Mark Lutes, attorney with Epstein Becker & Green discusses three payors whose relationship with ambulatory surgery centers may change over the next several years.
1. Medicare. In 2011, Mr. Lutes says virtually every local provider network and hospital system will discuss participation in Medicare shared savings. "The first conceptualization opportunity is to think about relating to those networks in a positive fashion — not simply, 'I want in, don't cut me out,' but, 'I have a care management methodology that will help you save money in the treatment of Medicare beneficiaries,'" he says.
He says the best way to think about Medicare shared savings is to consider the nature of cases the ASC has historically seen and the cases it wants to see. "Understand where each of those cases fall within an episode of care, because that's the conceptualizing framework that systems of care are going to be applying as they look for opportunities to bend the cost curve," he says. He says systems will seek to improve their performance for each episode, relative to how the episode would occur if it was unmanaged.
He says one approach is to contact the new physician networks that will likely pop up to take advantage of Medicare shared savings. "If the local hospital employs primary care physicians, they might be expected to participate in the hospital system's ACO, but in every market, there are unaffiliated or unemployed physicians who will be making applications to participate as a network in the beneficiary savings program," he says. Developing relationships with those networks as they form — and presenting data on ASC outcomes, patient satisfaction and cost — could benefit the ASC in the future.
2. Medicaid. The focus on accountable care organizations has drawn national attention to Medicare, but Mr. Lutes reminds ASC leaders that Medicaid, in the long-term, will likely be the biggest payor in the country. "Increasing number of states will mandate managed Medicaid, and the plans that assume risk for Medicaid patients therefore have the same cost imperative as ACOs."
He says ASCs should look to involve themselves in a dialogue about why the ASC should be part of the care path for Medicaid patients. This conversation could differ from ASC to ASC, depending on whether the facility wants to treat a significant number of Medicaid patients. "If it is part of their plans, there will be an additional number of managed care plans they need to have a conversation with."
3. Commercial payors. Mr. Lutes believes that as shared savings become prevalent through Medicare and eventually Medicaid, ASCs and other facilities will see the same behavior bleed into commercial plans. The healthcare reform bill calls for each state to set up an exchange where uninsured patients would shop for health insurance at competitive rates. "I think we will have some rules and some competitive bidding by [health plans] for exchanges, and while it won't simply be about price, a lot of it will be price-sensitive and motivated to deal with a cost-effective provider."
He says ASCs can take advantage of this competition by making the case to commercial payors about their cost-effective nature. "Additionally, as exchanges set rules for qualified health plans, some of those rules will deal with things like patient satisfaction and quality," he says. "The metrics we're talking about developing at the ASC level because useful to plans at that point."
Read more on billing, coding and collections:
-5 Ways to Improve Your Revenue Cycle Process in 2011
-10 Statistics on Cash in ASCs
-Understanding Financials: Your Cash Flow Statement
1. Medicare. In 2011, Mr. Lutes says virtually every local provider network and hospital system will discuss participation in Medicare shared savings. "The first conceptualization opportunity is to think about relating to those networks in a positive fashion — not simply, 'I want in, don't cut me out,' but, 'I have a care management methodology that will help you save money in the treatment of Medicare beneficiaries,'" he says.
He says the best way to think about Medicare shared savings is to consider the nature of cases the ASC has historically seen and the cases it wants to see. "Understand where each of those cases fall within an episode of care, because that's the conceptualizing framework that systems of care are going to be applying as they look for opportunities to bend the cost curve," he says. He says systems will seek to improve their performance for each episode, relative to how the episode would occur if it was unmanaged.
He says one approach is to contact the new physician networks that will likely pop up to take advantage of Medicare shared savings. "If the local hospital employs primary care physicians, they might be expected to participate in the hospital system's ACO, but in every market, there are unaffiliated or unemployed physicians who will be making applications to participate as a network in the beneficiary savings program," he says. Developing relationships with those networks as they form — and presenting data on ASC outcomes, patient satisfaction and cost — could benefit the ASC in the future.
2. Medicaid. The focus on accountable care organizations has drawn national attention to Medicare, but Mr. Lutes reminds ASC leaders that Medicaid, in the long-term, will likely be the biggest payor in the country. "Increasing number of states will mandate managed Medicaid, and the plans that assume risk for Medicaid patients therefore have the same cost imperative as ACOs."
He says ASCs should look to involve themselves in a dialogue about why the ASC should be part of the care path for Medicaid patients. This conversation could differ from ASC to ASC, depending on whether the facility wants to treat a significant number of Medicaid patients. "If it is part of their plans, there will be an additional number of managed care plans they need to have a conversation with."
3. Commercial payors. Mr. Lutes believes that as shared savings become prevalent through Medicare and eventually Medicaid, ASCs and other facilities will see the same behavior bleed into commercial plans. The healthcare reform bill calls for each state to set up an exchange where uninsured patients would shop for health insurance at competitive rates. "I think we will have some rules and some competitive bidding by [health plans] for exchanges, and while it won't simply be about price, a lot of it will be price-sensitive and motivated to deal with a cost-effective provider."
He says ASCs can take advantage of this competition by making the case to commercial payors about their cost-effective nature. "Additionally, as exchanges set rules for qualified health plans, some of those rules will deal with things like patient satisfaction and quality," he says. "The metrics we're talking about developing at the ASC level because useful to plans at that point."
Read more on billing, coding and collections:
-5 Ways to Improve Your Revenue Cycle Process in 2011
-10 Statistics on Cash in ASCs
-Understanding Financials: Your Cash Flow Statement