Payers putting 'downward pressure' on ASCs: How leaders are looking at payer behavior

ASCs have historically faced obstacles to reimbursements, and ASCs in some markets are seeing increased pressure from payers. 

"Payers continue to put downward pressure on ASCs, at a time when we are expanding services, and that tension makes all of our ASC partners nervous," Michael McClain, the executive director of ambulatory surgery at Renton, Wash.-based Providence, told Becker's. "As hospital ASC leaders, we need to be sure that we have both the clinical expertise and alignment in our ASCs as well as do our homework on the reimbursement piece."

In many markets, ASCs have to face competition from larger hospitals and health systems to secure payer contracts. 

"Most of my time is spent on payer negotiations and payer issues. I spend more time negotiating  with payers than I ever expected in this role," Jessica Rodriguez, administrator of OAM Surgery Center at MidTowne in Grand Rapids, Mich., told Becker's. "The payment landscape for ASCs is another big challenge that we face. Costs are going up exponentially, but we are not seeing a corresponding increase in reimbursement."

As unemployment numbers increase, ASC leaders are also worried there will be more people without insurance. Unemployment increased to 3.7 percent in October, according to the Bureau of Labor Statistics. 

"Even those with insurance will struggle meeting their new high deductible plans, copays and prescription bills," Marla Roberts, RN, founder and CEO of Periop Accreditation Readiness in Waverly, Tenn., told Becker's

Ravi Bashyal, MD, vice chair of patient and provider experience, director of outpatient hip and knee replacement surgery, and site medical director for Professional Football Hall of Fame Health at NorthShore University HealthSystem, sees sustainable solutions in partnering with public and private payers. 

"We need to partner with the payer both public and private to find productive ways for us to continue to cut costs and be more efficient, but to do it in a way that's sustainable for systems while still providing top-notch care for all patients in our communities," he told Becker's

Other leaders are seeing payers incentivizing physicians to perform procedures in low-cost settings, which means ASCs are becoming increasingly attractive, according to ASC leaders. 

In November 2019, UnitedHealthcare adopted a policy that restricted sites of care for some nonurgent surgeries. The payer now reimburses for surgeries performed in hospital outpatient departments only if the setting is medically necessary based on the acuity of the patient.

"Many payers are developing steerage mechanisms to shift cases to lower-cost settings, which will result in more pressure on physicians to move cases to the outpatient ASC arena," Andrew Lovewell, administrator of the Surgical Center at Columbia (Mo.) Orthopaedic Group, told Becker's.

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