The shift of cardiology procedures to outpatient settings has not gained momentum as quickly as many expected. Roadblocks such as infrastructure limitations, regulatory hurdles and payer reluctance have slowed progress, even as cost and efficiency pressures continue to mount.
Despite these headwinds, Vance Chunn, CEO of Mobile, Ala.-based Cardiology Associates, told Becker’s he remains optimistic. He believes the outpatient migration of cardiology is inevitable, just not immediate.
Here’s the timeline Mr. Chunn anticipates for cardiology’s outpatient evolution:
- One to two years: Expect slow but steady growth, concentrated in large markets with forward-thinking providers. Expansion will largely be led by private equity-backed or physician-led ASC models.
- Three to five years: As payer pressure increases and infrastructure improves, a broader migration will take shape. Hospitals may look to joint ventures or begin shifting select low-risk procedures to outpatient settings.
- Beyond five years: A more substantial transition — similar to what’s already occurred in orthopedics and GI — will unfold. Widespread adoption will require a mature ASC ecosystem and continued momentum from payers and physicians.
Here are the forces driving the change:
1. Payer pressure intensifying
Payers are ramping up efforts to cut healthcare costs, and shifting procedures to lower-cost sites of service is a major part of their strategy. ASCs are significantly more affordable than hospital outpatient departments, making them a prime target for volume migration.
Alignment between Medicare and private payers remains a challenge. Tracy Helmer, administrator of Mesa, Ariz.-based Tri-City Surgical Centers, told Becker’s last year that the biggest payer issue his ASC is facing is “denials that do not fall in line with the Medicare payable procedures.”
Many private payers aren’t matching Medicare codes for cardiology procedures, Mr. Helmer said, “For example, loop recorder implants are commonly denied for no prior authorization from private payers, yet, in the Medicare fee schedule, they require no authorization and there’s usually not a problem.”
2. Technology advances
Innovations in procedural safety, imaging, anesthesia and post-operative monitoring are making outpatient cardiovascular care safer and more feasible. As these technologies continue to evolve, a wider range of cardiac procedures can be safely performed in ASCs.
3. Private equity and ASC operators take the lead
Private equity firms and ASC management companies are key players in pushing cardiovascular care into the outpatient space. These groups are actively building cardiovascular ASCs and acquiring independent cardiology practices.
Between January 2013 and September 2023, PE firms acquired 342 cardiology clinics, with most deals occurring after 2021, according to the Journal of American College of Cardiology.
Optum’s ASC arm, Deerfield, Ill.-based SCA Health, acquired at least two cardiovascular providers in 2023. In 2024, Marriottsville, Md.-based Bon Secours and Compass Surgical Partners united to build a cardiovascular surgery center in Short Pump, Va.
“Private equity can provide capital, but you still need expertise. You can’t just jump into it,” Mr. Chunn said. “We’ve had interest from private equity firms wanting to buy our practice, and you have to be cautious. They can bring capital, sure, but you still need to know what you’re doing.”
Even among major players, there’s caution. Tenet’s ASC arm United Surgical Partners International, for example, is taking a measured approach to the outpatient migration of cardiology procedures.
“The opportunity in a wide variety of cardiovascular procedures is there,” Tenet Healthcare CEO Saum Sutaria, MD, said in the call. “[But], I’ve always been clear that I think that that opportunity will proceed more slowly than people anticipate.”
4. Hospitals and health systems facing pressure
Hospitals and health systems, under rising financial pressure and shifting payer dynamics, are rethinking their traditional care models. Joint ventures with physicians are increasingly seen as a way to stay competitive and retain procedural volume.
“What I’m seeing is that larger healthcare systems that have both the funding and a real ambulatory strategy are the ones getting into it,” Mr. Chunn said. “You need capital to do it right. And some systems are hesitating because they realize how expensive it is, and that they might lose revenue in a profitable service line. They’d have to share it with physician investors. So they drag their feet.”
Eventually, payer dynamics may force even smaller systems to invest in the shift, he said.
Cardiology is already top of mind at AdventHealth. Shyroll Morris, senior vice president and chief strategy officer of the system’s East Florida division, said a recent joint venture with Cardiology Physicians and North Florida Surgeons to build a medical office building and ASC was a strategic move.
“Our cardiology ASC was a big investment for us, and other cardiology groups are watching closely as we run it as an ASC,” she said. “There’s a lot of deregulation in cardiology — electrophysiology included — so we expect even more push into the outpatient setting. That’s why we positioned ourselves with this service line.”
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