In response to the AXO BILL Blog post “Surgery Center Deaths: Who Is to Blame, If Anyone?”, Dr. Vincent Jaeger, M.D. penned his comments:
Ambulatory Surgical Centers (ASCs), or outpatient surgical centers, exclusively provide surgical and medical procedures with the expectation that the patient will not need hospitalization nor exceed a twenty-four-hour stay. The first ASC was created because physicians were seeking a high-quality, cost-effective alternative to inpatient hospital care. The growth in ASCs is primarily attributable to the numerous benefits they provide for the patient. Numerous technological advancements and less invasive techniques over the last 40 years has caused a shift in the procedures that can be safely performed in an ASC.
Forty years ago, virtually all surgeries were performed in hospitals. Waits of weeks or months for an appointment were not uncommon, and patients typically spent several days in the hospital and several weeks out of work in recovery. ASCs specialize in providing patients who can walk in and undergo same-day procedures that are more intensive than those done in the doctor’s office, but not as extensive as to require a hospital stay. Faster acting and more effective anesthetics and less invasive techniques have driven this outpatient migration.
As a surgeon for many years, I was asked by Michelle Sperka to review a newspaper article, available at: https://www.usatoday.com/story/news/2018/03/02/medicare-certified-surgery-centers-safety-deaths/363172002/ and comment on its validity in this day and age in the performance of surgical procedures. The contents of the article present an argument that ASCs may be hazardous places of service because of their inability to handle moderate to severe surgical complications that may develop during or after surgical procedures. To support their claims, the authors offer a number of videos of family members who sadly suffered from the loss of a loved one because of perioperative or postoperative complications caused by inadequate care which should have prevented or properly treated those patients within the confines of these facilities. In my opinion. each video portrays a single incident that occurred by single families and, in no way, takes into account the many advantages that ASCs have produced over the years. In addition, these unfortunate incidences account for an extremely small percentage of the total number of patients safely treated in ASCs.
In response to their argument, anyone can make a negative allegation about anything if the only data collected proves their point of view while disregarding the rest of the data which would refute the authors’ original supposition. For a proposition to be considered truthful, one must look at and critically analyze the entire scope of data before one can reach a convincing conclusion. For instance, one can say that laparoscopic cholecystectomy should be banned as a surgical procedure because deaths have been reported to occur during and after the operation. They fail to consider the big picture where laparoscopic cholecystectomy has been proven to be beneficial in many ways by scientific evidence found in well-conducted studies in the medical literature.
Before the emergence of ASCs, all surgeries were performed in the inpatient hospital setting. I can remember when the patient’s inpatient stay after an inguinal hernia repair was 7 days. Now hernia repairs are almost exclusively done in ASCs where the patient undergoes the procedure with the benefit of returning home on the same day, while, in addition, reaping the many other advantages listed below. If the procedure is being performed at a surgery center and there’s a complication, the patient will likely be transferred to a local hospital by calling 911.
A hospital setting provides a comprehensive range of health services and is mostly reserved for treatment of sicker patients who are considered to be of moderate to high surgical risks, have coexisting medical conditions, especially the elderly, which may increase the possibility of well-known perioperative or postoperative complications, patients who require monitoring overnight, and patients expected to have an extended recovery. Moreover, hospitals can be a hazardous place for healthy patients. For example, it has been proven that the infection rate in ASCs is half that of hospitals.
The Advantages of ASCs:
- Recovery is faster
- The lack of occurrences to a wide range of complications, such as, wound infections, urinary tract infections, pneumonia, blood clots, and the need for blood transfusion
- The Centers for Disease Control and Prevention has shown that approximately 8.95 in 1,000 patients developed a surgical site infection in the hospital setting, as compared to only 4.84 in 1,000 patients who had surgery at an ASC
- Shorter wait times for scheduling of surgical procedures
- Schedule disruptions to accommodate emergency cases are very rare
- Hospital transfer at time of discharge from the ambulatory care center to a hospital is a rare event.
- Offer more personal attention because they may only be performing several surgeries each day versus a hospital that must potentially accommodate and care for many more patients.
- One study found that 92% of patients were satisfied with the medical care and service received at an ASC
- With no overnight stays, facility fees can be reduced significantly when compared to hospital programs
- Current Medicare payment policies reimburse ASCs, on average, 58 percent of the reimbursement for similar procedures performed in a hospital setting
- It has been shown that ASCs are 45-60% less expensive than hospitals, which provides significant savings to patients, insurers and taxpayers.
- Medicare saves $2.6 billion each year because it pays significantly less for procedures performed in ASCs, when compared to the rates paid to hospitals for the same procedures.
- Patient co-pays are significantly lower when care is received in an ASC.
- Save patients and their families valuable time
- More convenient locations
- Onsite parking
Disadvantages of ASCs:
- No overnight facilities.
- In the rare event of a surgical complication and emergency, transfers to a close by hospital may occur.
- Federal regulations limit the scope of surgical procedures reimbursed in ASCs
Advantages of Hospitals:
- Hospitals are better able to treat emergencies and complications in the unlikely event that they should arise
- Hospital are also able to handle procedures that require expensive overnight or longer stays and recoveries.
- Most diagnostic testing, if needed, can be performed on site in a hospital
Physicians have traditionally been the primary investors in ASCs. Recent publications report that physicians maintain ownership stakes in approximately 83 percent of ASCs and fully own approximately 43 percent. Given the history of their involvement in making ASCs a reality, it is not surprising that physicians continue to have at least some ownership in virtually all (90%) ASCs. But what is more interesting to note is how many ASCs are jointly owned by local hospitals that now increasingly recognize and embrace the value of the ASC model. According to the most recent data available, hospitals have ownership interest in 23% of all ASCs and 2% are owned entirely by hospitals. Of interest is the fact that physicians who do not have ownership interest in an ASC (and therefore do not benefit financially from performing procedures in an ASC) choose to work in ASCs in such high numbers.
ASCs are highly regulated by federal and state entities. The safety and quality of care offered in ASCs is evaluated by independent observers through three processes: (1) state licensure, (2) Medicare certification and (3) voluntary accreditation. In addition to state and federal inspections, many ASCs choose to go through voluntary accreditation by an independent accrediting organization. Accrediting organizations for ASCs include The Joint Commission, the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF) and the American Osteopathic Association. ASCs must meet specific standards during on-site inspections by these organizations to be accredited. All accrediting organizations also require an ASC to engage in external benchmarking, which allows the facility to compare its performance to the performance of other ASCs.
Authored by Dr. Vincent Jaeger, M.D. Find him on LinkedIn:https://www.linkedin.com/in/vincentjaegermd/