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What ASC execs expect from CMS, commercial payers next

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CMS added hundreds of surgeries and procedure codes to the ASC payable list in 2021 and revealed plans to eliminate the inpatient-only list over the next few years.

Administrators are paying close attention to how CMS rolls out new ASC approvals and whether commercial payers update their policies to follow suit.

"We've seen joint replacement, spine and cardiac procedures being done in ASCs," said Akshay Tavkar, senior director of ASC at Kelsey-Seybold Clinic in Houston. "It will be interesting to see what other cases will move from the hospital setting to an ASC in the near future."

The willingness of CMS to pay for more complex procedures, such as total joint, spine and cardiac cases in ASCs, gives centers access to a whole new patient population.

"As the 1,700 procedures come off the inpatient-only list, I expect additional opportunities for the ASC," said James Zenman, PhD, CEO of the Cardiac & Vascular Institute in Gainesville, Fla. "I am hoping that CMS will keep up with this trend and acknowledge our ability to do more cases in the ASC at less cost. I am working with legislators' staff to move this along."

But the transition from inpatient to outpatient may complicate the dynamic between hospitals and ASCs in some communities.

"Hospitals are not going to stay on the sidelines. They can't let their golden egg leave the goose," Daniel Lieberman, MD, of Phoenix Spine & Joint, told Becker's. "They're going to have to be heavily involved in ASCs, so they're going to be another stakeholder that will get even more fired up and involved in our industry."

Many of the procedures migrating to ASCs are high-reimbursing for hospitals, and the continued migration of these procedures will trigger more competition between independent centers and hospital-based ASCs. Vip Nanavati, MD, of Humphrey Shoulder Clinic in Eagle, Idaho, foresees hospitals increasing lobbying efforts at the state and national level to increase regulations and barriers to entry for ASCs as a result.

"To me, we will see regulatory changes and the development of barriers to new entry that will be driven by the loss of revenues that hospital systems have experienced, and continue to experience, from this pandemic and from the irreversible trend of lucrative income-generating high-volume surgical procedures leaving the hospital setting," he said.

Administrators also expect payers to place more emphasis on value-based contracts in the future.

"There is an ASC trend in shifting payments to value-based contracts from commercial payers and from CMS through their focus on implementing a program to reward centers for providing value, outcomes and innovation," said Becky Ziegler-Otis, administrator of Ambulatory Surgery Center of Stevens Point (Wis.). "Clearly, this transition will have an impact on surgical center revenue cycle and metrics-tracking."

Few ASCs have participated in Medicare bundled payments, and not always with great results. Dr. Zenman participated in a bundled payments program with Medicare on a select group of surgeries and said the results "were less than expected."

"The Medicare data was late, sometimes not accurate, and not inclusive," he said.

Glen Silverman, CEO of Mississippi Sports Medicine Clinic and Orthopaedic Center, said surgeons perform upward of 1,000 value-based care total joint and spine cases annually at the ASC. The group has become prudent about collecting data based on current value-based care models, but he is watching how they evolve.

"The real challenge is how do you change the market? How do you create opportunity for alignment with insurers and self-insured brokers in the future, and how do you prove you can do it better while being more cost effective?" he said. "The next step is to collect data on all cases, regardless of the venue, and for all specialties. That should give us a strong platform to becoming a market setter around value-based care in the future."

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