ASCs have long struggled to secure reimbursements — with CMS' proposal to remove 258 procedures from the ASC payable list, leaders are concerned that securing payment could become even more challenging.
Here are five predictions on the future of the payer market:
Andy Wilkinson. Financial planning and analysis, ambulatory surgery, for Shields Health Care Group (Boston): I expect to see more referral management and care direction programs put in place by payers. We’re starting to see some of this with the largest employers in the area as they look at their health benefits expenses as a potential cost-management solution. Payers will need to get creative around crafting a compelling story for administering cost-effective, self-insured products. As a result, I expect payers to start directing care to lower-cost sites of care, where patients can obtain the same high-quality care from the same physicians they would at their local hospitals. It’s for this reason that our ASC model focuses on partnering with existing community hospitals and physicians dedicated to lowering costs for patients. As payers see these experiments take off in their self-insured products, I’d expect a similar process to manifest in their fully insured products.
Kim Rand. Business office manager of The Surgery Center of Chester County (Exton, Pa.): I think the payer market will start to dwindle in the number of payers — smaller insurance companies are already being hosted by larger groups. I have many more insurance companies that are referred to as the "host" plan, but any payments to the provider go through the “home” plan. Smaller insurance companies seem to be in name only.
Matt Kraemer. Orthopedic service line administrator of Northern Arizona Healthcare (Flagstaff): Insurance companies will look for healthcare organizations to move some of these historically inpatient procedures to be moved to the ASCs. The ASC fee schedule is far less than that of the outpatient hospital outpatient department reimbursement schedule. This means their costs will be dramatically reduced, and it will allow them to reduce their premiums to their members, thus assisting in increasing their market shares.
Sam J.W. Romeo, MD. General partner at Tower Health & Wellness Center (Turlock, Calif.): I worry that the payers and their regulatory mindset will continue to erode the value of empathy, substituting regulations and audit findings for patient-centered satisfaction and quality, patient-centered care — My bold prediction is that the true payer, the patient, will eventually move the trend back to a friendlier, kinder, empathetic, patient-assessed quality standards.
Andrew Lovewell. Administrator of the Surgical Center at Columbia (Mo.) Orthopaedic Group: A truly bold thing that could happen would be that the insurance (commercial) payers come out and actually launch steerage programs to centers of excellence across the nation. This can’t be a race to the bottom, though. It has to be a focus on quality work with possibly a tiered approach for outcomes. For years, ASCs have been doing total joint and spine cases but haven’t been as handsomely rewarded as they need to be.