surgery procedures, ASCs are highly regulated, with requirements similar to hospitals, making ASCs a safer alter- native for outpatient surgery.

3. Physician preference Many surgeons demand to operate in an ASC because they can trust their ASC will start their cases on time and minimize the time between cases to get them back to their offices sooner. Also, physician ownership is a hall- mark of the ASC industry and provides an added incentive for moving cases to this lower cost setting. Ownership is not only financial but also helpful in ensuring the physician has a voice in the way the ASC is operated.

4. Operative techniques and technological advances

Improvements in surgical techniques, devices, pharmaceuticals and other innovations have spurred the transition of more complex cases to the ASC. Minimally invasive technologies like arthroscopy, laparoscopy, endoscopy and laser allow big surgeries to be per- formed with minimal discomfort and quick recovery. Drugs like Exparel, which remains active long after the surgery, help avoid inpatient hospital- ization for pain control. Disposable instrumentation addresses sterilization limitations in most ASCs.

5. Innovations in post-recovery care Innovative recovery care techniques that provide a safe, pain-controlled experience after discharge also are driving the shift of surgeries from hos- pitals to ASCs. Options for recovery care have grown significantly and con- tinue to expand. Some ASCs recover patients overnight in their facility. Other ASCs use recovery care, inter- mediate care and skilled nursing facilities (to read an article on post- acute care options, go to www.asc acute-services). Home health is used by many physicians to send patients

home the same day. All these agen- cies are becoming more astute in car- ing for the post-surgical patient, some specializing in certain procedures, like total joints. Most ASCs also have for- malized their methods for engaging the patient’s family/friend support network, which is key for any home recovery situation.

6. Hospitals embracing ASCs With the advent of Accountable Care Organizations (ACOs) and other pay- ment systems that bonus providers for reducing the cost of care while maintain- ing quality, more hospital systems are embracing the ASC model as an impor- tant part of their cost effectiveness strat- egy. Many systems are identifying sur- gical cases that can be safely performed in their ASC and actively moving those cases from the main hospital operating rooms (OR). Many hospitals without an ASC in their network are seeking to acquire an interest in an existing ASC or build a de novo (new) ASC.

7. New surgeons entering the ASC This new spectrum of higher level cases available to be performed in the ASC brings a slew of potential new physician investors who previously simply did not have enough outpatient cases for an investment to make sense. For exam- ple, a total joint specialist, who previ- ously was not seen as someone who could bring many cases to an ASC, is now enjoying a full dance card of suit- ors for these potentially lucrative cases.

Higher Acuity Surgeries Moving to ASCs Based on the key drivers of ASC vol- ume growth, which surgical procedures are most likely to move to the ASC?

Total joints With baby-boomers now reaching Medicare age and beyond, the average age of the US population is increasing. This new population is much more active than generations before. The

number of total joint surgeries per- formed in the US is expected to double over the next 10 years, and nearly all of this growth is expected to be in the out- patient side. With 1 million total joint surgeries currently performed annu- ally, that is an additional 1 million sur- geries per year, much of which will likely be in the ASC setting.


While most spine surgery is performed in hospitals, discectomies, laminecto- mies, laminotomies and other outpa- tient spine procedures are all safely performed in ASCs every day. Spine is very expensive in the hospital setting, which makes the ASC value proposi- tion irresistible to payers, employers and patients. As more and more spine surgeons become comfortable with ASCs, spine will be a big growth spe- cialty for the industry.

Cardiology and vascular Interventional cardiologists and cardio- vascular surgeons, previously limited to hospital ORs and catheterization (cath) labs, are now starting their own ASCs (see ASCA 2018 column on page 10). The Centers for Medicare & Medicaid Services (CMS) has allowed the inser- tion of pacemakers and internal cardiac defibrillators (ICDs) in the ASC for Medicare patients since 2008 and this service is still transitioning to the ASC. Vascular procedures such as vascular stents also are becoming more common in the ASC. Cardiology and vascular procedures will soon be commonplace in the ASC, adding a virtually untapped specialty with significant volume.

And so on

Other specialties like general surgery, gynecology, reconstructive plastics and urology also will experience ASC vol- ume growth for all the same reasons that the other specialties will grow: improved pain control medications and techniques, more options for over- night care and lower cost. We may see


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