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ADVOCACY SPOTLIGHT


example is especially pertinent, with CMS taking total hip arthroplasty (THA) off the Medicare Inpatient-Only (IPO) list in the CY 2020 OPPS/ASC Proposed Payment Rule.


Outpatient Total Hip Arthroplasty Performed at an Ambulatory Surgery Center versus Hospital Outpatient Setting: Complications, Revisions, and Readmissions Published in The Journal of Arthroplasty, July 2019 This study looked


at almost 1,000


outpatient THA episodes performed by two surgeons from 2013 to 2018, with more than 300 THAs performed in an ASC and the remaining 600 performed in the HOPD. The authors state that to their knowledge it is the first study to directly compare safety profiles of patients undergoing outpatient THA in a freestanding ASC versus HOPD. However, it is important to note that the authors did not match underlying patient comorbidities and even acknowledge that ASC patients were younger and healthier (possibly due to patients over 65 being ineligible to have their surgery in an ASC due to the lack of Medicare reimbursement for the procedure). The authors found no difference in 90-day complications, revisions, reoperation, readmission or emergency department visits and conclude that with appropriate patient selection protocols, THA can be safely performed on an outpatient basis at ASCs.


How it impacts ASC advocacy: As previously mentioned, CMS removed THA from Medicare’s IPO payment list in 2020. Although this will not make the procedure eligible for reimbursement for Medicare patients in ASCs, it is the first step on that path by allowing for reimbursement in other outpatient sites of service. Total knee arthroplasty (TKA) was removed from the IPO list in 2018, and CMS made it eligible for ASC reimbursement in 2020. Although many ASCs have been performing


total joint replacements and similar complex orthopedic procedures for years, CMS tends to be more reticent to begin reimbursement for outpatient procedures than private payers. Therefore, advocacy to CMS in support of moving complex surgical procedures to the ASC space must involve definitively showing patient outcomes at ASCs equal to or better than other sites of service. A study such as this one shows that surgeons are already performing THA in ASCs with no adverse outcomes and that proper patient selection protocols make the procedure a good candidate for ASC payment by Medicare.


Cost-Focused Study


The final type of research study that can be instrumental as an advocacy tool looks at cost rather than clinical outcomes. The idea of healthcare “value” as a measurable concept that incorporates both cost and quality considerations has arguably been the defining characteristic of healthcare policy this century, according to a column “Can the Value Proposition Work in Health Care?” published in Inquiries Journal, volume 10, in 2018. Therefore, to truly achieve healthcare value, one must consider the cost of care at differing sites of service when quality is comparable.


Medicare Cost Savings Tied to Ambulatory Surgery Centers University of California-Berkeley, September 2013


This study commissioned by ASCA and performed by researchers at the University of California-Berkeley’s Nicholas C. Petris Center on Health Care Markets and Consumer Welfare examined ASCs’ cost-saving effects on the Medicare program. Researchers focused on the 120 procedures most commonly performed in ASCs, which represented almost three quarters of total procedure volume in 2011. They found significant single-year savings for several high-volume procedures,


32 ASC FOCUS JANUARY 2020 | ascfocus.org


including $829 million saved by Medicare on cataract surgery alone in 2011. In total, from 2008 to 2011, the lower reimbursement for procedures performed at ASCs as compared to HOPDs and physician offices saved Medicare and its beneficiaries $7.5 billion. These savings could be even greater if not for the growing disparity between ASC and HOPD payments and the slowed migration of even the most common, safe outpatient procedures. At the time of the study, the authors projected that possible Medicare savings due to ASCs could exceed $50 billion over 10 years, a goal that has likely not been achieved due to federal payment policies.


How it impacts ASC advocacy: Anybody who has ever been to a congressional office or federal agency to advocate for ASCs knows that lawmakers and regulators are singularly focused on program costs. As stewards of public money, they must be cautious about advocating for any policies that will cause the government to spend more. Conversely, policies that save money while delivering health outcomes that are the same, or better, are viewed favorably. In this sense, research studies such as this one show that ASCs have an incredibly strong case to make as preferred sites of service for eligible outpatient surgeries in the Medicare program. ASCs should have seen greater migration of baseline procedures such as cataract surgery and colonoscopies, procedures that have been proven many times over to be safe and very cost-effective to perform in an ASC. Leveraging cost research alongside quality data might be the most powerful tool to show lawmakers and regulators the untapped savings potential of ASCs for public and private payers alike.


Alex Taira is ASCA’s regulatory policy and research manager. Write him at ataira@ ascassociation.org.


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