Five ASC owners and operators outline their payer mix and what they anticipate for future reimbursement trends.
Eric Mehlberg, MD. Comprehensive Pain Specialists (Golden, Colo.): The average family insurance premium in Colorado is a little over $19,000 with an average deductible of around $3,700. Because of this, we are seeing many patients defer care or maintain unsafe treatment strategies like opioids rather than seek out definitive surgery. As a result, I suspect, like many parts of the country, much of our revenues come at the back end of the year. Compound this with COVID-19 and 60 percent revenue drops in April and May, 2020 is very tight.
What I anticipate is that CMS and then private payers will continue cutting physician reimbursement, at least relative to inflation. A 2 percent increase in fee schedule with net inflation of 1.3 percent is hardly a newsworthy increase. This will drive providers into seeking employed, hospital jobs where their salary is based on facility fees not service codes. Yet, this is shortsighted as payers are (and should) continue to push towards the cheapest and safest site of service. Eventually, we will end up with an imbalance of providers working site-of-service that is entirely contrary to what is best for the patient in terms of outcomes and cost. Those who do not fall into that trap are being paid less than they were in the 1990s.
Beyond inflation there are other costs both financially and emotionally. Clinical practice has added new treatments, EMRs, endless rules and obsolete self-referral rules, and Dr. Google has changed patient expectations — they want more for less and sooner or your online reputation suffers. I foresee payers having stricter 'preferred provider' networks based on what they perceive as over-utilization, online reviews and whatever outcomes they internally measure. In the meantime, there will be increased prior authorization requirements (that still do not guarantee payment), which demand excessive time, increased denials and fewer staff on the insurer side for appeals and authorizations. Just recently, BCBS of Michigan laid off a significant portion of its workforce.
This will drive the 'survivors' to increase volume, utilize mid-levels more aggressively and avoid treatments that may be better to ease administrative burden.
Is any of this good for patients?
David Horace. Vice president of site development and administration at Cardiovascular Centers of America (Belleville, Ill.): The commercial payer market is looking for opportunities to save money on care and will use site of service changes to accomplish lowering costs on select procedures that Medicare may not have approved for alternate site performance. Rates are somewhat higher than Medicare rates and use the same multiple procedure discounts or more if not careful.
I am anticipating that cardiac mapping procedures, IVUS, iFFR, and simple ablation procedures will be approved for performance in the ASC setting by Medicare for 2022 and a further expansion of these types of procedures by commercial payers based on the demonstrated efficacy of cardiac caths and coronary stents being performed in the ASC setting at significantly lower cost than HOPD rates coupled with higher patient satisfaction.
Ramona Robinson. Administrator of Tresanti Surgical Center (San Ramon, Calif.): Our market is 80 percent non-Medicare. Blue Cross/Blue Shield being our largest payer. I anticipate CMS rate increase of just under 4 percent for 2021. I do not have information about the commercial payer increases at this time.
Jack Jensen, MD. Athletic Orthopedics & Knee Center and Houston Surgery Center: Our market is dominated by Blues and self-funded. It's a highly competitive and saturated market. Hospitals still somewhat control the market. We're expecting CMS and commercial carriers to move higher acuity cases to a lower cost setting. CMS and carriers need to be realistic about reimbursement for total joints in an ASC or they'll have trouble moving them and defeat the purpose. In orthopedics, as technology advances, it tends to cost more and thus can use up most of the reimbursement for a case.
Kristin Anderson. Administrator of Parkway Surgery Center (Myrtle Beach, S.C.): We have a large Medicare population in our area, so a large part of our ASC volume consists of Medicare patients and governmental payers. Second would be the Blues, then some of the bigger commercial carriers such as UHC, Aetna and Cigna. I hope that the ASC will have greater parity with the outpatient hospital payments with CMS and commercial payers in future, but it will take time. I would hope commercial payers and CMS continue to recognize the importance of the ASC in the healthcare market and that many surgeries are shifting from the outpatient hospital departments to the ASCs.