It’s increasingly likely that if you need certain surgeries or procedures, you’ll go to an outpatient facility rather than a hospital.
But the quality of care at these facilities has long been a well-kept secret because they don’t have to publicly report whether patients were harmed or received inappropriate care.
In California, which has several thousand of these outpatient settings, it is even difficult to know who has official oversight, let alone whether the center was inspected and whether it meets requirements for accreditation or federal reimbursement.
Brenda Klütz, former director of the California Department of Public Health’s Licensing and Certification Division, recently authored a scathing report on the current system.
“I really want quality of care to be transparent … but this system drives me nuts,” Klütz said.
“Consumers need to know about compliance history and quality of care, and that regulatory standards are different, depending on the setting,” she said. “How can they get this information? The answer is, right now they can’t.”
That is about to change, at least in part. Provisions in the Affordable Care Act of 2010 require that some quality information be made available for about 5,400 ambulatory surgical centers approved to receive Medicare reimbursement nationally — including at least 35 in San Diego County. These are facilities for surgeries and procedures that typically do not require an overnight stay.
The federal Centers for Medicare & Medicaid Services, or CMS, said that later this month it will release eight new quality scores for these facilities. The Ambulatory Surgical Center Quality Collaboration, an industry trade group, reports a national average for some measures based on voluntary reporting from some facilities, whose overall scores are shown in parentheses below. Some centers’ rates will be much higher, and some zero.
- Patient burns (.024 per 1,000)
- Patient falls (.122 per 1,000)
- Patients who underwent surgery on the wrong site or wrong side; surgery that was performed on the wrong patient; and patients who underwent the wrong procedure or received the wrong implant (.035 per 1,000)
- Patients who required transfer from the facility to a hospital (.998 per 1,000)
- Patients who did not receive intravenous antibiotics within an appropriate timeframe to prevent infection (10 per 1,000)
- The percentage of health care workers who received an influenza vaccination.
- Two measures intended to show overutilization of colonoscopies, which carry higher risks in older people. These measures reflect whether patients had a follow-up colonoscopy within appropriate intervals, which is at least 10 years for those who had a normal prior colonoscopy and at least three years for someone who had a polyp finding.
“For so long, so much in the health care system has been behind the curtain, not even known to the people who are doing the work,” said Dr. Harlan Krumholz, director of the Yale Center for Outcomes Research & Evaluation, which developed some of the measures under contract with CMS. The surgery centers “are a big area in the system that’s avoided much scrutiny, and it’s time to understand its level of performance.”
Added David Hopkins, senior adviser to the Pacific Business Group on Health in San Francisco: “CMS is so serious about this (because) so much surgery has moved outpatient, to ASCs. That’s why this is so important. It’s time for ambulatory surgical centers to be held accountable for their outcomes, just like hospitals are.”
Surgery center facts
• In 2014, 3.4 million Medicare beneficiaries received care in more than 5,400 ambulatory surgical centers nationally, at a cost of $3.1 billion to the federal government.
• Medicare has approved about 3,500 types of procedures for payment when they are performed in an ambulatory surgical center.
• The number of centers grew between 1.5 percent and 1.9 percent per year from 2009 to 2014, or between 76 and 103 facilities a year.
• From 2009 to 2013, Medicare payments to ambulatory surgical centers paid under fee-for-service contracts increased 2.6 percent per year, and 3.1 percent in 2014.
• Medicare does not require cost data from ambulatory surgical centers as it does from hospitals. The federal Medicare Payment Advisory Commission recommends that the data should be submitted.
• Ambulatory surgical centers are increasingly performing more difficult procedures, which have been migrating from inpatient settings.
• The California Business and Professions Code requires that whenever a patient is referred to a surgical center in which a physician or the physician’s immediate family has a significant beneficial interest, defined as 5 percent or $5,000, that interest must be disclosed either in writing or through the posting of a conspicuous sign in an area likely to be seen by all patients who use the facility.
Consumers will be able to tell a lot, for example, from statistics that show how often a patient needed to be transferred from a surgery center to a hospital, said Leah Binder, president and CEO of the Leapfrog Group, which annually publishes hospital safety scores. The rate of transfers to hospitals may indicate that physicians had poor oversight of patient suitability for care in an outpatient facility or had little oversight of the competency of those doctors allowed to practice there.
“The center that treated Joan Rivers is the perfect example of why we need these numbers,” Binder said. “She didn’t die at the ASC, she died in a hospital after being transferred.” That center, Yorkville Endoscopy in Manhattan, was denied Medicare reimbursement and lost its accreditation last year, although it apparently is re-approved.
Quality reporting for ambulatory surgical centers will in some ways be a moment of truth, said Jim Lott, former executive vice president of the California Hospital Association who is now a health care consultant and professor. “It definitely will put a crimp on their marketing. And it will level the playing field a little bit in the competition between hospitals and ASCs.”
Also coming under scrutiny is how the Medicare agency monitors quality in the surgery centers. The Office of the Inspector General in the Department of Health and Human Services thinks the issue is so important that it announced in its 2016 work plan that it will publish “an analysis of Medicare’s quality oversight of ASCs.”
The federal data release doesn’t include information about centers not approved for Medicare reimbursement and which rely on private payer reimbursement or self-pay.
Dr. David Shapiro, vice chairman of the Ambulatory Surgical Center Quality Collaboration, a trade group for these centers, said nearly all of them track their patients and know if there are problems. He believes the centers do a good job on prevention, but when CMS asked them to show the data that proved they were providing better care, “indeed, we didn’t have it,” Shapiro said. That led to an agreement that a quality program was needed.
“Surgeons aren’t shy,” he said. “They will pick up the phone and be very diligent about informing us if there were any problems with their patients postoperatively at any point after their discharge.”
“To this point, these ASCs may not have been measuring any of these unless they’ve been required to. So this is a good way to get them started,” said Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University in Chicago.
CMS used a financial incentive to encourage surgery centers to publicly report their data. Those that didn’t received a 2 percent cut in their Medicare reimbursement. Asked how CMS is auditing or verifying the data, a spokeswoman wrote that at this time it is not.
Publicly reporting these eight new measures is just a start. Late next year, CMS will release data on two additional measures, one of which will help millions of Medicare beneficiaries who undergo a colonoscopy know more about their chance of having a serious complication.
Colonoscopies have higher risks than most patients or their gastroenterologists appreciate, studies show. A recent report that used actual Medicare claims rather than providers’ voluntary reports found 1.6 percent of healthy beneficiaries at low risk of a complication needed emergency care in a hospital within seven days of their colonoscopy. That surprises a lot of doctors who don’t track what happens after their patients leave their facilities.
This new measure will reveal centers whose providers may need to improve their skills.
Dr. Daniel Stonewall Anderson, a gastroenterologist at Kaiser Permanente Medical Center in San Diego, said showing what are called adverse events for colonoscopies by center is a good idea. “It’s important to get it out there, because we know the risk increases with age, and maybe (gastrointestinal doctors) will be more careful about doing them in older people.”
He also noted numerous studies showing that many gastroenterologists nationally don’t know the age and interval cutoffs for colonoscopy and do more than necessary. Older people are more at risk for complications.
The last measure, to be released later, looks at the percentage of cataract patients who had improved visual function within 90 days of their surgery center procedure. Ophthalmology centers can choose to report this measure.
The public has had some scant information about surgical centers, but few know where to find it and others question its value.
In October, CMS released two other measures related to ambulatory surgical centers.
One asked whether surgeons perform a safe surgery checklist, and almost all said they did.
The other reflects total volume and individual volume for seven categories of procedures, those involving the eye, the gastrointestinal system, the genitourinary system such as prostate biopsy, musculoskeletal such as wrist joint repair; nervous system such as nerve blocks or spine injections, respiratory procedures such as nasal septum repair and skin procedures such as skin grafts.
The data show, for example, that the Otay Lakes Surgery Center performed 2,545 procedures in 2012, nearly all involving the nervous, gastrointestinal and musculoskeletal systems, except for two skin procedures and two genitourinary procedures. Likewise some centers don’t appear to specialize in any one procedure, such as Surgical Center of San Diego, which performed 194 gastrointestinal, 362 eye, 317 musculoskeletal and 480 genitourinary procedures.
To many experts, volume speaks volumes.
How many procedures a center performs is important for both the physician and the center to know, says the Leapfrog Group’s Binder. “I am not personally ever going to go to an ASC that only does a handful of procedures like the one I need,” she said. “I’m going to look for the one that has the higher volume.”
Krumholz agreed. “I wouldn’t want to have a procedure performed by someone who is not doing very many, unless they have done a million in their lives and are the world’s expert.”
He thinks that volume is such an important measure of quality that he and colleagues recently developed a free app called Doc Stats. It uses CMS data to show procedural volume for any provider in an area the user selects.
Officials with the large ambulatory surgical center trade group said its members are generally uncomfortable with volumes reported by CMS, because some surgeons do procedures at multiple facilities, and those procedures add up to higher volume overall.
Krumholz said that while surgeon-specific complications would be nice, and will eventually come, what’s also meaningful to consumers is quality data by center. .
“Should we get crash results from pilots or airlines?” asked Krumholz. “Probably the airlines are a little better. We want to know how the engineers and maintenance teams work, and a lot of other things.”
It’s important to know how well the center’s staff work as a team, said Leapfrog’s Binder. “That’s as important as the surgeon’s skill.”
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