Administrators want equal reimbursement for ASCs and HOPDs

As a growing number of procedures migrate out of the hospital to the outpatient environment and costs continue to rise across the healthcare industry, ASC administrators are calling on CMS to pay ambulatory surgery centers the same as hospital outpatient departments.

Administrators say ASCs have demonstrated their value to the U.S. healthcare system from a cost savings standpoint in addition to offloading hospitals for more critical care, especially during the COVID-19 pandemic.

"CMS should change the reimbursement calculator on a basket of codes to put ASC and outpatient departments on a level playing field," Gil Tepper, MD, founder and CEO of Prime Surgeons in Los Angeles, told Becker's. "[It] should use a transparent, unified fee schedule which applies equally to ASC and outpatient departments. [It] needs to set a new reimbursement schedule that puts HOPD and private ASCs on equal footing."

Currently, the playing field is uneven with reimbursement calculations using one index for HOPDs and another for ASCs, a product of unfair and uneven lobbying size that favors hospitals, according to Dr. Tepper.

The cost differential is partly attributed to how CMS uses different measures of inflation to update each payment system. For HOPDs, CMS uses the hospital market basket, which measures the cost of medical expenses. For ASCs, CMS uses the Consumer Price Index-Urban, which measures the cost of products such as milk and bread, arriving at an inflation rate that historically is lower than the hospital market basket.

"ASCs should be paid the same as HOPDs under the market basket, especially considering the services we provide are very similar and the costs are no different," said Andrew Lovewell, administrator of Surgical Center at Columbia (Mo.) Orthopaedic Group. "CMS needs to pay more attention to ASCs and shoring up the reimbursement gap between HOPDs and ASCs in the future to assure that ASCs are fairly reimbursed. "

One small win for ASCs that came out of CMS' outpatient payment rule is its decision to apply the hospital market basket update to ASC payment rates through 2023, a move that stems from a section of the 2019 outpatient final rule. But ASC administrators will no doubt call for the agency to revisit the reimbursement gap next year.

"With more patients asking for procedures to be performed at an ASC, payers steering to ASCs, and even employers looking to save money by preferentially using an ASC, CMS needs to catch on," Mr. Lovewell said. "ASCs represent a lower cost and more efficient option for patients, employers and payers, and CMS needs to embrace that."