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Overnight Status for Outpatients in MD Raises Safety Concerns

 |  By John Commins  
   January 10, 2014

Offering patients extended recovery time by keeping them overnight in an ambulatory surgery center may comply with CMS regulations, but Maryland's Office of Health Care Quality and the Maryland Hospital Association are voicing concerns about patient safety.

An ambulatory surgery center in suburban Washington, D.C., is taking federal regulations down to the final minute.

The Massachusetts Avenue Surgery Center, LLC, in Bethesda, MD, says it will fall within Centers for Medicare and Medicaid guidelines when it hold patients overnight because the stays will be no longer than 24 hours.

"Under CMS rules a surgery center may keep a patient for no more than 23:59," says Randall Gross, executive director at MASC, which provides mostly orthopedic, GYN, and general surgery services.

"There are a lot of procedures our docs have not been able to do, [such as] total knees and total hips, that are done at the hospital and then the patients are either sent home or sent to a rehab center and sent home the next morning. All we are really doing is extending the recovery time and creating an environment where our patients can spend 12 more hours here approximately."

Gross says he requested clarification from the state of Maryland and was assured that any recovery periods within the 24-hour window were acceptable under CMS regulations. MASC is negotiating with payers now and hopes to begin offering procedures that may require extended recovery times by March.

"Everyone is going to win here," he says. "Patients are going to win because they don't have to go to the hospital and be subjected to that environment. And the extra rates that they are paying, their co-insurance and deductibles, are much higher in the hospital. Payers win because they pay us a lot less money and we win because we get the ongoing business."

Quality Concerns
Barbara Fagan, program manager of ambulatory care services in the Maryland's Office of Health Care Quality, confirmed that MASC will be operating under the federal guidelines. However, she says that doesn't necessarily make it a good idea.

"We don't have a policy. We enforce the CMS regulations and I am going to tell you if you were to be a lawyer in court, [that] technically because it says it can't be 24 hours, 23:59 would be within that definition for an ASC," Fagan says.

"But I always tell anyone who asks that if you are going into an ASC and you are there for 23 hours for a procedure, I would question whether that is the safest place to have a procedure done."

Fagan says ASCs are not designed for prolonged stays. "The hospital is going to have housekeeping and changing linens and food service and none of that is required at an ASC. Me personally, I wouldn't want to be in a surgery center if I had to be there for 23 hours."

The Maryland Hospital Association has raised also concerns about overnight stays at ambulatory surgery centers. MHA spokesman Jim Reiter says any number of potential problems could arise when patients stay overnight in ambulatory surgery centers.

"Their very name implies that they are not equipped to keep patients overnight. They are designed for outpatient treatments," Reiter said in an email exchange with HealthLeaders Media.

'A Hospital is a Hospital'
"The issue is not how much volume hospitals might lose. The issue is the safety of the patients involved. Investing in meals, linens, and other things does not make an ASC a hospital. What happens if something goes wrong? The patient will be taken to the nearest full-service hospital, where he or she probably should have been anyway if the treatment required an overnight stay."

"And how likely are these places to accept uninsured and Medicaid patients, as hospitals do? Not likely. Will they "cherry pick" the patients who have coverage, leaving the others for the rest of the state's consumers to pay for through our unique system of paying for hospital care in Maryland, which ensures that all get the hospital care they need whether they can pay or not?"

"In short, a hospital is a hospital. If these places want to be hospitals, they should go through the regulatory process, open an emergency department, have 24-hour professional health care provider coverage, and do all the other things that ensure care is available for everyone who needs it, 24 hours a day, 7 days a week."

Gross says he's not overly concerned about what hospitals think of the idea.

"I don't think the hospitals have anything to say about it. This is Medicare law. This is CMS regulation," he says. "As the technology has changed, there is so much more shifting out of the hospital and so much more we can do on an outpatient basis."

"This is procedure driven. Anyone having a particular procedure, we would plan on having them overnight. It does not change the profile of our patients. They are still healthy patients. The people who would have issues that would keep them in the hospital, we don't want them."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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