Redefining Nephrology Care: The Triumph of Interventional Nephrology in Office-Based Labs and ASCs

The field of nephrology, dedicated to the care of kidney-related diseases, is undergoing a transformative revolution led by interventional nephrology. Renowned for its precision and innovation, interventional nephrology is at the forefront of a paradigm shift in healthcare. Recent changes in market dynamics and regulatory policies are steering nephrology procedures towards cost-effective settings, with office-based labs (OBLs) and ambulatory surgery centers (ASCs) taking center stage in this evolution.

This transformation gained substantial momentum when the Centers for Medicare and Medicaid Services (CMS) expanded the ASC-covered procedure list (CPL) to encompass various interventional nephrology procedures in 2020. This monumental decision has left an indelible mark on the nephrology landscape, opening doors to a future where advanced kidney procedures are no longer restricted to traditional hospital settings.

The journey towards OBLs and ASCs as preferred settings for interventional nephrology began earlier. In 2009, procedures related to minimally invasive vascular access management started migrating to OBLs, marking the initial phase of this transition. Subsequently, in 2016, cases related to percutaneous dialysis access interventions and renal angioplasties joined this migration. The momentum continued with diagnostic ultrasound-guided kidney biopsies being performed in ASCs in 2019, and a transformative moment arrived in 2020 when Medicare approved complex interventional nephrology procedures for ASCs. These milestones have reshaped the future of nephrology care.

Industry experts anticipate that CMS will continue expanding the ASC-CPL to include additional interventional nephrology procedures, such as arteriovenous fistula (AVF) creation, peritoneal dialysis catheter placements, and renal denervation. Some ASCs are already performing these procedures on commercial patients, marking a promising trend towards the inclusion of more interventional nephrology interventions in the ASC-CPL.

Commercial payers are closely following these changes and aligning their strategies accordingly. Similar to their approach with complex interventional nephrology procedures before their inclusion in the ASC-CPL, commercial payers are already covering these procedures, even before they are included in the Medicare CPL for ASCs. This proactive stance underscores their commitment to cost-effective, high-quality nephrology care in OBLs and ASCs.

Medicare has further reinforced this transition by introducing an outpatient procedure price comparison tool. This tool highlights the substantial cost advantages of ASCs. For instance, it demonstrates that a complex peritoneal dialysis catheter placement procedure (CPT 49421) costs $5,200 in an ASC, with a patient responsibility of $1,040, compared to $8,500 in a hospital, with a patient responsibility of $1,700. These cost disparities are compelling payers to incentivize the migration of interventional nephrology procedures.

Bundled payment arrangements through Medicare Advantage are evolving, allowing providers to share savings generated from cost differences across various surgical sites of care. This dynamic further accelerates the migration of interventional nephrology procedures to lower-cost settings.

These changes, combined with the rise of physician-owned ASCs and direct contracting entities, are poised to reshape healthcare systems’ care delivery and financial performance. To bridge potential revenue gaps when interventional nephrology ASCs become prominent in their region, healthcare leaders must proactively develop comprehensive physician alignment and backfill strategies.