Payers are leading the outmigration of care by steering patients from hospital outpatient departments to ASCs, according to an Advisory Board report.
Three steerage tactics payers employ:
1. Medicare policy. CMS has implemented site-neutral payments, made payment rate increases benefiting ASCs, maintained lax ASC quality reporting requirements and expanded the definition of "surgery" to include "surgery-like" services.
2. Payer-provider contracts. Some payers have held ASC reimbursement rates steady while lowering HOPD payments. Some insurers also require hospital to perform a certain volume of outpatient procedures in ASCs. Minnetonka, Minn.-based UnitedHealthcare, for instance, permits primary care physicians to directly refer patients for most ASC procedures but mandates preauthorizations for HOPD services.
3. Patient benefit design. UnitedHealthcare, Aetna and Medicare beneficiaries have lower copays for ASCs than HOPDs, and the California Public Employees' Retirement System drives patients to ASCs by requiring them to pay any costs exceeding a set price.