1. Ambulatory Surgery Centers
in the
United States of America
David Shapiro, MD
National Conference on Ambulatory Surgery
Bangalore

2.  Physician
 Anesthesiologist (Specialization in Outpatient Anesthesia)
 Florida Society of ASCs (FSASC) : Board Member
 ASC Association (ASCA) : Chairman of the Board
 ASC Quality Collaboration : Co -Chair
 AAAHC : Surveyor
 AORN ASC Administrator Course : Faculty
 Certified Administrator Surgery Center (CASC) by the Board of Ambulatory Surgery
Certification
 Certified in Health Care Quality and Management (CHCQM) by the American Board of
Quality Assurance & Utilization Review Physicians
 Certified in Healthcare Compliance (CHC) by the American Hospital Association
 Certified Professional in Healthcare Risk Management (CPHRM) by the Health Care
Compliance Board
 Licensed in Healthcare Risk Management (LHRM) by the State of Florida
Dr. David Shapiro

3. Opened February 12, 1970 in Phoenix, Arizona
Founded by
Wally Reed, MD
John Ford, MD
Named “Surgicenter”
Originally 4 ORs
Now 6 ORs, 4 Endoscopy Suites
History of ASCs in the United States

4. First sketch of Surgicenter
made on the back of a tent
table ad at Smuggler’s Inn
in Chicago in 1968.

5. John L. Ford, MD and Wally Reed, MD in the OR on Surgicenter’s opening day, February 12, 1970.

7. ASC Timeline
1968
Wallace Reed, MD, and John
Ford, MD, commit their idea for
a freestandingambulatory
surgery facility to paper for the
first time and develop
objectivesfor the facility. They
begin collecting endorsements
from the governmental bodies
and members of the health
care communityto obtain
financingfor the project.
1970
Reed and Ford’s idea becomes
reality when on February 12
Surgicenter,the nation’s first
freestandingambulatory
surgery facility, opens for
business.Five physicians
perform five procedures at the
facility that day, four requiring
general anesthesia.
1974
The Society of Freestanding
AmbulatorySurgicalCare
(ASCA’s original name) is
incorporatedduring an ASC
seminar conducted in
Phoenix, Arizona.
1975-1976
Rapid growth. A total of 42
surgery centers are in
operation in the US by 1975
and an additional 25
facilities open in 1976.

8. 1979
The industry continuesto
grow, with the number of
ASCs reachingtriple digits.
ASCA and others join together
to form the Accreditation
Association for Ambulatory
Health Care (AAAHC).
1982
Medicareapprovespayment
to ASCs for approximately200
procedures,which are placed
in one of four payment groups
with payment rates between
$231 and $336, based upon a
cost survey of 40 ASCs.
1987
Medicaremodifies the ASC
list to use specific CPT codes
and expands the list to
include1,535 procedures.
1988
The number of ASCs in the
US reaches1,000. Using the
information from a 1986
cost survey of ASCs,
Medicareimplementsa new
payment system, which
remains the basis for ASC
paymentstoday.
ASC Timeline

9. 1995
ASCs go internationalwhen
the InternationalAssociation
for AmbulatorySurgery
(IAAS) is founded during the
1st International Congresson
AmbulatorySurgery in
Brussels. Medicare expands
the ASC list to cover more
than 2,000 procedures.
2002
Seventy-eight individualsearn
the CASC credential,the first-
ever ASC-specific credential,
establishingthe ASC
administratoras a separate
and distinct career from other
health care management and
clinical positions.
2011
More than 5,300 ASCs exist
in the US today, performing
23 million surgeries
annually. Medicarehas
granted approval for ASCs
to perform more than
3,500 procedures.
ASC Timeline

10. Number of ASCs Per State

11. Number of ASCs Per Capita (Top Ten)
State Population ASCs
ASCs per
100,000 People
Maryland 5,773,552.00 354 6.13
Wyoming 563,626.00 19 3.37
Washington 6,724,540.00 220 3.27
Idaho 1,567,582.00 51 3.25
Georgia 9,687,653.00 287 2.96
Delaware 897,934.00 24 2.67
New Jersey 8,791,894.00 233 2.65
Nebraska 1,826,341.00 47 2.57
Arizona 6,392,017.00 152 2.38
Tennessee 6,346,105.00 149 2.35

12. Surgical Trends

13. Surgical Trends

14. Specialties Served in ASCs by Claims
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
278,000
4.4%
1,971,000
31.1%
76,000
1.2% 14,000
0.2%
1,802,000
28.4%
508,000
8.0%
74,000
1.2%
1,384,000
21.8%
3,000
0.0%
209,000
3.3%
23,000
0.4%
InThousandsofDollars

15. Specialties Served in ASCs by Reimbursement
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$120
3.6%
$627
18.8%
$68
2.0% $15
0.4%
$1,416
42.4%
$463
13.9%
$59
1.8%
$407
12.2%
$1
0.0%
$134
4.0%
$30
0.9%
InMillionsofDollars

16. ASC Ownership
Corporate, 6%
Hospital, 2%
Physician, 65%
Corp-Phys, 8%
Hosp-Phys, 17%
Corp-Hosp-Phys,
2%
*Note: The Corporate-Hospital category had 0% ownership in the survey results.

17. ASC Ownership Trends
2009 2008 2007 2006 2005 2004
PHYSICIAN 62% 63% 61% 61% 63% 61%
CORPORATE 6% 7% 7% 7% 5% 7%
HOSPITAL 2% 2% 2% 3% 3% 3%
CORP-PHYS 9% 10% 10% 11% 10% 11%
CORP-HOSP 0% 0% 0% 0% 0% 0%
HOSP-PHYS 17% 16% 17% 16% 16% 16%
CORP-HOSP-PHYS 3% 2% 2% 3% 2% 2%
Physician Other
2009 92% 8%
2008 90% 10%
2007 91% 9%
2006 91% 9%
2005 91% 9%
2004 90% 10%

18. • Federal Regulation
Center for Medicare & Medicaid Services (CMS)
• State Regulation
Various State Health Department and/or Agencies
• Local Regulation
Primarily Building and Fire Code Compliance
Enforcement
ASC Regulation

19. Effective May 18, 2009 -
“means any distinct entity that operates
exclusively for the purpose of providing
surgical services to patients not requiring
hospitalization and in which the expected
duration of services would not exceed 24 hours
following an admission.”
42 CFR 416.2 DEFINITIONS
CMS: Definition of an ASC

20. • Defines ASCs in Federal Law
• Determines Payment Policies
– Allowable Procedures
– Applicable Rates
– Annual Updates
• Determines ASC’s Participation in Federal Programs
– Conditions of Coverage
-Infection Control Checklist
• Administer Quality Reporting Programs
CMS

21. ASC Accreditation
ASCs are Accredited by 4 different Organizations:
Accreditation Association for Ambulatory Health Care (~3,010)
Joint Commission (~637)
American Association for Accreditation of Ambulatory Surgical
Facilities
American Osteopathic Association
As of Spring 2011: Over 70% of ASC facilities in the U.S.
are accredited by one of these four organizations

22. Top Ten Procedures by Volume
Specialty
HCPCS
Code
2010
Volume
Short Descriptor
Ophthalmology 66984 1,123,252 Cataract surg w/iol 1 stage
Gastrointestinal 43239 516,603 Upper gi endoscopy biopsy
Gastrointestinal 45380 358,733 Colonoscopy and biopsy
Gastrointestinal 45385 275,898 Lesion removal colonoscopy
Gastrointestinal 45378 271,762 Diagnostic colonoscopy
Ophthalmology 66821 256,749 After cataract laser surgery
Pain Management 64483 245,274 Inj foramen epidural l/s
Pain Management 62311 229,492 Inject spine l/s (cd)
Pain Management 64494 191,097 Inj paravertebral facet joint
Pain Management 64484 128,510 Inj foramen epidural add-on

23. Reimbursement: Most Highly Paid Procedures
HCPCS
Code
Short Descriptor
Final CY 2011
ASC Payment
69930 Implant cochlear device $29,056.15
33249 Implant pacemaker leads $25,360.04
33240 Insert pulse generator $22,212.75
64568 Neurostimulator implantation $21,333.84
61886 Placement cr. neurostimulator $17,849.58
61885 Insertion /redo neurostimulator $13,816.04
63685 Insertion/redo spinal stimulator $13,816.04
64590 Insertion/redo gastric stimulator $13,816.04
62361 Implant spine infusion pump $12,221.29
62362 Implant spine infusion pump $12,221.29

24. Operational Data
ASCA Outcomes Monitoring Project
Business Operations (#4)
Net Charges
Days in A/R Outstanding
Paid Clinical Non-Physician Hours
Clinical Operations (#19)
On Time Rate
Operating Room Time
Cancellation Rate
Clinical Outcomes (#19)
Cardiac/Respiratory Arrest
Nausea / Vomiting
Retained Foreign Object

25. ASC Quality Collaboration
• Funded by ASCA & ASC companies
• Outcomes reporting
• Outcomes measure development
• Sharing best practices
• Clinical studies
• Promoting transparency

26. Quality Data Reporting
Six NQF Endorsed Measures
• Patient Burn
• Patient Fall
• Wrong Site, Side, Patient, Procedure or Implant
• Hospital Transfer / Admission
• Prophylactic Intravenous Antibiotic Timing
• Appropriate Method of Hair Removal

27. Current Trends
0
10
20
30
40
50
60
70
20022003200420052006200720082009
Physician Employment
0
10
20
30
40
50
60
70
1990 1995 2000 2005 2010E
MDs per ASC
0
1
2
3
4
5
6
7
8
9
10
2005 2007 2009 2011 2013 2015
Unemployment
0
5
10
15
20
25
30
2006 2007 2008 2009 2010
High Deductible Plans

28. Impact
-8
-4
0
4
8
12
1998 2000 2002 2004 2006 2008 2010
Year-over-Year%Change
Growth in
Outpatient Surgery
0
2
4
6
8
10
12
1998 2000 2002 2004 2006 2008 2010
Year-over-Year%Change
Growth in
Number of ASCs

29. ASCs: The Innovative Solution for Health Care
Access
Convenience
Provision of Critical Services
Cost
Efficiency
Transparency
Quality
Clinical Outcomes
Patient Satisfaction
ASC Future

30. Ambulatory Surgery Centers
in the
United States of America
David Shapiro, MD
National Conference on Ambulatory Surgery
Bangalore