Available online 15 April 2024, 100955

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Despite reimbursement pressures and scrutiny on procedural appropriateness, the demand for peripheral vascular ambulatory services remains strong. Improvements in minimally-invasive technologies, coupled with a supportive regulatory environment and considerable preference for ambulatory services among purchasers, patients, and providers, have resulted in the rapid proliferation of ambulatory facilities in a number of markets. Emerging ecosystem dynamics, notably the rapid growth of Medicare Advantage and the growing presence of private equity and venture capital within healthcare, will likely have an impact on future growth trends but will not fundamentally alter the incentives driving the ambulatory shift. Indeed, it is likely that the dynamics currently at work within peripheral vascular services will become come to characterize a variety of other services, as more care shifts away from the hospital.

Section snippetsDriver 1: Technology

The outmigration of vascular procedures has its roots in the development of minimally-invasive technologies for peripheral artery disease (PAD) treatment, which sparked rapid growth in endovascular interventions in the lower extremities around the turn of the twenty first century. The number of therapeutic endovascular interventions in the lower extremities more than quadrupled between 1996 and 2011, largely driven by growth in peripheral angioplasty and atherectomy. Over the same period,

Driver 2: Regulatory and Policy Environment

Another requirement is the presence of a supportive regulatory and policy environment, which has been instrumental in the case of PVI. Responding to rapidly-rising costs associated with inpatient care of vascular patients,9 in 2008 CMS established new ambulatory payment classifications that allowed payments for PVI procedures to be bundled for HOPD and OBL settings. This was followed by the introduction of a new family of bundled Current Procedural Terminology (CPT) codes for PVI in 2011, which

Driver 3: Payer and Purchaser Preferences

Aside from regulators, we are also witnessing emerging pressure from payers and purchasers to efficiently deliver vascular care in non-hospital settings. This is a relatively new source of pressure, as the vast majority of PVI procedures performed in the OBL over the last fifteen years were reimbursed through Medicare. As commercial plans come to manage more senior lives through Medicare Advantage (MA), this is now changing.

MA plans have a strong incentive to attract and retain senior lives

Driver 4: Provider Preferences

Vascular providers also often show a preference for working in the ASC and OBL settings, especially in contrast to employment in a hospital setting. Physician employment reduces entrepreneurial risk, but it also reduces entrepreneurial opportunities. The promise of financial security is appealing in bad economic times, but is less of a draw in specialties like vascular, where reimbursement for procedures has been relatively high. Hospital employment also entails obligations that providers often

Conclusion

The dynamics we have seen at work in the vascular ambulatory space are rapidly becoming present across healthcare as a whole. The pressure to manage out-of-control costs and care for a complex and aging population is prompting the growth of new delivery models placing ambulatory services at the forefront. As such, patterns we have witnessed in the adoption and expansion of ambulatory PVI hold significant lessons for the future of a wide array of healthcare services.

Some of the most fundamental

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© 2024 Published by Elsevier Inc.