ASCs can often deliver surgical care more efficiently and at a lower cost than HOPDs, but regulatory and reimbursement barriers continue to stand in the way.
Scott Shapiro, MD, a cardiologist with Horsham, Pa.-based AMS Cardiology and past president of the Pennsylvania Medical Society, recently joined Becker’s to discuss the policies making it harder for ASCs to expand access — and ultimately driving patients toward more expensive sites of care.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What regulatory or policy fight — prior authorization, CON laws, Medicare reimbursement — is creating the most friction for your ASC right now, and how are you pushing back?
Dr. Scott Shapiro: The ASC is the best answer we have to improved access and reduced cost in healthcare. A cardiac patient can get a cath or a device done the same week, in a facility Medicare pays roughly half of what it pays a hospital outpatient department for the identical procedure, with the patient’s coinsurance cut in proportion. Prior authorization is what stands between the patient and that care. A senior with new chest pain should get a stress test this week, not three weeks from now while a plan reviewer who has never examined her decides whether her symptoms are real.
One in 4 physicians report a prior auth delay that led to a serious adverse event. We have seen these tragic endings in our practice. Patients also just give up, and we see them later in the ED, sicker and for now far more expensive care.
It is time for all patients to insist the leaders they elect into office pass laws requiring statutory gold carding, real time electronic prior auth, and a requirement that every denial come from a physician in the same specialty with no delay in the time it takes to obtain the approval. Timely access to care for a sick patient should never take a back seat to insurance company profitability.
Medicare payment
Nobody outside medicine cares what a cardiologist earns, and they shouldn’t have to. What they should care about is that the site of care that saves Medicare and seniors the most money, is the one the payment system makes hardest to grow.
Physician payment has fallen 33% in real terms since 2001, the 2.5% patch for 2026 disappears next year, and CMS proposes another conversion factor cut for 2027. You cannot recruit physicians, invest in equipment, or open a second lab against a payment stream that shrinks every year…. So capacity does not get built, practices get absorbed, and the same procedure migrates to the hospital outpatient department where Medicare pays more and the patient pays more for identical care.
That is the whole story: elected officials fail their constituents, reform stalls, and care gets more expensive and harder to reach. Working nationally with physician leaders from other large states, we have been trying to stop Washington from considering annual patches and demand a permanent [Medicare Economic Index]-linked update, modernized budget neutrality, and real alternative payment pathways. Congress knows what to do and keeps choosing not to.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
