Just which procedures should -- and shouldn't -- be performed at ambulatory surgical centers (ASCs) remains the subject of debate.
Procedures less advisable in the ASC setting, according to risk assessment researcher Lee Fleisher, include operations lasting more than two hours and those that will require general anesthesia.
Fleisher's study on ASC safety, published this year in the journal Archives of Surgery, found that higher rates of death and disability correlated with "greater invasiveness." He listed prostate removal, laparoscopic gallbladder operations, radical mastectomy and umbilical hernia repair as among the more problematic operations. He also cautioned against certain plastic surgeries that take so long anesthesia can wear off, the "bigger belly surgeries" and certain orthopedic surgeries that produce a lot of bleeding, among others.
"Laparoscopic gallbladder removal is on the edge of how far I would go" in an ASC setting, Fleisher said. He needed this operation a few years ago and chose the traditional hospital setting.
The Center for Medicare and Medicaid Services (CMS) authorizes reimbursement for some 2,500 procedures -- from cataract surgery to breast reduction -- at ASCs. Last month , it revised the list of approved procedures, adding 25, including knee arthroscopy, chin reconstruction and bladder repair, and deleting 105.
Among the items deleted as too risky: muscle and skin grafts, reconstructive cleft palate surgery, excision of the parotid gland, draining ovarian abscesses, repair of facial nerves and eardrum revision.
Publication of the list is closely watched by private insurers and HMOs, which use it to decide what procedures to cover. That, in turn, affects ASC conduct. Medicare's decision last year against reimbursing laparoscopic gallbladder removal in the ASC setting, for example, effectively stopped many ASCs from performing it.
CMS gave no explanation for its removal this year of two popular urology procedures: prostate biopsies carried out with needles; and cystoscopy, a telescopic inspection of the bladder and the urethra. ASCs, professional societies and individuals have until January 25 to challenge the changes.
-- Ranit Mishori
