Donald S. (Buck) Cross, MD, FACC
Cardiologist, Waco, TX
Can you tell us about the kinds of cardiac procedures being done on an outpatient basis today?
Right now, there is a full spectrum of cardiac procedures that are safely and successfully performed on an outpatient basis, in both hospital outpatient departments (HOPD) and ambulatory surgery centers (ASC). In fact, the majority of cardiovascular cases are performed on an outpatient basis today. The most common are right and left heart catheterizations, coronary interventions, peripheral vascular interventions and defibrillator and pacemaker implants.
In 2019, CMS added diagnostic cardiac catheterization procedures to the ASC-approved list. For 2020, CMS also included cardiac treatment procedures. These codes relate to three specific percutaneous coronary interventions (PCI), including drug-eluding stent placement, which means that Medicare patients will no longer have to endure multiple visits to diagnose and treat their conditions.
Like all prior approvals, these decisions came about deliberately and were based on clinical data and unrelenting educational and advocacy efforts.
As you recognize, CMS recently added several new cardiac codes to the list of approved, reimbursable procedures that can be performed in an ASC. Should we expect to see the approval of more cardiac codes by CMS in the future?
Absolutely. As the technology and surgical techniques continue to improve, we should expect to see more and more cardiac procedures being safely performed on an outpatient basis.
I am optimistic that we will see CMS approve stent procedures to vein bypass grafts in the near future.
Do you find patients are apprehensive about having a cardiac procedure on an outpatient basis? What do you tell them about the outpatient experience?
Actually, we have found just the opposite to be true. Our patients are not apprehensive at all. They consistently tell us they prefer the ambulatory surgery setting to inpatient experiences.
I’m affiliated with National Cardiovascular Partners, the owners and operators of about 25 cardiovascular ASCs throughout the US. We keep very close track of safety and quality data, as well as patient satisfaction. Right now, our patient satisfaction rate is 98 percent. Our patients comment on the high quality of care they receive, and they also tell us they find the ASC setting to be more personal, more convenient and more comfortable than their experiences with hospitals.
What about cost? How does performing a cardiac procedure in an ASC compare to having the same procedure performed on an outpatient basis in an HOPD?
On average, Medicare pays ASCs about 35 percent less than HOPDs for the same approved cardiovascular procedures. That’s a very significant savings since it can also result in a substantially lower out-of-pocket expense for the patient.
Today, we are realizing considerable savings when cardiac procedures are performed in ASCs rather than HOPDs. In the future, those savings could be even greater when you consider that we currently perform about 500,000 heart stent procedures in the United States each year—procedures that are likely to be approved for outpatient treatment in the very near future.
What kinds of cardiac procedures do you foresee happening in the outpatient setting five years from now? In 10 years?
As long as we can continue to demonstrate, through clinical data, that patients can be treated safely, I believe we will see many more cardiovascular procedures migrating out of hospitals and into outpatient settings. CMS has requested feedback on a number of other procedures, including atherectomy and thrombectomy. It's a clear signal that those are among the procedures they will consider in the future.
Looking further ahead, a key determinant of which cardiac procedures are approved for outpatient treatment will be based on emerging technologies. As this technology continues to improve, I believe the day is not far off when we will be able to treat structural heart conditions, such as heart valve repairs or replacements, in ASCs.