When faced with an upcoming surgery, you might be presented with an unexpected option: Do you want to have your surgery in the hospital or in an ambulatory surgery center (ASC), a fully licensed facility that performs surgeries on an outpatient basis?
For some procedures, both the costs and the risks may be lower at an ambulatory care center.
In 1970, the nation’s first freestanding ambulatory care center opened, and today there are more than 5,400 Medicare-certified ASCs throughout the United States, according to the Ambulatory Surgery Center Association (ASCA). Illinois was a late adopter, but there are now 122 Medicare-certified ASCs in the state, performing more than 400,000 surgeries a year.
Many surgeons find that ambulatory care centers give them more control over their surgical practices, the ability to assemble specially trained staff and an escape from hospitals’ scheduling delays and slow operating room turnover. There’s also financial gain — physicians have at least some ownership in 90 percent of all ASCs, according to the ASCA.
For patients, ambulatory care centers provide same-day surgery that can cost less than procedures performed in a hospital. ASCs reduce healthcare system costs by more than $38 billion annually and save patients more than $5 billion in out-of-pocket costs through lower deductible and coinsurance payments, according to a study by Healthcare Bluebook.
How do you know if an ambulatory care center is right for you? Check with your physician to assess appropriateness. Patients with a history of heart attacks, heart disease, stroke or poorly controlled diabetes are not good candidates for surgery at an ambulatory center. Obese patients’ eligibility may depend on their body mass index (BMI). You may also want to check with your insurance company about coverage.
Juan Alzate, MD, a neurosurgeon at the American Center for Spine & Neurosurgery, performs more than 500 outpatient surgical procedures each year.
Ambulatory centers are smaller facilities built specifically for outpatient surgery with the tools and equipment needed for certain procedures, “which translates to lower overhead and reduced costs to payers and patients,” he says.
“Some of the biggest benefits of ASCs are lower costs and reduced risk of infection to patients,” Alzate says. “Since patients are not staying overnight, risk of exposure to bacteria is lower.”
Ambulatory care centers provide benefits to physicians as well, he says. “ASCs provide faster turnover times and focused teams without the risk of cases being bumped or delayed due to emergencies, allowing us to focus on our patients, perform surgeries as scheduled and get our patients back to their lives.”
Hospital safety net
David Manning, MD, an orthopedic surgeon who specializes in hip and knee replacements at Northwestern Memorial Hospital, says the surgical care pathway is the same at a hospital as at an ambulatory care center. Even at a hospital, surgery can be performed on an outpatient basis with the patient going home the same day. The differences are the cost structure and the fact that a hospital-based center offers more support for less-healthy or higher-risk patients, he says.
“The fixed costs of doing care in a large hospital-based setting are enormous and they affect the bottom line,” he says. “In the ambulatory care center, the fixed costs are remarkably lower and that profit-loss statement goes to the owners of the ambulatory care center, i.e. the doctors. They are owners in these facilities, and there’s some inherent conflict of interest. Any conflict should be recognized, disclosed and can be reasonably managed.”
Hospitals have a greater safety net, Manning says. “You have specialists in every sub-specialty of medicine. So if something happens to you, there’s a specialist immediately available for whatever condition might arise. There is advanced imaging immediately on premise. There are ICUs. There’s a blood bank in case someone needs a transfusion.
“If you are a low-risk patient, then the likelihood that you need those facilities is slim to none. So your added risk of having surgery at that [ambulatory] center is minimal and it’s perfectly reasonable to do it. For the other folks [with moderate or high risk of complications], it’s higher risk to have it in those centers.” There is no definitive research study proving ASC procedures result in better quality outcomes, he adds.
Minimally invasive options
Technological advances have allowed more surgeries to be performed on an outpatient basis. Procedures such as joint replacements that only a few years ago required major incisions and long recovery times can now be performed through minimally invasive techniques at an outpatient center.
Ritesh R. Shah, MD, a surgeon at Illinois Bone & Joint Institute (IBJI), one of Chicago’s leaders in outpatient joint replacement surgery, performed approximately 400 knee and hip surgeries in 2016 — 75 percent of which were knee and hip replacements. ASC surgeons, Shah says, practice a streamlined, patient-centered model that results in higher efficiency and greater value outcomes. To assess the efficacy of these surgeries, Shah is conducting a multi-year study examining the outcomes and safety of ASC procedures in more than 100 hip replacement patients.
Both ambulatory care centers and hospitals can work together to meet patient needs, Shah says, pointing to the surge in outpatient hip and knee replacement surgeries. From 2005 to 2030, knee replacements are expected to jump 673 percent and hip replacements 174 percent, according to the Journal of Bone & Joint Surgery. Robert Caliendo, 55, chose Shah to perform his total hip replacement on an outpatient basis at IBJI in March 2016.
Caliendo liked Shah’s approach. Shah spoke at length about what actions he would take to reduce risk and had Caliendo take a tour of the facility. Caliendo checked in for the surgery at 7 a.m. and was home by lunchtime. He quickly returned to the activities he loves.
“Being home that quick and having a team who knows what to do was so important. I was walking the dog the next day,” Caliendo says. “Dr. Shah and his team have given me my life back. Now I’m doing the things I did before, and it’s incredible. After a few months, I rode a bicycle 60 miles in one day.”
While the surgery is the same in an ambulatory care and a hospital setting, ASCs offer an alternative for low-risk patients.
“At the end of the day,” Manning says, “the patient should be looking for a physician in a setting that they’re comfortable with and should ensure that if they are having surgery outside of a hospital-based system that they are adequately medically screened for appropriateness.”