Q & A with Bill Prentice, CEO Ambulatory Surgery Center Association

Recent reporting in “USA Today” and “Kaiser Health News” claims that surgery centers do not have to report adverse events in several states. What’s your response to those claims?

Regrettably, there are many flaws in the story, but chief among them is the notion that adverse events do not get reported. In fact, some states don’t have stand-alone reporting systems, but medical boards in every state review adverse events involving physicians. In addition, insurers review events, and the Medicare program requires Medicare-certified ambulatory surgery centers (ASC) to report adverse events for Medicare beneficiaries.

The story claims hospitals report more information about adverse events than ASCs. Is that true?

It is not true. Hospitals and ASCs have different reporting requirements, but there is no way for patients to compare the two sites of care using those reporting systems. There have been, however, numerous studies that have compared the quality of care provided in ASCs with hospital outpatient departments (HOPD). To our knowledge, every single study has concluded that ASCs are as safe or safer than HOPDs. The story also failed to point out that, of the 17 states that do not have an adverse reporting system for ASCs, 13 of them do not require hospitals to report those events either.

The story relies on narratives involving fewer than 10 patients who experienced adverse events at ASCs over a 6-year period. What can you conclude from those individual patient reports?

The implication that the 10 patient stories used in the story—which are tragic and from which lessons should be learned to prevent their recurrence—out of more than 50 to 60 million procedures that were performed in ASCs during this time frame are representative of the quality of care provided in ASCs is, quite frankly, intentionally misleading. The truth is that, despite the many clinical advances in care we’ve made in health care, a small number of tragic events occur in all health care settings. Had the story reported on the quality of care in ASCs using national data or medical studies, the authors would have been compelled to report that ASCs are, indeed, as safe as any other setting.

Did ASCA provide the reporter with any information that was left out of the story?

In our multiple conversations with the reporter, we gave her easily verifiable information about the safety and quality of ASCs, the rigorous regulatory requirements we follow and the side-by-side comparison of our Medicare quality measure reporting requirements versus that of hospitals. None of it is referenced in the story. The reason for that is easy to understand—using any of it would have wholly undermined the basis of the story. As an example, the reporter did not see fit to note that ASCs report to Medicare on patient falls, patient burns, wrong site surgeries and hospital transfers, while hospital outpatient departments do not.

What is ASCA’s position regarding the reporting of adverse events in health care settings?

In a surprising development, Medicare recently proposed that ASCs discontinue reporting to them the serious adverse events I mentioned above: patient falls, patient burns, wrong-site events and hospital transfers. Their rationale for doing so was that ASCs have shown such success in preventing these events on Medicare beneficiaries that it was almost impossible to make any meaningful distinctions between facilities when reviewing the results. While we take pride in that achievement, we are wondering whether eliminating these four reporting requirements is the appropriate response. We are still having a lot of internal conversations with our members and quality experts about that and may have an alternate strategy to offer to Medicare staff in our final comments on that proposal.

That said, the value to patients of any of the health care quality reporting programs in place today is limited. To be truly meaningful to patients and allow patients to make informed choices about their care, the same data must be collected in all the sites of service that provide the same care. Patients considering outpatient surgery, for example, should be able to compare quality data provided by HOPDs, ASCs and physician offices on identical measures.

Medicare requires ASCs to report quality data on only half of their patients. Please discuss the ASC community’s position on that decision and whether ASCs are using that threshold to game the system as one independent researcher quoted in the story suggests they might.

It is our understanding that at least part of the reason Medicare set the 50% threshold was to help Medicare staff and ASCs get the quality reporting program up and running as quickly and efficiently as possible—since then, we have actually requested that the threshold be increased, but Medicare staff apparently have not seen a reason to do so.

While the 50% reporting threshold would appear to allow ASCs to report quality data on selected patients only, the reality is that the system used to report this information discourages that. All these reports are filed as part of the claims data submissions process, and once the reporting system is in place, it is time-consuming to remove the quality reporting measures from individual claims. In reality, because of the time and technology required to change the process coupled with a desire to provide and review more comprehensive data, a large percentage of ASCs already report on 100% of their Medicare patients to Medicare.

Meanwhile, about one-third of Medicare-certified ASCs also voluntarily participate in a separate quality reporting program coordinated by the ASC Quality Collaboration (ASCQC)—an industry-sponsored effort developed before Medicare’s national reporting program became available. In the ASCQC program, ASCs report on all their patients. Those numbers track very closely with the numbers we are seeing in the Medicare quality reporting program, suggesting that the Medicare sample size accurately reflects the comprehensive data.

The story points to discrepancies between data on hospital transfers reported to Medicare and state quality and adverse event reporting programs. Please discuss the significance of those discrepancies and the fact that Joan Rivers’ transfer did not appear in any Medicare data reports.

It is important to remember that hospital transfers are not a proxy for low-quality medical care and can, in fact, be an indicator of high-quality care. ASCs frequently transfer patients to the hospital before their procedures begin because some unrelated condition is detected when a patient arrives at the ASC and a hospital visit is deemed necessary. Transfers like those are a positive reflection on the care ASCs provide.

Because ASCs cannot provide overnight care and monitoring, it is often the physician operating out of an abundance of caution who transfers higher numbers of his or her patients to the hospital for overnight care.

It is true that different quality reporting programs have different requirements, so, if Joan Rivers wasn’t a Medicare patient, for example, her hospital transfer would not have been reported to Medicare since that program collects data only on its beneficiaries. Likewise, a state quality reporting program might not ask for information on some measure like patient falls although that information would be reported to the Medicare quality reporting program when a Medicare beneficiary is involved.

As I said earlier, the quality reports that would be most useful to patients considering outpatient surgery would allow them to make direct comparisons over all the sites of care—ASCs, HOPDs and physicians’ offices. Ideally, these patients would also be able to compare the costs of their care in each of those settings as well.

The story says that the ASCs Medicare decertifies—the term used when a health care facility is prevented from participating in the Medicare program because it fails to meet federal regulatory standards—can reopen with little effort, while hospitals that are decertified often close permanently or reorganize and reopen as another entity. Do these disparate outcomes mean that patients in ASCs are at higher risk?

Not at all. Hospitals are complex entities that manage patient care of many kinds ranging from emergency room services to organ transplants, patients afflicted with highly infectious diseases and more. The facilities themselves also need to be designed to allow the health professionals who work there to manage complex cases and multiple levels of care 24 hours a day, 7 days a week. The hospitals that Medicare decertifies could easily have multiple regulatory violations in need of correction, and if tied to an aging facility, may not be able to correct some at all.

ASCs, on the other hand, are focused on the specific procedures they provide so need to manage much less complex systems. Additionally, surveys conducted by the accrediting bodies consistently show that lapses in regulatory compliance in ASCs typically involve recordkeeping rather than practice deficiencies or facility design. It is far easier to address an operational area with a singular focus or a single recordkeeping error than to redesign operations affecting multiple operational areas or to retrofit an aging facility to meet new standards.

The story questions whether an ASC’s governing body is independent enough to perform the typical physician oversight patients are able to rely on in the hospital and says there is nothing to stop a physician “exiled by a hospital for misconduct from opening a surgery center down the street.” Are those valid concerns?

The same credentialing and reporting systems that would prevent a physician barred from practicing in one hospital from practicing in another would prevent that physician from practicing in an ASC. Regulatory requirements related to governing bodies and the documentation required when those entities meet provide for oversight in ASCs just as in hospitals. In addition, the other health professionals in the ASC must meet licensing standards that hold them to the highest standards of practice.

Do you have any final thoughts to share about this story?

Patient selection criteria are an important focus for ASCs since not every patient in need of outpatient surgical care can receive that care in an ASC. It is also important to keep in mind that there is no such thing as “routine” surgery that comes with a 100% risk-free guarantee of success. Patients experience negative outcomes, and some die, in every setting where outpatient surgery is provided.

This story fails to provide important context that would mention the risks involved in surgery in every setting and the reporting requirements in each of those settings. It also fails to provide a more balanced perspective on the care ASCs deliver that would reference the tens of millions of highly successful procedures ASCs perform each year. Rather than provide readers with meaningful information they could use to make wise choices about their health care, this story does its readers a disservice, discouraging them from choosing high-quality care in a convenient environment at lower cost.