ASC leaders far and wide agree payers have the upper hand in reimbursement negotiations, but each has their own take on which particular set of tactics is doing the worst damage to the economics of outpatient surgery.
From rates that haven’t kept pace with inflation and implant carve-outs that favor hospitals to prior authorization burdens that drain administrative resources, these are the payer tactics five ASC leaders told Becker’s are slowly hollowing out what should be one of the most cost-efficient care settings in the healthcare system.
Editor’s note: Responses have been edited lightly for clarity and length.
Question: What’s the one payer tactic that’s quietly breaking ASC economics?
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): One challenge that is becoming more apparent is the quiet compression of anesthesia reimbursement while still expecting guaranteed coverage. Historically, anesthesia in ASCs functioned more like a variable cost tied to case volume. Today, because of workforce constraints and coverage expectations, anesthesia has become much closer to a fixed cost. When reimbursement does not reflect that operational reality, it creates a gap that ASCs and anesthesia groups have to absorb.
Michelle Kastler, RN. Nurse Administrator and Credentialing Coordinator at Four Peaks Surgery Center (Sun City, Ariz.): The payer tactic hurting ASC financials is the fact that reimbursement rates are not increasing at the rate of inflation.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: Hospitals often get paid for the cost of implants. ASCs often are “pay one price.” Hopefully, the side of service changes will help that.
Monina Pascua, MD, PharmD. Clinic Medical Director and Gastroenterologist at The Oregon Clinic Gastroenterology South (Tualatin): The payer tactic that is quietly breaking ASC economics is the requirement of additional documentation for procedures that are clearly medically indicated, which costs so much in administrative burden and delay in AR.
Leiv Takle Jr., MD. CEO of Takle Eye Group (Locust Grove, Ga.): The most damaging tactic is the gradual compression of ASC facility reimbursement while hospital outpatient departments continue to receive higher payments for the exact same procedures. When payers steer cases back into hospital settings or fail to appropriately update ASC rates for inflation, staffing, and supply costs, it undermines one of the most cost-effective sites of care in the healthcare system.
In ophthalmology specifically, many procedures that are routinely performed safely in ASCs — such as cataract surgery — are still reimbursed in a way that favors hospital outpatient departments despite the ASC delivering the same or better outcomes at lower overall system cost.
