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The U.S. health care system continues to become more decentralized. As part of that trend, health care services continue to trickle down from hospitals and health systems to freestanding entities, including ambulatory surgery centers (ASCs).

While the pace of such site-of-care shifts feels fast, it has actually been a gradual process. And ASCs have likely yet to feel the full force of the procedure volumes headed their way in the not-too-distant future, recent insights from the Advisory Board suggest.

“Significant changes have occurred,” the global health care research and consulting firm noted about site-of-care shifts in its 2024 annual report. “Following several years of outpatient and ASC eligibility, joint replacement volumes shifted to majority outpatient. The COVID pandemic disrupted volume trends and created a clinical impetus to minimize inpatient utilization. Operational changes solidified outpatient shifts, while care practices changed across service lines, resulting in structural changes to care delivery.”

To evaluate site-of-care shifts, the Advisory Board team analyzed Optum’s de-identified Clinformatics Data Mart Database, with the review period ending in 2022.

Among the findings, the team determined that 55 outpatient procedures have experienced significant site-of-care shifts since 2017.

“We define this as 5 percentage points or greater share shift in the highest-share site of care and at least 2,500 volumes in 2022 in the dataset,” they specified in the report.

Overall, the most common site-of-care shift was the migration of health care services from clinic settings into hospital outpatient departments (HOPDs). At least 14 outpatient procedures have noticeably moved from clinics to HOPDs, according to the Advisory Board’s research.

In many ways, that could be a leading indicator for ASCs. As more procedures shift into HOPDs, they could, in turn, migrate into ASCs, which typically present the more cost-effective setting.

At least four outpatient procedures have shifted from mostly in HOPDs to the ASC setting.

Looking ahead, further site-of-care shifts are likely, with payers playing an important role in the trend. Yet payers are only one piece of the puzzle.

“Payers have traditionally relied on payment incentives to steer volumes to freestanding settings,” the Advisory Board’s report explained. “But slow non-hospital volume growth for most procedures proves that this lever alone isn’t enough. To accelerate the site-of-care shift, payers must preserve specialist independence and partner with operators to build the necessary infrastructure. With members, plans are using care navigation strategies and price transparency. With providers, plans are using value-based care arrangements and data sharing.”

Other common site-of-care shifts include procedures from clinic to lab settings.

Additionally, and of note for ASC operators, a handful of procedures appeared to move back into higher-cost settings. In its analysis, the Advisory Board team found that at least three procedures moved from ASCs to HOPDs.

Several types of procedures – particularly those of higher-acuity varieties – are gaining momentum in ASCs.

Complex spine procedures are one clear example of that trend.

“Hospitals, understandably, have to handle a wide range of medical issues and cannot be as hyper-focused on one area of medicine,” Dr. Luke Macyszyn, a neurosurgeon with California-based DISC Sports & Spine Center, previously told ASC News. “In our ASC, we don’t have to jump through hoops to change equipment between cases or manage various skill sets. We excel at one thing — spine and orthopedics — at a very high level.”

Cardiovascular procedures are another clear example.

“Cardiology did a phenomenal job of gathering data to prove these procedures can be safely done in an ASC setting,” Dr. Samuel Jones, a cardiologist with the Chattanooga Heart Institute, previously told ASC News.

But as site-of-care shifts accelerate, ASCs may need to consider teaming up with partners with deep pockets and plenty of resources.

“Independent providers can drive volumes to the freestanding setting to grow their businesses,” the report noted. “However, as shifts accelerate, they may need to partner with health systems to fund the capital investments needed to scale outpatient care.”