OIG targets Medicare oversight of ambulatory surgery

Report raises concerns about possible alternative agenda,’ attorney says

The Centers for Medicare & Medicaid Services’ (CMS) oversight of ambulatory surgical centers (ASC) has not kept pace with the explosive growth of these facilities, which more than doubled in number between 1990 and 2000, according to the Health and Human Services’ Office of Inspector General (OIG). "Oversight of ASCs is more important then ever," the OIG asserts in a final report issued Feb. 26. "Medicare’s system of quality oversight falls short."

While no one questions the need for adequate oversight, the OIG’s missive troubles some observers. "It is hard to argue with the need for quality care," says Robert Homchick, a partner with Davis Wright in Seattle. "What I am concerned about reading in this report is that the resulting conditions of participation and other steps suggested by the OIG could result in new regulatory hoops that are meaningful only to CMS rather than the quality of the care provided."

In fact, the OIG itself says the question of quality of care was beyond the scope of the report. "We did not attempt to answer that question in this report," says OIG spokesman Ben St. John. But he adds that the study did find some anecdotal information that it considers troubling. Although ambulatory surgery has been shown to have good outcomes, routine procedures can result in serious complications and death, St. John says.

Between 1990 and 2000, the OIG reports, the annual volume of major procedures ASCs performed increased by 730%, from 12,000 to more than 101,000 procedures.

But according to the OIG, CMS oversight of these services has not kept pace. Nearly a third of ASCs certified by state agencies have not been recertified in five or more years, and the conditions of participation, which drive the state agency certification process, have not been updated since 1982.

ASCs are surveyed at least every three years, notes the OIG. But it points out that this survey process devotes less attention to verifying compliance. CMS also found that CMS does little to hold state agencies and accreditors accountable to Medicare and the public.

Based on these findings, the OIG recommends that CMS determine an appropriate minimum survey cycle by state agencies, update the Medicare conditions of coverage of ASCs, and hold state agencies and accreditors more fully accountable to the public and the Medicare program.

Homchick says he worries about "an alternative agenda" that might lie behind these recommendations. "ASCs are lower-cost entities for the delivery of care, and I would hate to see them encumbered by regulations that are not tailored to maximize their efficiency," he asserts.

While the OIG says CMS responded "positively" to its report, it also notes that CMS did not fully commit itself to a number of the recommendations, particularly those calling for a minimum survey cycle and a more accessible complaint process.

According to the OIG, Medicare pays more than $1.6 billion per year for procedures performed by more than 3,000 ASCs. ASCs must become Medicare-certified by a state survey and certification agency or privately accredited to show that they meet the conditions of participation. The overwhelming majority of ASCs choose to become certified by state agencies, according to the OIG.