Outpatient surgery providers have been slow to adopt bundled payments, which offer an opportunity for ASCs to prove themselves as a viable care option, according to Roji Health Intelligence CEO Theresa Hush.
Note: Responses were edited for length and style.
Question: What are the biggest payer and reimbursement changes ASCs have experienced over the past two to three years? Are you seeing more risk-based contracts or price transparency?
Theresa Hush: ASCs have been expanding and will continue to do so in the years ahead, stimulated by reimbursement incentives from payers, especially Medicare/Medicaid. ASCs are also featured in both hospital and health plan acquisition strategies because of their attractive cost profiles and the eagerness of payers and other purchasers to expand outpatient surgeries.
Development of risk-based contracts and price transparency for outpatient surgery is occurring through the development of episodes of care and corresponding bundled payments. Creation of episodes is the basis for comparing facility and professional costs for outpatient procedures performed within a given time frame (such as 90 days). The movement to bundled payments for outpatient surgery is slow, however. There is little data outside Medicare that shows the extent of adoption of bundled payments, and the Medicare bundled payments initiative (BPCI) is totally voluntary, with just over 1,000 conveners. Restriction of BPCI conveners to be hospitals, physician groups and ACOs, excluding ASCs, will effectively slow the adoption of risk-contracting strategies since they can't attain the experience necessary to succeed.
Q: Are you seeing more patients with high-deductible health plans in your market/customers' markets? What is the best strategy for working with those patients?
TH: Yes, high-deductible health benefit plans have been expanding for the past few years across the country. Patients in high-deductible plans would benefit by predictable package pricing supported by bundled payment contracts, to include arrangements for covered post-acute services. ASCs should develop contracting strategies with health plans and employers that strengthen the underlying process of patient decision-making to undergo the procedure and commitment to pay.
ASCs should ensure that patients engage with their primary care physicians before making decisions to undergo procedures, with a full understanding of surgical and post-surgical costs, ASCs, as well as other providers, will be vulnerable to patients' inability or unwillingness to pay for procedures where the benefits and costs were not understood. But they can facilitate that process of commitment by transparency of costs and outcome/quality data as part of their discussions with health plans and other entities.
Q: How do you approach payer negotiations? What are your top pieces of advice to make sure they're successful?
TH: ASCs have been given an opportunity to prove themselves as a viable and quality alternative to hospital outpatient facilities in value-based healthcare. But there is some concern in the market that ASCs do not have the equivalent ability as hospitals to perform more complex procedures or provide services to higher-risk patients. Pressure will be on ASCs to develop their capacities to offer the full spectrum of surgical services [and] become a competitive alternative to hospital-based care. To succeed, ASCs will need to take [the following] steps to achieve greater depth and sophistication:
1. Develop ancillary services to arrange for economic bundles of care, such as radiology and pathology.
2. Adopt technology and infrastructure to measure and improve cost and quality performance, and provide interoperable records to patients.
3. Establish coordination-of-care processes to communicate with other physicians (especially primary care physicians) and other services in procedural episodes.
4. Implement contract strategies for bundled payments with health plans, employers, ACOs and hospital partners.
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