ASCs across the country are examining how to make the most of their managed care contracting opportunities for orthopedic and spine procedures.
At the Becker's 16th Annual Future of Spine + Spine, Orthopedic & Pain Management-Driven ASC Conference in Chicago on June 16, Principal of ECG Management Consultants I. Naya Kehayes delivered a keynote titled "The Future of Managed Care Contracting – A Focus on Spine, Orthopedics and Pain Management."
Here are five key trends from Ms. Kehayes:
Out-of-network reimbursement opportunities: "Access to reimbursement is becoming limited without a payer contract so out-of-network facilities aren't working so well anymore. These opportunities are diminishing and if you are the last one to the table your rates aren't going to be so great. Payers don't need you anymore because they have enough in-network access."
CMS removing total knee replacements from the hospital-only list: "What [CMS taking total knee replacement off the hospital-only list] does is give you a lot more momentum with commercial payers. But the fact is most commercial payers are already there. Most commercial payers are willing to discuss total joints."
CMS adding codes to the ASC payable list: "When there are approved codes on the ASC payable list that allows payers to add more codes. Typically the medical directors will feel comfortable when Medicare approves a code."
Value-based care: "Value-based pricing; some of the most common things we're seeing out there with alternative payment methodologies are risk sharing where payers provide incentives for quality outcomes and reduced cost. So if you can demonstrate better outcomes at a reduced cost you will see some payers are willing to pay you the benefit of the cost savings. That happens more often when the physicians can hold the risk, surgery centers can hold the risk too, but typically the physician's holding the risk and if they can lower the total cost of care they'll get a benefit from that."
Hospital joint ventures: "Hospitals and physicians quite often will share the onus for cost [in risk-bearing contracts]. Sometimes it will be a hospital-based contract and ASCs will play a bigger role in that where the hospital may come out and say I'm going to sign this contract with you for this service because if you can lower their cost they actually will make money on the contract. If you're at a hospital joint venture ASC, that is a potential opportunity for you. It will encourage the hospital to put additional volume into the center because they could see a potential upside, especially if it's in a bundled payment and they're able to push it into the surgery center."