Same-day surgery can be stay-the-night surgery in the few states that let ASCs keep patients overnight to recover from complex cases. Rather than shuttle its total joints and spinal fusion patients to a hotel across town to spend the night, these surgical centers can admit patients to a "recovery" or a "convalescence" center that's usually a cove of private rooms attached to their facility. Depending on state law, patients can stay 24, 48 or 72 hours.

"We call it a recovery center, which makes it sound like it's in a separate building, but it's through 2 sets of doors and down a hallway," says Jennifer Arellano, CASC, the director of operations at Pinnacle 3, which manages the Orthopedic & Spine Center of Southern Colorado in Pueblo, 1 of 11 Colorado ASCs licensed as a convalescence center that can admit patients for multiple-night stays.

Though it can keep patients for up to 72 hours, the average length of stay is 1 overnight, says Ms. Arellano. Roughly 30 patients a month stay over in 1 of 9 private rooms Monday through Wednesday (closed on weekends) under the supervision of at least 2 members of a dedicated recovery center nursing staff: a registered nurse, always present, joined by either a certified nurse aide or medical assistant.

Surgeons inform the ASC when they want a patient kept overnight and how long they anticipate the patient staying. "The ability to send patients to the recovery center does not lower our ASC's standards for patient selection criteria," says Ms. Arellano. "We do not risk patient safety solely to increase volume."

On this day, 3 overnight cases are on the schedule, a couple of total knees, but first an 8:30 a.m. spinal fusion. If all goes as planned, the patient will be home by lunchtime tomorrow. She'll spend about 3 hours in surgery and 2 hours in recovery. After she's discharged from PACU, she'll be wheeled to the recovery center (which must have a license, entrance, waiting room, and medical records system separate from the ASC) and admitted around 1 p.m. to her room.

Room amenities include: private bathroom, closet space, TV, pullout chair a family member can sleep on and a gorgeous window view of the mountains. Meals are served and visitors are welcomed most of the day. The patient will order a late lunch — or an early dinner — off a menu from a licensed food vendor that delivers. (There's no kitchen in the recovery center, but they stock individually packaged snacks such as soups, crackers, yogurts and popsicles.) The surgeon will visit her the next morning, and she and her toiletries should be gone by 11 a.m.

Rarely covered

There are no financial gains to be made by providing overnight care, says Ms. Arellano. Medicare and most insurers don't cover it, and those that do reimburse around $500 per night — at best a break-even proposition when you account for staffing, food and linen costs, she says. But that's not a dealbreaker.

"If reimbursement for the procedure itself cover the ASC's expenses and those associated with the recovery center as well as a reasonable profit margin, we'll still take the case," says Ms. Arellano. "Without the ASC convalescence center, our surgeons would have to perform these procedures in a hospital."

The ASC and convalescence center opened in late 2014, right around the time increasingly complex cases were moving from hospitals to surgical centers. Overnight care has helped the ASC capture significantly more surgical volume. Last year, more than 400 patients stayed in the recovery center overnight.

"While the growth is exciting, what's even more gratifying is the feedback we receive from our recovery center patients, says Ms. Arellano. "They rave about it on our patient satisfaction survey."

Workarounds

In addition to Colorado, a few other states let ASCs keep patients overnight. An Illinois pilot program allows for a maximum stay of 72 hours, Connecticut allows for 3 to 21 days while Arizona's law is for patients with expected "uncomplicated recoveries." In March, the Oregon Legislature passed a bill that lets ASCs add extended stay recovery centers where patients can have 48 hours to recover from the time of admission at the ASC. ASCs must be safely in operation for 2 years before applying to offer overnight services and have a transfer agreement with a local hospital for emergency patient care.

No matter state law or what creative workarounds can be imagined, most outpatient centers are still years away from being able to handle overnight stays. The buildout alone would be prohibitive.

"This is not transformative," says Bill Prentice, CEO of the Ambulatory Surgery Center Association. "This provides another option for a patient needing outpatient surgery by giving the surgery center and the surgeons an additional option to make sure that they are truly stabilized and ready to go home."

But others see the arrival of extended stays as potentially eliminating a barrier to growth that will let ASCs eventually move into other surgeries like spines. "The next frontier for innovation is spine cases," says an ASC CEO. "As we talk to spine surgeons in the community about doing cases, they would love the opportunity to have an overnight observation stay or a 2-night stay for many of their cases. I think if we had that a lot spine cases can move to the outpatient setting."

Mr. Prentice, too, concedes that over time more states might choose to follow examples like Oregon's. "I think the need for this could grow as policy makers become more and more comfortable with the great care that's being provided in surgery centers. It gives those states who choose this an additional option in terms of ensuring that patients can be seen in surgery center, even those who may require a little extra time to recover from a procedure." OSM