April 2, 2020

Lower-Cost Procedure Alternatives in an Ambulatory Surgery Center

By Michael Fabrizio, MD, FACS


The national push toward value-based care is transforming many aspects of healthcare delivery, including where specialty procedures are performed. 

Just a few decades ago, virtually all surgeries occurred in hospitals. Yet increasingly, minimally-invasive surgeries are moving out of hospital outpatient programs entirely and into ambulatory surgery centers (ASC), reducing costs by anywhere from 25 to 50 percent.  

In Urology, we have found certain procedures are ideal for an ASC setting and same-day service, including: Endoscopic procedures such as cystoscopy and ureteroscopy, to treat issues such as kidney and bladder stones, bladder and prostate procedures, ESWL (a procedure to break up kidney stones), and even more complex urological procedures. 

Patients should feel confident that a lower-cost procedure in a surgery center will be equally effective and safe – if not safer – than one performed in a hospital. Improvements in operative techniques, anesthesia delivery, pain medications and medical equipment, including advanced robotic tools, have paved the way for faster, less invasive treatments.

For medical practices, ASCs involve lower overhead costs, fewer staffing inefficiencies, greater ease of scheduling, close partnerships between physicians and a dedicated staff and, generally, better control over cleanliness and infection prevention. 

Unfortunately, large hospitals systems often try to leverage their “in-house” insurance plan and forbid participation in these lower cost ASCs, directing patients to higher-cost hospital environments which in turn raises premiums and deductibles for patients and the companies insuring them.

Hospitals also state that if surgeons are allowed to operate ASCs in Virginia, they will only work with insured patients. Nothing could be further from the truth and in fact, most surgical practices provide a significant volume of unreimbursed care for the uninsured or under-insured. In fact, on a percentage basis of revenue, our practice for example provides as much or more unreimbursed care annually as any hospital system.  

While health systems can actually get reimbursed for their unreimbursed care through Section 1887 of the Social Security Act, physicians cannot apply for such reimbursement and are not even allowed to “write off” for tax purposes any of their unreimbursed care. Physicians who own or participate in ambulatory procedures centers will still provide such care, and in fact promise to do so in the COPN application.

Looking ahead, patients and healthcare companies should be prepared for ASC services to continue to grow and disrupt traditional care models. Along with consumer preference and closer cost scrutinization by patients and government entities, new technology is constantly redefining what is possible in outpatient services. 

According to the consulting firm Future Market Insights, LLC, the ASC market is projected to experience a 4 percent compound annual growth rate from 2017 to 2027, as outpatient volumes steadily rise and inpatient numbers fall.

Specialty surgery practices should strive to deliver high-quality, low-cost, consumer-driven care, featuring the most effective and minimally-invasive therapies possible. In my view, the ability to offer such procedures in an advanced ASC will be ever more critical to that mission.

Michael Fabrizio, MD, FACS, is a Professor of Urology at Eastern Virginia Medical School, President of Urology of Virginia, and on the Board of the Large Urology Group Practice Association. urologyofva.net