Cardio Procedures Are Moving Out of Hospitals. Is That Good?
'Cardiovascular procedures that were traditionally thought of as only being able to be performed in the hospital setting are increasingly performed in a safer manner such that their conduct in facilities outside of hospitals is not only possible but being encouraged in many ways,' said Robert Yeh, MD, a cardiologist at Harvard Medical School, Boston.
Financial Incentives Driving the Shift
For the study, Yeh and his colleagues examined the regulatory and financial drivers behind the shift in procedural geography.
They found that much of the growth in outpatient clinics has been driven by financial consideration. Federal policy and payer incentives have fueled much of the move toward outpatient cardiovascular care. Starting in the mid-2000s, Medicare expanded the list of procedures reimbursed in ambulatory settings, including device implantation and peripheral vascular interventions. In 2020, the Centers for Medicare and Medicaid Services also began covering coronary stenting in ASCs, projecting $20 million in savings if just 5% of cases shifted out of hospitals.
Third-party payers often follow Medicare's lead, Yeh said, 'so there's an incentive to promote that care.'
Physicians themselves also have an incentive to perform procedures in outpatient clinics. ASCs and OBLs are often physician-owned and so provide a way to reclaim some financial autonomy at a time when physician-owned practices are in decline and hospital employment is becoming more common. Private equity groups and even hospitals themselves are increasingly investing as partners in outpatient clinics, seeing them as a growing revenue stream, Yeh said.
Patients See Convenience and Access
The shift to outpatient clinics has clear benefits for patients as well.
'Patients' journey through healthcare has never been easy. Many hate having to go to the hospital, dealing with parking and a big, confusing building,' said Mustafa Husaini, MD, chair of the American College of Cardiology Cardiovascular Management Council.
They much prefer having procedures done at ASCs and OBLs, which are faster, more efficient, and often closer to home, he said. And OBLs in particular can enhance access to care for underserved communities, said Yeh, with those undergoing peripheral vascular intervention in OBLs more likely to be Black individuals and of lower socio-economic status than those treated in hospitals.
'If we can increase access to high-end procedures that's an inherent good,' Yeh said. 'There's an opportunity to meet patients where they are.'
Questions Remain on Safety and Oversight
While advances in technology have made cardiovascular procedures safer outside the hospital, gaps remain in ensuring consistent standards of care. Few data exist on complication rates and adverse events in ASCs and OBLs, or on what the outcome of those complications are — whether they are dealt with at the clinic or require hospital support, for example.
'In the hospital-based world we have a robust network of quality registries which ensure a very high level of care and help identify where gaps exist,' Yeh said. 'In the ASC or OBL setting we don't have that same rigorous data collection system to understand how patients are doing in these settings.'
Yeh and his colleagues suggest developing that system is an important step in ensuring that the right patients are treated at outpatient clinics.
'We need better guidelines, so we don't leave it up to patients and physicians,' he said. 'We need more data and collaborative action to develop and adopt those guidelines.'
Yeh and Husaini reported no relevant financial conflicts of interest.
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