ASCs in many markets are struggling for leverage with payers, up against massive hospital systems and sparse cost information from the insurance companies.
For Greg DeConciliis, administrator of Boston Out-Patient Surgical Suites and president of Massachusetts' ASC association, because there's no threat to go out of network with the payers in his market, his team often has "no leverage" with payer contracts.
This power imbalance is exacerbated by the fact that there's no real intel into the exact cost savings of ASCs for payers, Mr. DeConciliis told Becker's.
"It's very tough in our state, where most of our contracts are statewide with very little negotiation," he said.
And while payers have been consistent with mirroring Medicare and approving orthopedic procedures that are migrating to ASCs, it's difficult to get coverage for other procedures, such as biological treatments like platelet-rich plasma injections.
Mr. DeConciliis added that the lack of leverage is in part due to the strength of large hospitals and health systems in the area.
"In our market, at least, we're so dependent on the hospitals," he said. "They're the big players, and we're just lucky to have anything. That's how I think they look at it."
Price transparency could ease this imbalance.
"If there was transparency in pricing and we knew what hospitals were getting paid, we could point to that and show the tremendous money insurers are paying through the use of ASCs," he said. "That would help our argument."
Another strategy is doubling down on education, he added.
"If you're talking to an administrative person who doesn't understand the medical reasons behind your requests, it's important to move up the ladder and speak with their medical folks," he said. "It's hard for an administrative person, whose job is to save money, to understand why you're asking for increased reimbursement for a procedure."
Gaining payer leverage is particularly difficult for independent ASCs.
"I think that the single biggest challenge is really payer consolidation," Axion Spine & Neurosurgery COO Joy Taylor said at the 21st Annual Spine, Orthopedic & Pain Management-Driven ASC + The Future of Spine Conference in Chicago. "We've recently had to start a de novo facility, … and getting payers to give you the time of day, even though you represent substantial savings over the [explanation of benefits] that are coming out of the hospital, it's very, very difficult to get on their radar. So that's really been the single biggest challenge for us."
Mr. Concilliis wishes payers would capitalize on the cost-saving benefit of ASCs: Procedures done in hospital outpatient departments can cost 58% more compared to a physician's office or ASC, according to a 2023 analysis by Blue Health Intelligence, the Blue Cross Blue Shield Association's data analytics company.
"Don't take for granted the fact that we're contributing positively to the bottom line," he said. "The only time it gets brought up is when there's a threat to our existence. If there's a way for them to constantly be made aware of the savings we provide, that would help."