As the demand for cardiac care in the US continues to rise, and as more patients are screened and treated for cardiovascular disease, cardiac catheterization (CATH) and percutaneous coronary intervention (PCI) procedure demand will also continue to grow. The American Heart Association (AHA) estimates almost half of the US population will have some form of cardiovascular disease by 2035. Back in 2011, the AHA estimated 100 million Americans—almost 40% of the US population—would have a cardiovascular disease by 2030. We reached that projection in 2015—15 years early.¹ 

CMS approved 17 cardiac procedures that are predominantly cardiac CATH procedures and that are separately payable in the ambulatory surgery center (ASC) setting effective January 1, 2019.² CMS further expanded the approval of cardiology procedure codes in 2020, with the addition of six PCI procedure codes to the ASC-approved covered procedure list.³ In states where it is permitted, utilization of ASCs for CATH and PCI procedures has increased access for patients while lowering the cost of care. Based on a recent study conducted by ECG, claims data from 2022 and 2023 suggests approximately 10% of CATH and PCI procedures are being performed in the ASC setting.⁴ 

In California, however, the majority of these cardiology procedures are not approved for ASCs, which limits access for CATH and PCI procedures to hospitals. ECG conducted an analysis utilizing third-party claims data in three California metropolitan statistical areas (MSAs), including San Diego, Los Angeles, and San Francisco. The outcomes of the study indicate there is a need for additional access points for scheduled, nonemergent CATH/PCI procedures. Findings indicate that the length of time that elapsed from the initial patient outreach to a cardiologist to the time the patient had a CATH or PCI procedure can be as long as five months. We would expect to see similar trends, or even greater, in secondary markets and more rural areas attributed to the limitations in access to care.  

Moreover, when studying a sample of ASC and hospital outpatient department (HOPD) claims data from states where these procedures are approved in both sites of service, trends show a slow rate of migration from the HOPD to ASC of 1.4% for CATH and 2.6% for PCI.⁵ This data demonstrates that the approval of CATH and PCI in the ASC setting does not present a meaningful risk to hospitals associated with a migration of volume; however, it offers an alternative site of service that enhances capacity and access to care. 

With the AHA study demonstrating the accelerated incident rate of cardiovascular disease in the US at 40% of the population and growing, demand for cardiology CATH and PCI procedures will increase as well. Enabling access to ASCs with the approval of CATH and PCI procedures in the ASC site of service expands access to care in a lower-cost setting while enabling hospitals to enhance capacity that is needed to accommodate the increased demand for services. 

Finally, ensuring that patients are receiving procedures in the appropriate site of care will help to reduce cost overall. The opportunity for savings in the ASC setting is material when considering the reimbursement differential, which is 36% to 47% lower when compared to the HOPD Medicare rate for common CATH and PCI procedures. Approving CATH and PCI procedures for the ASC in California not only provides increased access to cardiology care in large MSAs as well as rural markets, but it also aligns with the commitment of the Office of Healthcare Affordability (OHCA) to reduce the annual cost growth in healthcare spending in California from 3.5% in 2025 to 3.0% by 2029.⁶ 

_{Prepared by ECG in partnership with CASA.}

¹Burden-Report-Consumer-Report.pdf (heart.org).

²January 2019 Update of the Ambulatory Surgical Center (ASC) Payment System (cms.gov).

³Ibid.

⁴Based on Stratasan’s APCD Claims Detail Data for 2022 and 2023 for claims with cardiac CATH CPT codes 93451–93461 or PCI CPT codes 92920, 92928, or C9600.

⁵Ibid.

⁶Health Access California, “Office of Health Care Affordability Takes Major Action to Rein in Health Care Spending” (April 25, 2024). Retrieved May 19, 2024, from https://health-access.org/office-of-health-care-affordability-takes-major-action-to-rein-in-health-care-spending.