Navigating the Shifting Landscape of Cardiovascular Care: Embracing Growth in Office-Based Labs and ASCs

Navigating the Shifting Landscape of Cardiovascular Care: Embracing Growth in Office-Based Labs and ASCs

Market dynamics and evolving regulations in the cardiovascular healthcare sector are driving a significant shift towards cost-effective settings for medical procedures. Office-based labs (OBLs) and ambulatory surgery centers (ASCs) are witnessing a surge in demand, accelerated by the inclusion of diagnostic heart catheterizations and percutaneous coronary interventions (PCIs) on the ASC-covered procedure list (CPL) by the Centers for Medicare and Medicaid Services (CMS) in 2020. This trend is likely to continue, driven by the cost advantages offered by these facilities.

The transition of cardiovascular procedures from hospitals to these lower-cost facilities is an ongoing phenomenon. It started with peripheral artery disease (PAD) procedures shifting to OBLs in 2009, followed by cardiac rhythm management cases in 2016. In 2019, diagnostic heart catheterizations began being performed in ASCs, and in 2020, CMS approved PCI stenting for ASCs.

Anticipations are high that CMS will continue expanding the ASC-CPL to include procedures like electrophysiology (EP) ablations, left atrial appendage occlusion (LAAO), transcatheter aortic valve replacement (TAVR), and abdominal aortic aneurysm (AAA) repair. Some ASCs are already performing EP ablations on commercial patients, and commercial payers are gradually paving the way for Medicare to add more procedures to the ASC-CPL.

Currently, around 66% of cath lab procedures can be comfortably performed in an ASC setting. These include cardiac rhythm management (CRM) implants, PAD procedures, diagnostic catheterizations, and PCIs. However, the majority of cardiovascular procedures still take place in hospital outpatient departments (HOPDs). It’s estimated that over 80% of all HOPD cardiovascular procedures will eventually be added to Medicare’s CPL, making them eligible for migration to ASCs by 2030.

Commercial payers are closely monitoring these changes. ASC reimbursement rates for all procedures increased by an average of 3% in 2023. Payers, similar to what they did with PCI before its inclusion in the ASC-CPL, are now covering cardiac ablations, even before they are added to Medicare’s ASC CPL.

Last year, Medicare introduced an outpatient procedure price comparison tool that highlights cost differences between ASCs and HOPDs, making it clear that the benefits of ASCs are significant. For instance, the tool demonstrates that a common left heart catheterization procedure (CPT 93458) costs $1,735 in an ASC, with a patient responsibility of $346, compared to $3,259 in a hospital, with a patient responsibility of $923.

Moreover, bundled payment arrangements through Medicare Advantage are evolving, enabling providers to share savings generated from cost differentials across surgical sites of care.

Commercial payers are now following CMS’s lead by redirecting a larger proportion of cardiovascular procedures to lower-cost care settings. United Healthcare, for example, has implemented a cardiovascular prior authorization program aimed at shifting cases from HOPDs to ASCs, where additional diagnostic and interventional CV procedures are expected to be offered.

These changes, coupled with the growth of physician-owned ASCs and direct contracting entities, will impact hospitals’ care delivery and financial performance. To avoid significant revenue gaps when cardiovascular ASCs become prominent in their area, healthcare leaders need a comprehensive physician alignment and backfill strategy, involving adjustments to budgets, capital expansion projects, and future forecasts.

Here are five strategies to embrace the migration of cardiovascular procedures to OBLs and ASCs for sustainable growth:

(1) Physician Alignment: Explore integration efforts with cardiologists, interventional radiologists, nephrologists, and vascular surgeons. Consider joint ventures in ASCs with both employed and independent cardiovascular specialists. Enhance physician engagement through co-management agreements and shared risk initiatives.

(2) Market Positioning: Develop creative strategies to differentiate your healthcare system in the market. Leverage your position as a leading cardiovascular program and an integrated health system in the region. Align with desirable cardiovascular physicians to create value-based care.

(3) Integrated Strategy: Embed your cardiovascular ASC strategy into your overall health system strategy. Align joint-venture CV ASCs with employed and independent physicians to deliver high-value care.

(4) Marketing Program Benefits: Promote the benefits of your program, including new technologies, high-quality outcomes, patient experience, access, and convenience. Focus on service-line additions and aim to be the first to market with a CV ASC.

(5) Pursue Value Across Sites of Service: Actively seek payer and consumer value across all service sites. Expand programs for complex cases like left side ablations, structural heart, critical limb ischemia (CLI), and complex PCI to offset routine procedure shifts outside the hospital setting.

The migration of cardiovascular procedures to lower-cost settings is driven by a complex interplay of clinical and financial factors. With a well-planned strategy, a commitment to risk management, business insight, and effective management, healthcare systems can adapt to these changes while ensuring the delivery of high-quality care. The time to start planning for cardiovascular ASCs is now.