Physicians know when ASCs are the best choice

Reversal of a CMS plan to eliminate Medicare reimbursement of ambulatory surgery centers for certain procedures is a victory for organized medicine and for physicians.

Posted June 6, 2005.

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Physicians are well trained to make sure that they know how to treat a patient's condition. Fortunately, the Centers for Medicare & Medicaid Services now agrees that fine training also gives physicians the insight to know where to treat a patient's condition.

After firm and vocal opposition by the AMA, the Federated Ambulatory Surgery Assn. and at least 30 other medical societies, CMS rescinded plans to delete 100 Medicare-reimbursed procedures from the list of those that could be done at ambulatory surgery centers.

The CMS' proposed ASC coverage update, released in November 2004, added 25 procedures, such as knee arthroscopies and bladder repairs, but took away 100 others, such as prostate biopsies and diagnostic cystoscopies. At the time, CMS' reasoning was that most of the deleted procedures were done primarily in the office setting -- perceived as the least expensive venue.

But CMS has now reversed course, deleting only five procedures and adding 65 more.

What changed its mind? Comments from organized medicine, individual physicians and a powerful senatorial ally. Doctors impressed upon CMS that for many of the procedures in question, ASCs were used only 20% of the time, and that number was not likely to rise quickly. The evidence showed that although physicians tend to be investors in ASCs, they were sending patients to them out of medical necessity, not their own financial interest.

As it turns out, in some cases ASCs would be the least-expensive alternative. As some commenters told CMS, certain Medicare patients need a sterile setting or anesthesia for even so-called minor treatments, and if ASCs weren't available, then the patients would need to go to hospital outpatient facilities.

But the issue is also one of access. What if, particularly in a rural area, a nearby hospital wasn't available? What if the physician's office didn't have the equipment necessary to perform a procedure, as CMS dictated? Senate Finance Committee Chair Charles Grassley (R, Iowa) raised that point in his own comments. In a letter to CMS, Grassley said the proposed plan would hinder access to care in rural areas because often an ASC is more conveniently located than a hospital outpatient facility.

The AMA, FASA and others are urging CMS to add at least 50 more procedures beyond the 65 it already has approved. Meanwhile, they also are urging CMS to abandon its current list for an exclusionary list for ASCs, meaning that any medically appropriate procedure could be performed on a Medicare patient unless specifically prohibited.

For now, this CMS change of heart is a testament to what can be accomplished by determined advocacy when a government agency is receptive to a fair hearing of the facts before making a final decision.

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