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No Plateau in Sight for Ambulatory Surgery Center Growth

Analysis  |  By Christopher Cheney  
   May 11, 2022

An orthopedic ambulatory surgery center executive says an easing in the upward trajectory of ASC growth is unlikely.

The coronavirus pandemic has accelerated the growth of ambulatory surgery centers (ASCs) and growth is likely to continue for the foreseeable future, an ASC expert says.

The first ASC in the United States opened in 1970 and explosive growth happened through the late 1980s and into the 1990s, according to the Ambulatory Surgery Center Association (ASCA). ASC growth as been steady over the past two decades, with more than 5,800 ASCs performing an estimated 30 million procedures in 2020, the ASCA says.

"ASC growth has continued in the United States, and particularly for orthopedics, the number of ASCs is growing, and the number of cases shifting from main hospitals to ASCs continues to grow. We have seen this trend in recent years; but with the coronavirus pandemic, we have seen ASC growth accelerate over the past two years," says Alexander Sah, MD, co-director of the Institute for Joint Restoration and Research in Fremont, California.

Several factors are driving ASC growth, he says. "We see that there is an increasing movement of cases from the main hospitals into ASCs, mainly for increased safety for patients, profitability, removing costs from the health system, and better patient outcomes. Many surgeries that used to be thought to only be done in a main hospital can be done safely in a surgery center, which can be beneficial for physicians, health systems, and patients."

Sah says ASC growth is strong in his field. "Particularly in orthopedics such as elective hip and knee replacements, there has been a major shift, where it has been projected that by 2030 more than 50% of joint replacements would be performed in ASCs. That trend has likely been accelerated by the pandemic."

ASC growth is likely to continue for years, he says. "ASC growth will continue. I do not know when it will plateau—one would assume that at some point it will plateau because the number of ASCs would saturate the market, or the number of patients appropriate for ASCs would plateau. But we are not near that point yet."

ASC benefits

ASCs benefit healthcare providers, patients, and payers, Sah says.

"For healthcare providers, ASCs are an opportunity to have more control over how things are done. In a main hospital, you have many resources at your disposal, but you also have the challenges of emergency cases as well as operating rooms that have a wide scope of procedures that they perform. In an ASC, there is an opportunity to fine-tune skills and develop very specific programs. For example, you can develop an orthopedic-specific ASC or another facility that has a narrow focus of care. In that way, you can have areas of excellence. You can have centers that focus only on hip and knee replacement. Those centers can fine-tune their protocols and processes so that patients can have more efficient and predictable surgeries and outcomes."

For patients, there are benefits in avoiding main hospitals, he says. "For elective surgeries, such as joint replacement, many patients do not want to go to a main hospital. They do not want to be in a building where there are ill people—they want to avoid infection risk or other complications. By avoiding exposures to potential risks in the main hospitals, patients can achieve better outcomes."

An example of superior care for patients in ASCs is MicroPort Orthopedics' comprehensive pathway for patients, which looks at the entire episode of care for patients having elective joint replacement so that they can have the best preoperative experience and preparation, the best surgical experience, and the best recovery over the first 90 days after a procedure, Sah says.

"This program has virtual joint classes, engagement with patients throughout their episode of care, and good communication with surgeons. These surgeries are done in an ambulatory surgery setting with rapid discharges, where patients get to go home the same day, they do not have to sleep in a hospital, they can recover in the comfort of their own home, and there are ways to have patients tightly connected with their surgeons, thereby having better outcomes, quicker recoveries, and a more satisfactory experience," he says.

Compared to procedures done in main hospitals, ASCs have reduced costs, which benefits payers, Sah says.

"With the growth of ASCs, the amount of dollars that are saved by the healthcare system are in the realm of billions. When cases and surgeries move to ASCs, billions of dollars are saved by the healthcare system because procedures can be done more efficiently outside of the main hospitals. For payers, ASCs save money. There is less waste and less cost because ASCs can be more efficient in how they deliver their care. Both Medicare and commercial payers can save money by having cases shifted from the main hospitals to ASCs," he says.

Best practices for operating an ASC

There are two primary considerations when a health system or hospital operates an ASC, Sah says.

"The most important thing in opening an ASC is looking at what procedures are done and what the surgeons are capable of. A lot of the confusion for surgeons about ASCs is they think just because you do the same surgery under a different roof called an ASC, you will automatically have better outcomes and save money. You must have surgeons who are able to do surgery in an efficient way. They must be able to do surgery in a predictable fashion," he says.

The only way to make an ASC profitable is to be efficient, Sah says. "For example, if an elective joint replacement should only take an hour, if some cases it takes two hours and others take 40 minutes. The variability can make it challenging for the ASC to produce a consistent product. So, surgeons need to be capable, and they need to have the proper protocols in place. That means there needs to be buy-in from the anesthesia team, the recovery nurse team, and the physical therapy team. A successful ASC is more than just what happens in the operating room—it's everything that is involved surrounding a surgery."

Related: Watchdog Group Surveys Outpatient Surgery Facilities for Safety and Quality

Christopher Cheney is the CMO editor at HealthLeaders.


In 2020, there were more than 5,800 ambulatory surgery centers performing an estimated 30 million procedures.

For healthcare providers, ASCs are an opportunity to have more control over how episodes of care are done compared to the hospital setting.

For patients, ASCs offer a better patient experience and avoid hospital-acquired infections.

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