Are Cardiovascular ASCs Hitting the Mark of Health Care’s Quadruple Aim?

The shift of cardiovascular procedures to value-based sites of service, such as office-based laboratories (OBLs) and ambulatory surgery centers (ASCs), began > 12 years ago when Medicare approved peripheral artery disease procedures in the OBL. Despite powerful hospital lobbying efforts, Medicare has continued to add more cardiovascular cases to the ASC Covered Procedure List (CPL), including electrophysiology implants, diagnostic heart catheterization (cath), and coronary stenting. Most agree that this trend of CPL expansion will continue. Since 2009, tens of thousands of cardiovascular patients have been treated in comfortable, convenient, low-cost settings, thus freeing up valuable hospital lab space for higher-acuity cases and helping reign in ever-expanding health care costs. This shift continues at an accelerating pace, but the underlying question remains whether this outmigration is helping achieve the quadruple aim of health care: improved patient experience, improved clinician experience, lower cost, and increased quality.

The ultimate question is how to make these outpatient shifts effective and efficient while delivering optimal value to patients, providers, and payors. To achieve this, we must model the necessary change using a value-based care perspective with a significant focus on the quadruple aim of health care. A subjective interpretation is of little value in a world in which data must prevail, especially at such an important juncture of ASC and OBL education and adoption. Therefore, structuring data solutions to guide optimization efforts is critical. These basic tenets will enable us to create a framework for cardiovascular ASCs to achieve admirable outcomes and provide data supporting the development, management, and optimization of ASCs nationally.

STRENGTHENING THE PATIENT AND PROVIDER EXPERIENCE

Experience data are almost universally captured through surveys due to their subjective nature. Although many different surveys can be designed to capture the sentiment of this market, the consistency of the survey instruments holds new importance. Preparing for a future in which these comparisons will be requested more frequently by payors, providers, and patients, the challenge of industry is to create a standardized instrument that meets the needs of multiple stakeholders. It also means collaborating nationally for the greater good, across competitive entities in some instances.

The standardization of a measurement tool is essential to advocating for ASCs and comparing the impact that clinical practices and optimization strategies have on patient and provider satisfaction. This also enables tracking the performance of ASCs over time and in a time-defined fashion for benchmarking purposes. Although most ASC development and management organizations have their own tools that are adopted across their centers, these tools are rarely if ever implemented in a similar fashion with identical questions industry wide. This cardiovascular-focused standardization will help unify the ASC industry in measuring cost and quality best practices and their effect on patient and provider satisfaction.

REDUCING COST OF CARE

As we move into cost and operational efficiency as the next frontier of standardization, the data become easier to collect and manage when compared to measuring patient and provider satisfaction. Technology systems easily create utilization metrics on the number of cases, billable and collected charges, and so on. The ground to cover here relates to staffing and process efficiency metrics, such as on-time starts, net cost per case, and lab turnaround time. These types of metrics are also being implemented across industry, but there is significant variation in how they are measured. It is essential to standardize operational efficiency metrics with complete definitions and data collection mechanisms to enable data comparison across facilities and track progress over time as operational changes are implemented in an ASC. Oftentimes, the simple process of collecting these data in a facility gives operators the sense that they are doing this well. However, the lack of uniformity and standardization of metrics and the absence of external benchmarking across organizations leave room for improvement.

IMPROVING QUALITY

The final and most important data set to be standardized is clinical quality metrics. The procedures performed in a cardiovascular ASC are the same procedures that have been tracked for quality in the hospital cath lab for > 2 decades. Today, any ASC can submit data to the American College of Cardiology’s National Cardiovascular Data Registry to track their clinical performance and outcomes. What has not been consistent is the willingness of all ASCs to engage in that level of quality data submission. Quality should be at the very forefront of any ASC discussion. Revenue and cost metrics are being measured and managed in nearly every ASC, but only a select few have taken the time to participate in quality registries. Labs that do not submit data are certainly dedicated to quality, but they may have an issue with the resource commitment required to participate.

The reasons that some ASCs do not participate need to be further explored and solutions to overcome the lack of participation implemented. Examples include a shortened cardiovascular-focused data set, a more ASC-oriented reporting structure, or tools with a more streamlined design to support data submission from an ASC environment as opposed to what is often a more technologically robust hospital environment. Having a large quantity of uniform data will enable national quality tracking, better determination of case appropriateness for ASCs, and data sets that are meaningful to payors, legislators, and quality improvement organizations.

Uniformity in tool sets is just the beginning of standardizing care delivered in the ASC environment. Telling the stories of how these successes are achieved and examining the operational science that enables the clinical quality and financial sustainability is where the real learnings will occur.

TRANSFORMING CARDIOVASCULAR CARE, TOGETHER

Atlas Healthcare Partners, which specializes in developing and managing ASCs, and MedAxiom, which is dedicated to cardiovascular organizational performance improvement, recently formed a first-of-its kind cardiovascular ASC joint venture to transform cardiovascular care delivery and expand patient access.

The goal is to transform care in the outpatient site of service, with a focus on achieving the quadruple aim of health care as it relates to cardiovascular procedures in the ASC. With an abundance of key stakeholders impacted by outmigration, this joint venture will work diligently to:

1. Improve patient and provider experiences by offering patients an affordable and efficient setting for their cardiology treatment, while allowing providers to have increased influence in the management and operation of centers via physician ownership (either alone or in conjunction with hospital partners). Patient and provider satisfaction surveys from ASCs have consistently shown very high levels of comfort in the ASC, with no differences in readmission rates, surgical site infections, or need for medical care after the procedure.¹ Atlas and MedAxiom will work to standardize and customize surveys for cardiovascular ASCs to capture, track, and improve patient and provider satisfaction to create a national data set related to quality, performance improvement, and advocacy.

2. Continue to drive lower cost of care in ASCs. Lowering cost to patients and payors is in the DNA of an ASC. The stakes are high: A 10% to 30% migration of cardiovascular Medicare cases to ASCs will yield approximately $500 million in annual savings.² Atlas and MedAxiom will set standards and appropriate use criteria to ensure the right patients are treated at the right time with the right therapy in safe, high-quality, efficient settings.

3. Drive better outcomes by building a foundation that starts and ends with quality clinical outcomes. Creating, implementing, and managing clinical data collection tools is a top priority and will enable the safe performance of currently approved and newly added cardiovascular cases in the outpatient setting. Everyone—from patients to providers and payors—wins when high-quality care is delivered.

CONCLUSION

The journey of optimizing a site of service that is by nature designed to be operationally efficient is not for the faint of heart. Atlas and MedAxiom will focus on providing the best patient and provider experience, driving efficient performance in each ASC and delivering the highest-quality cardiovascular care in ASCs nationally. Although competitive differentiators are core to decisions being made in this space, some degree of unification (and certainly in data creation) will be required to ensure the sustainability of all centers. Our goal of providing nationally accepted data sets will further the cause for all ASCs and will provide better outcomes for all patients and providers. The combination of an ASC organization with dozens of centers and a focus on building hospital and physician partnerships with a national organization dedicated to improving cardiovascular clinical and operational excellence is a first for the ASC industry. We have a responsibility to truly transform cardiovascular care—and we will.

1. Nelson CG, Murphy WG, Mulligan RP, et al. A retrospective comparative study of patient satisfaction following ambulatory outpatient and inpatient total shoulder surgery. Curr Orthop Pract. 2019;30:435-438. doi: 10.1097/BCO.0000000000000787

2. Becker’s ASC Review. What every health system leader needs to understand about current trends in cardiology. Published September 14, 2020.