Ambulatory Surgery Centers in the

United States of America

David Shapiro, MD

National Conference on Ambulatory Surgery

Bangalore

Physician

Anesthesiologist (Specialization in Outpatient Anesthesia)

Florida Society of ASCs (FSASC) : Board Member

ASC Association (ASCA) : Chairman of the Board

ASC Quality Collaboration : Co -Chair

AAAHC : Surveyor

AORN ASC Administrator Course : Faculty

Certified Administrator Surgery Center (CASC) by the Board of Ambulatory Surgery Certification

Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance & Utilization Review Physicians

Certified in Healthcare Compliance (CHC) by the American Hospital Association

Certified Professional in Healthcare Risk Management (CPHRM) by the Health Care Compliance Board

Licensed in Healthcare Risk Management (LHRM) by the State of Florida

Dr. David Shapiro

Opened February 12, 1970 in Phoenix, Arizona

Founded by

Wally Reed, MD

John Ford, MD

Named “Surgicenter”

Originally 4 ORs

Now 6 ORs, 4 Endoscopy Suites

History of ASCs in the United States

First sketch of Surgicenter made on the back of a tent table ad at Smuggler’s Inn in Chicago in 1968.

John L. Ford, MD and Wally Reed, MD in the OR on Surgicenter’s opening day, February 12, 1970.

ASC Timeline

1968

Wallace Reed, MD, and John Ford, MD, commit their idea for a freestanding ambulatory surgery facility to paper for the first time and develop objectives for the facility. They begin collecting endorsements from the governmental bodies and members of the health care community to obtain financing for the project.

1970

Reed and Ford’s idea becomes reality when on February 12 Surgicenter, the nation’s first freestanding ambulatory surgery facility, opens for business. Five physicians perform five procedures at the facility that day, four requiring general anesthesia.

1974

The Society of Freestanding Ambulatory Surgical Care (ASCA’s original name) is incorporated during an ASC seminar conducted in Phoenix, Arizona.

1975-1976

Rapid growth. A total of 42 surgery centers are in operation in the US by 1975 and an additional 25 facilities open in 1976.

1979

The industry continues to grow, with the number of ASCs reaching triple digits. ASCA and others join together to form the Accreditation Association for Ambulatory Health Care (AAAHC).

1982

Medicare approves payment to ASCs for approximately 200 procedures, which are placed in one of four payment groups with payment rates between $231 and $336, based upon a cost survey of 40 ASCs.

1987

Medicare modifies the ASC list to use specific CPT codes and expands the list to include 1,535 procedures.

1988

The number of ASCs in the US reaches 1,000. Using the information from a 1986 cost survey of ASCs, Medicare implements a new payment system, which remains the basis for ASC payments today.

ASC Timeline

1995

ASCs go international when the International Association for Ambulatory Surgery (IAAS) is founded during the 1st International Congress on Ambulatory Surgery in Brussels. Medicare expands the ASC list to cover more than 2,000 procedures.

2002

Seventy-eight individuals earn the CASC credential, the first-ever ASC-specific credential, establishing the ASC administrator as a separate and distinct career from other health care management and clinical positions.

2011

More than 5,300 ASCs exist in the US today, performing 23 million surgeries annually. Medicare has granted approval for ASCs to perform more than 3,500 procedures.

ASC Timeline

Number of ASCs Per State

Number of ASCs Per Capita (Top Ten)

State Population ASCs ASCs per

100,000 People

Maryland 5,773,552.00 354 6.13

Wyoming 563,626.00 19 3.37

Washington 6,724,540.00 220 3.27

Idaho 1,567,582.00 51 3.25

Georgia 9,687,653.00 287 2.96

Delaware 897,934.00 24 2.67

New Jersey 8,791,894.00 233 2.65

Nebraska 1,826,341.00 47 2.57

Arizona 6,392,017.00 152 2.38

Tennessee 6,346,105.00 149 2.35

Surgical Trends

Surgical Trends

Specialties Served in ASCs by Claims

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

278,000 4.4%

1,971,000 31.1%

76,000 1.2% 14,000

0.2%

1,802,000 28.4%

508,000 8.0%

74,000 1.2%

1,384,000 21.8%

3,000 0.0%

209,000 3.3%

23,000 0.4%

In T

ho

usa

nd

s o

f D

oll

ars

Specialties Served in ASCs by Reimbursement

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$120 3.6%

$627 18.8%

$68 2.0% $15

0.4%

$1,416 42.4%

$463 13.9%

$59 1.8%

$407 12.2%

$1 0.0%

$134 4.0%

$30 0.9%

In M

illi

on

s o

f D

oll

ars

ASC Ownership

Corporate, 6% Hospital, 2%

Physician, 65%

Corp-Phys, 8%

Hosp-Phys, 17%

Corp-Hosp-Phys, 2%

*Note: The Corporate-Hospital category had 0% ownership in the survey results.

ASC Ownership Trends

2009 2008 2007 2006 2005 2004

PHYSICIAN 62% 63% 61% 61% 63% 61%

CORPORATE 6% 7% 7% 7% 5% 7%

HOSPITAL 2% 2% 2% 3% 3% 3%

CORP-PHYS 9% 10% 10% 11% 10% 11%

CORP-HOSP 0% 0% 0% 0% 0% 0%

HOSP-PHYS 17% 16% 17% 16% 16% 16%

CORP-HOSP-PHYS 3% 2% 2% 3% 2% 2%

Physician Other

2009 92% 8%

2008 90% 10%

2007 91% 9%

2006 91% 9%

2005 91% 9%

2004 90% 10%

• Federal Regulation

Center for Medicare & Medicaid Services (CMS)

• State Regulation

Various State Health Department and/or Agencies

• Local Regulation

Primarily Building and Fire Code Compliance Enforcement

ASC Regulation

Effective May 18, 2009 -

“means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.”

42 CFR 416.2 DEFINITIONS

CMS: Definition of an ASC

• Defines ASCs in Federal Law

• Determines Payment Policies

– Allowable Procedures

– Applicable Rates

– Annual Updates

• Determines ASC’s Participation in Federal Programs

– Conditions of Coverage

- Infection Control Checklist

• Administer Quality Reporting Programs

CMS

ASC Accreditation

ASCs are Accredited by 4 different Organizations: Accreditation Association for Ambulatory Health Care (~3,010)

Joint Commission (~637)

American Association for Accreditation of Ambulatory Surgical Facilities

American Osteopathic Association

As of Spring 2011: Over 70% of ASC facilities in the U.S. are accredited by one of these four organizations

Top Ten Procedures by Volume

Specialty HCPCS Code

2010 Volume

Short Descriptor

Ophthalmology 66984 1,123,252 Cataract surg w/iol 1 stage

Gastrointestinal 43239 516,603 Upper gi endoscopy biopsy

Gastrointestinal 45380 358,733 Colonoscopy and biopsy

Gastrointestinal 45385 275,898 Lesion removal colonoscopy

Gastrointestinal 45378 271,762 Diagnostic colonoscopy

Ophthalmology 66821 256,749 After cataract laser surgery

Pain Management 64483 245,274 Inj foramen epidural l/s

Pain Management 62311 229,492 Inject spine l/s (cd)

Pain Management 64494 191,097 Inj paravertebral facet joint

Pain Management 64484 128,510 Inj foramen epidural add-on

Reimbursement: Most Highly Paid Procedures

HCPCS Code

Short Descriptor Final CY 2011 ASC Payment

69930 Implant cochlear device $29,056.15

33249 Implant pacemaker leads $25,360.04

33240 Insert pulse generator $22,212.75

64568 Neurostimulator implantation $21,333.84

61886 Placement cr. neurostimulator $17,849.58

61885 Insertion /redo neurostimulator $13,816.04

63685 Insertion/redo spinal stimulator $13,816.04

64590 Insertion/redo gastric stimulator $13,816.04

62361 Implant spine infusion pump $12,221.29

62362 Implant spine infusion pump $12,221.29

Operational Data

ASCA Outcomes Monitoring Project

Business Operations (#4) Net Charges

Days in A/R Outstanding

Paid Clinical Non-Physician Hours

Clinical Operations (#19) On Time Rate

Operating Room Time

Cancellation Rate

Clinical Outcomes (#19) Cardiac/Respiratory Arrest

Nausea / Vomiting

Retained Foreign Object

ASC Quality Collaboration

• Funded by ASCA & ASC companies

• Outcomes reporting

• Outcomes measure development

• Sharing best practices

• Clinical studies

• Promoting transparency

Quality Data Reporting

Six NQF Endorsed Measures

• Patient Burn

• Patient Fall

• Wrong Site, Side, Patient, Procedure or Implant

• Hospital Transfer / Admission

• Prophylactic Intravenous Antibiotic Timing

• Appropriate Method of Hair Removal

Current Trends

0

10

20

30

40

50

60

70

2002 2003 2004 2005 2006 2007 2008 2009

Physician Employment

0

10

20

30

40

50

60

70

1990 1995 2000 2005 2010E

MDs per ASC

0123456789

10

2005 2007 2009 2011 2013 2015

Unemployment

0

5

10

15

20

25

30

2006 2007 2008 2009 2010

High Deductible Plans

Impact

-8

-4

0

4

8

12

1998 2000 2002 2004 2006 2008 2010

Year

-ove

r-Ye

ar %

Ch

an

ge

Growth in Outpatient Surgery

0

2

4

6

8

10

12

1998 2000 2002 2004 2006 2008 2010

Year

-ove

r-Ye

ar %

Ch

ange

Growth in Number of ASCs

ASCs: The Innovative Solution for Health Care

Access Convenience

Provision of Critical Services

Cost Efficiency

Transparency

Quality Clinical Outcomes

Patient Satisfaction

ASC Future

Ambulatory Surgery Centers in the

United States of America

David Shapiro, MD

National Conference on Ambulatory Surgery

Bangalore