Payer partnerships: how to move spine & total joints from hospitals to ASCs

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At the 12th Annual Spine, Orthopedic and Pain Management Driven ASC Conference in Chicago on June 12, I. Naya Kehayes, MPH, managing principal and CEO of EVEIA HEALTH Consulting and Management, and Anna Gimble, vice president of ancillary contracting west with UnitedHealthcare, discussed how ASC leaders can partner with payers to shift spine and total joint procedures from the hospital to the ASC setting.

Payer perspective
Payers, like all healthcare stakeholders, are being forced to look for ways to cut costs. They will be looking to partner with providers that can help them achieve the goal of lower cost care without sacrificing quality. "In my experience, independent centers are a lot more creative in the cases they are willing to take on. When I look at a surgery center in that mode, that adds a lot of value to the contracting discussion," says Ms. Gimble. "If you can do it faster, better and cheaper, you will be attractive."

Payers also seek stability. "We are willing to spend time with an ASC with a good management team and great physicians," said Ms. Gimble. "There are a lot of things that can be done that historically have not been."

ASC perspective
The Patient Protection and Affordable Care Act has dramatically reshaped the way ASCs get paid. "Out-of-network access to reimbursement is extremely limited," said Ms. Kehayes. "It is much more difficult to get paid due to changes in benefit structure." In addition, with limited and reduced OON access, ASCs are facing the challenge of receiving payment directly from patients with rising deductibles and co-pays.

Working together
Spine and total joints are being performed in the ASC setting, but it takes dedicated payer and ASC coordination to bring those higher acuity cases out of the hospital. "You have to build the business case," said Ms. Kehayes. When presenting the case for spine and total joints in the ASC setting, ASC leaders must have a complete grasp of:

•    All codes that will be involved
•    Potential volume
•    Implants
•    Physicians performing the cases

"Pricing spine is not easy," says Ms. Gimble. "What helped us get over the hurdle was mutual education." Engage a surgeon with the center and allow him or her to build a rapport with a payer's medical director. Gather ample data to present to the payer. Important data includes:

•    Physician billing
•    Hospital utilization
•    CPT code combinations
•    Variances among physicians
•    High cost disposables
•    Vendor quotes vs. expected discounts

"Show savings to the patient and savings to the payer," said Ms. Kehayes.

It can take six months to a year to negotiate a rate, plus the possibility of an additional 90 days to solidify a contract. "Spine surgery takes longer than total joints; be prepared," said Ms. Gimble. Payers are ultimately looking for an ASC's evidence-based plan. Why will spine and total joints work in that particular center? Prepare and share:

•    Patient selection criteria
•    Protocols
•    Discharge criteria
•    Extended and recovery care plans
•    Complications protocols

"The best opportunity is to prove cost effectiveness and demonstrate savings to the payor" said Ms. Kehayes.

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