart fromHOPDs and well-equipped offices.In June 1998, the Health Care Financing Administration (HCFA) proposed an ASC rule in which atleast 60% of interventional procedures were eliminated from ASCs, and the remaining 40% facedsubstantial cuts in payments. Following the publication of this rule, based on public commentsand demand, Congress intervened and delayed implementation of the rule for several years. TheCenters for Medicare and Medicaid Services (CMS) published its proposed outpatient prospectivesystem for ASCs in 2006, setting ASC payments at 62% of HOPD payments. Following multiplechanges, the rule was incorporated with a 4-year transition formula which ended in 2010, with fulleffect occurring in 2011 with ASCs reimbursed at 57% of HOPD payments.Thus, the landscape of interventional pain management in ambulatory surgery centers has beenconstantly changing with declining reimbursements, issues of fraud and abuse, and ever-increasingregulations.Key words: Outpatient prospective payment system, ambulatory surgery center payment system,Government Accountability Office, Medicare Modernization and Improvement Act, interventionaltechniques