The United States boasts a staggering 5,400 ambulatory surgery centers (ASCs), which account for approximately 35% of all surgeries performed nationwide [1]. ASCs tend to specialize in one or a few fields, including gastrointestinal, ophthalmology, pain management, orthopedic, and genitourinary procedures, which make up 70% of all cases [1]. With benefits such as improved patient accessibility, reliable scheduling, customized surgical environments, efficient surgical teams, shorter operative stays, lower costs, and less exposure to hospital-acquired infections, ASCs have seen a surge in demand and are increasingly preferred over traditional hospital settings for many procedures [1]. In order to address a potential shortcoming of ASCs, it is common for outpatient facilities to establish transfer agreements with hospitals in case of emergency. 

Transfer agreements between outpatient facilities and hospitals serve as an essential safety net, ensuring that patients receive appropriate care in the event of an emergency [2]. Prior to 2019, federal law mandated that ASCs have a written transfer agreement with a local hospital or that every physician performing surgery at the ASC have admitting privileges at a nearby hospital [2]. However, in November 2019, the Centers for Medicare and Medicaid Services (CMS) announced significant changes in the requirements for ASCs, relieving them of the obligation to have a written transfer agreement or hospital admitting privileges for all practicing physicians [3]. Instead, ASCs were instructed to periodically provide the local hospital with written notice of their operation and patient demographics [3]. So far, only Alaska and Delaware have removed the requirement for ASCs to have a written transfer agreement with a local hospital from their state law since 2019, and transfer agreements remain crucial for ensuring patient safety and proper care [3]. 

One of the primary benefits of transfer agreements is that they ensure that patients receive the appropriate level of care, as ASCs may not have the resources to handle complex medical emergencies [2,4]. Hospitals possess specialized equipment and staff necessary to provide advanced care in such situations and transfer agreements provide a structured process for getting patients from an ASC to a hospital, ensuring that they receive timely, appropriate care [4]. Transfer agreements can also help to improve patient outcomes by facilitating a smooth transition of care when unforeseen inpatient admissions are required [4]. 

However, a challenge with requiring transfer agreements between outpatient facilities and hospitals at the state level is that the requirements can vary state by state, creating confusion and inconsistencies for ASCs operating across state lines [3]. Negotiating and executing a transfer agreement can also be a time-consuming and resource-intensive process for ASCs, which may not have the same level of administrative and financial support as larger hospitals [3,6]. In 2019, CMS estimated savings of $843 million in the first year of implementation when it proposed new guidance on not requiring transfer agreements [6].  

While CMS has not changed its stance on transfer agreements, it encourages outpatient facilities and hospitals to work together to establish a transfer process that meets their respective needs while ensuring patient safety remains the top priority [3]. ASCs and local hospitals must also abide by state laws, which vary across the country [3]. 

References 

1. MacKoul, P., Danilyants, N., Baxi, R., van der Does, L., & Haworth, L. (2019). Laparoscopic hysterectomy outcomes: hospital vs ambulatory surgery center. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 23(1). 

2. Fox Rothschild LLP. (2017). When an ASC Dials 911: The Basics of Hospital Transfer Agreements. Fox Rothschild LLP. https://www.foxrothschild.com/publications/when-an-asc-dials-911-the-basics-of-hospital-transfer-agreements/. 

3. ASC Focus. (2022). States Move Slowly to Align with CMS Changes. ASCA. https://www.ascfocus.org/ascfocus/content/articles-content/articles/2022/digital-debut/states-move-slowly-to-align-with-cms-changes. 

4. Chambers, M., Huddleston, J., & Halawi, M. (2020). Total knee arthroplasty in Ambulatory surgery Centers: the New Reality!. Arthroplasty Today, 6(2), 146-148. 

5. Centers for Medicare and Medicaid Services. (2017). Transmittal 171: Medicare Claims Processing Manual, Chapter 14 – Ambulatory Surgical Centers (ASCs). https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R171BP.pdf 

6. Dyrda, L. (2019). CMS eliminates ASC-hospital transfer agreement, updates other requirements in new rule. Becker’s ASC Review. https://www.beckersasc.com/asc-news/cms-eliminates-asc-hospital-transfer-agreement-updates-other-requirements-in-new-rule.html 

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