From bundled payments to measurable outcomes, two ASC leaders joined Becker’s to discuss their best practices in leveraging payer relationships.
Question: How can ASCs leverage partnerships with payers to create more sustainable reimbursement structures?
Editor’s note: These responses were edited lightly for clarity and length.
Trina Cole. Administrator of St. Luke’s Surgicenter Lee’s Summit (Mo.): If your payers are willing to consider carveouts for procedures that can easily be performed in the ASC setting, that is something to consider. Our ASC is a joint venture between a host hospital, physician investors and a management company. Our contracts are negotiated by the hospital system. This is a wonderful benefit for us. However, I have found that on occasion, it is beneficial for us to request additional review on procedures that are being performed at other ASCs that have not been included in our contracted coverage. I would say our success rate with this is roughly 50%.
Shaibal Mazumdar, MD. Gastroenterologist in Richfield, Wis.: For ASCs to thrive; we have to create value e.g. best care at the lowest cost with good quality & safety outcomes; those metrics should be measured. They include costs of procedure which includes reimbursements related to anesthesia, path in the form of bundled payments. Should also have metrics related to quality which includes ADR (polyp detection rates); compliance with interval follow up surveillance colonoscopy data and metrics established by the national GI societies.
ASCs are pivotal in delivering efficient, high-quality outpatient care, but their long-term viability hinges on sustainable reimbursement models. As healthcare shifts toward value-based care, ASCs must collaborate with payers to align incentives around delivering the best care at the lowest cost, while maintaining robust quality and safety outcomes. This partnership involves measuring key metrics — encompassing procedural costs through bundled payments and quality indicators like adenoma detection rates and compliance with surveillance colonoscopy intervals established by national gastrointestinal societies. By focusing on these elements, ASCs can foster reimbursement structures that reward value creation, ensuring mutual benefits for providers, payers and patients.
Embracing value-based care:
Value-based care reorients reimbursement from volume to outcomes, linking payments to performance on quality, cost and patient satisfaction metrics. For ASCs, partnering with payers under VBC models like accountable care organizations or bundled payments can drive sustainability by incentivizing efficiency and excellence. This approach requires ASCs to demonstrate value through data-driven evidence of superior care at reduced costs, such as migrating procedures like colonoscopies from hospitals to lower-cost ASC settings.
To initiate partnerships, ASCs should engage payers in joint planning sessions to define shared goals, such as reducing overall healthcare expenditures while improving outcomes. Successful examples include contracts where ASCs receive bonuses for meeting benchmarks, fostering a collaborative rather than adversarial relationship. By emphasizing transparency in data sharing, ASCs can build trust and negotiate terms that support long-term financial stability.
Bundled payments:
Bundled payments represent a key mechanism for sustainable reimbursement, where a single payment covers an entire episode of care, including the procedure, anesthesia, pathology, and related services. For ASCs specializing in GI procedures like colonoscopies, bundled models can streamline costs and encourage efficiency, as providers assume financial risk for the full care bundle. This shifts focus from fee-for-service to value, with payers benefiting from predictable expenses and ASCs gaining volume through preferred provider status.
To team effectively, ASCs can propose “Pay One Price” bundles for colonoscopies, negotiating rates that encompass pre-procedure consultations, the procedure itself, and post-op follow-up. Metrics for cost should include total procedural expenses, tracked via standardized reporting to ensure bundles remain viable without compromising care. Partnerships with commercial payers, such as those seen in contracts with major insurers, have shown increased colonoscopy volumes and revenue for GI-focused ASCs while curbing payer costs. ASCs should leverage tools like episode-based cost measures to align with payer expectations, ensuring bundles are tied to quality to prevent underutilization.
Quality metrics:
Sustainable reimbursement demands rigorous measurement of quality outcomes, ensuring that cost savings do not erode care standards. For colonoscopy-focused ASCs, priority metrics include the adenoma detection rate, which measures the proportion of screening colonoscopies identifying at least one adenoma. National GI societies, such as the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology, recommend an ADR of at least 35% for individuals over 45 undergoing screening or surveillance, as higher rates correlate with reduced colorectal cancer incidence.
Another critical metric is compliance with recommended surveillance intervals, aligned with the U.S. Multi-Society Task Force guidelines, which dictate follow-up based on findings like polyp characteristics. ASCs should aim for ≥90% adherence to these intervals to optimize resource use and patient safety. Integrating these into reimbursement structures — such as through performance tiers in contracts — allows payers to reward ASCs exceeding benchmarks, while ASCs use data analytics to track and improve metrics. Safety outcomes, like low complication rates, further bolster these partnerships by demonstrating holistic value.
Payer contract strategies:
To create enduring structures, ASCs should adopt proactive strategies. First, form multidisciplinary teams including administrators, clinicians and data experts to negotiate with payers, presenting evidence of past performance on cost and quality metrics. Second, participate in payer-led initiatives like ACOs, where shared savings models distribute gains from efficient care. Third, invest in technology for real-time data sharing, enabling payers to verify outcomes and adjust reimbursements dynamically.
