Safety a top priority as more heart procedures move to outpatient settings

CMS first approved percutaneous coronary interventions being performed in ASCs in 2020. This prompted the Society for Cardiovascular Angiography and Interventions (SCAI) to publish a guidance on ASC quality, safety and operational considerations. More recently, CMS approved EP ablation procedures being performed in ASCs.

The new joint HRS/ACC guidance is designed to help physicians safely transition appropriate procedures into ASCs while emphasizing quality, patient experience and clinical outcomes.

Marine said financial incentives for doing so vary considerably across health systems. In Maryland, where hospitals operate under a unique all-payer reimbursement model, health systems have strong incentives to move lower-risk, high-volume procedures such as cardiac device generator replacements into outpatient facilities. Other health systems, however, may be reluctant if lower outpatient reimbursement reduces revenue.

The economics also depend on whether health systems participate in value-based care models or own health insurance plans that benefit from reducing overall healthcare costs.

"There are a lot of interesting financial dynamics that go into these decisions," Marine said.

State regulations make ASCs appealing is some states

State regulations also remain a major factor. About half of U.S. states still require certificates of need (CON) for certain healthcare facilities, while others prohibit cardiovascular procedures in ASCs altogether. Marine said Arizona and Texas have emerged as leaders in cardiovascular ASC development because of more favorable regulatory environments.

One example is MedAtlas, which has partnered with Banner Health and the University of Arizona to develop three cardiovascular ASCs in the Phoenix area. Under the model, physicians can own up to 49% of the centers while health system partners maintain majority ownership. Marine said giving physicians operational authority and financial alignment has contributed to strong early satisfaction among participating electrophysiologists.

Migration of procedures to outpatient ASCs should focus on safety

Marine said professional societies have not take a position for or against ACSs, but see them as a growing trend in cardiology and want to make sure the migration of any procedures is safe.

"The purpose of these statements was not to suggest procedures should be done in one environment or another," he said. "It was to provide guidance on establishing the highest quality, safety and putting the patient at the forefront."

Quality oversight remains a central recommendation. Marine said ASCs performing EP procedures should conduct quarterly reviews of all cases and complications while participating in clinical registries. The ACC has developed an ASC registry to help facilities benchmark outcomes and demonstrate quality.

Patient convenience is also proving to be a significant advantage. At Johns Hopkins, most cardiac device generator replacements are already performed in a suburban ASC with easy parking and simplified check-in. Marine said most patients prefer the outpatient setting because it is easier to access than a large hospital campus, although some still choose the hospital for added peace of mind.

For health system executives considering an ASC strategy, Marine's advice is to involve physicians from the beginning. He said physicians often have concerns about safety, workflow and whether procedure volumes justify operating at an additional location. Giving physicians meaningful input into operations and governance can help build support and create successful partnerships as healthcare systems increasingly balance rising EP procedure volumes with the need to improve efficiency and lower costs.