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Six reflections on how COVID-19 has likely changed ambulatory surgery centers (ASCs) for the long term.

On May 11, the U.S. COVID-19 public health emergency (PHE) came to an end. The declaration is largely symbolic and comes less than a week after the World Health Organization (WHO) declared the end to the global PHE. These declarations come more than three years after both PHEs were declared. While PBS notes that COVID deaths are the lowest they've been since 2020, the virus still claims hundreds of lives daily and is likely to remain ever-present in our lives.

The symbolic end to the pandemic led to a spirited discussion here at SIS where we reflected on these past three years and discussed how COVID-19 has likely forever — or at least for the long term — impacted ambulatory surgery centers. Below are the six ways we identified. Despite the pandemic being an unquestionable tragedy, the list we came up with has some positive developments as well as changes that were likely inevitable but still accelerated by the circumstances.

1. Increase in surgical volumes

A positive for the surgery center industry was that we saw a notable increase in ASC case volumes as hospitals were filled with COVID patients and worked to manage those emergencies, on top of the routine emergencies that continued during the pandemic. While hospitals are no longer overwhelmed with COVID cases, we are not seeing reports or evidence that cases which made their way to ASCs are going back to the hospitals.

The ASC industry growth had largely been flat to slow for several years, but now we're in a situation where surgery centers are experiencing a growth period. ASC case volumes continue to increase, and we're starting to see more complicated and complex cases being approved for the surgery center environment. Some reports are projecting 25 percent growth in surgical volume over the next decade.

2. Value of remote access

On April 17, 2020, the Ambulatory Surgery Center Association (ASCA) issued a statement on resuming elective surgery — welcomed news to ASCs eager to resume caring for their patients. But this was easier said than done as ASCs needed to undertake a number of initiatives and meet requirements intended to help ensure safety for staff and patients.

ASCs with the ability for staff to remotely access their technology systems to help with everything from scheduling to billing to completing documentation were able to more effectively and properly resume operations and navigate the staffing challenges that presented themselves in the coming months. Meanwhile, surgery centers with older systems lacking such capabilities experienced a further strain on operations.

The importance of remote access remains today because staffing challenges — e.g., recruitment, retention, rising costs — largely remain. There are not as many healthcare workers as there are positions needing to be filled. We find ourselves in an economy where having the ability to employ offsite staff is increasingly crucial for filling openings and maintaining optimal operations. Given the staffing challenges during COVID, the industry also saw an increase in ASCs electing to outsource billing to meet their needs for staffing and to cost controls and that trend continues today.

3. Growing need for ASC automation

Since the staffing crisis isn't going away, ASCs must find ways to improve efficiencies — i.e., do more (work) with less (people). This points to the growing need for greater automation. We cannot expect the federal government or insurance companies to make our work any easier and should likely expect the opposite, so ASCs must ensure they can meet requirements and complete the work needed to maintain compliance and get paid. Automation is undoubtedly one of the most effective ways we can make ASCs more efficient.

4. Importance of communication and engagement capabilities and technology

Unlike at a hospital, work in an ASC tends to be predictable. We know when patients are supposed to come in and what procedure(s) they are coming in for. Significant disruptions in this routine are rare, and that helps surgery centers safely maximize operating room time and patients/cases.

But the pandemic seemingly brought with it one major change and distraction after another. Thankfully, ASC agility helped us respond well, but surgery centers that better weathered the ongoing storms typically had strong communication and engagement capabilities, supported by technology. The ability to get timely updates and announcements to patients, staff, and physicians — information that was received, reviewed, and acted upon — was crucial to help maintain safety, compliance, and satisfaction while reducing the number of procedures that needed to be postponed.

5. Fragility of the supply chain

In the years leading up to the pandemic, there were a few significant events that started to reveal major challenges and shortcomings in the healthcare supply chain. In 2018, Hurricane Maria contributed to a substantial IV bag shortage. And just weeks before the pandemic, Cardinal Health issued a recall of more than 9 million surgical gowns. When the pandemic hit, nearly every item healthcare providers needed became scarce. Then they became overpriced.

ASCs are now able to acquire most of their supplies with relative ease compared to what they experienced in 2020 and even into 2021, but we are still seeing regular disruptions in the supply chain. Contributing factors include natural disasters, logistics delays/failures, recalls, trade restrictions, heightened demand, global turmoil, and cyberattacks. Prices remain high as well. There is every reason to believe our supply chain will remain fragile over the long term, putting pressure on ASCs to make strategic purchasing and storage decisions so they can weather at least a short-term, significant disruption.

6. Greater interest in ASCs

With surgical procedures migrating to ASCs, payers looking to get their members into lower-cost settings for care, and patients taking on more active roles in choosing safer, more convenient sites for their treatment, the likes of hospitals, health systems, payers, and private equity firms are taking an increased interest in surgery centers. This is translating to a growth in the number of hospital-physician ASC joint ventures, hospital acquisition and development of ASCs, conversions of hospital outpatient departments to ASCs, payer acquisition of ASCs and private equity investments in surgery centers, sometimes via investment in a medical group with one or more centers.

While the physician-owned surgery center remains the predominant model of ASC, and we are seeing an uptick in physician-developed de novo centers, what is apparent is that organizations hoping to find success with an outpatient strategy will need to include one or more ASCs in their portfolios.

Interest in ASCs by hospitals, health systems, payers, and private equity firms was on the rise leading up to 2020. The pandemic supercharged this interest. ASCs have cemented their position as the optimal site for most outpatient surgical procedures. It will be interesting to see how this increased interest and investment in ASCs and transactions involving surgery centers will affect the industry over the long term.

ASCs: Built for agility

Despite the pandemic creating challenges ASCs had never experienced, the industry managed to largely thrive in the face of this adversity. Why? Surgery centers are agile. Cross-training is common, and team members often wear many hats. It's not unusual to see an administrator scrubbing in on a case or helping a patient pay their bill. ASCs do whatever is necessary to serve their patients.

The list of obstacles goes on and on, yet our industry bobbed and weaved when confronted with each new challenge and requirement. We updated policies, created new procedures, implemented nimble technologies, and made frequent changes to staffing schedules, all while continuing to deliver safe, high-quality care. The pandemic demonstrated the importance of being agile and how surgery centers are a model for such agility.