Biden hasn't picked a new CMS head, but ASC leaders have a wishlist for the agency

President Joe Biden hasn't selected his nominee for CMS administrator, and Politico reported the post may not be filled any time soon. However, that hasn't stopped ASC industry advocates from pushing for change.

When a new CMS administrator is installed, ASC industry leaders will have many issues on their wishlist for the new head of the agency. On Jan. 1, 2021, CMS eliminated the inpatient-only list and Ambulatory Surgery Center Association CEO William Prentice hopes the agency eliminates the ASC payable list as well and closes the gap in reimbursement between hospital outpatient departments and ASCs.

"One of the things we find concerning, and a big barrier to migration of more cases from the more expensive hospital setting to the ASC setting, is reimbursement — the fact that ASCs are reimbursed roughly 50 percent of what the hospital outpatient department is for the same code," Mr. Prentice told Becker's. "We think that really needs to be addressed if we're really going to try and migrate more volume, which is going to save the Medicare program billions of dollars and save Medicare beneficiaries money in terms of copays and deductibles."

Thomas Obermeyer, MD, an orthopedic surgeon at Barrington Orthopedic Specialists in Schaumburg, Ill., hopes Medicare begins to pay for more higher acuity cases in the ASC. There is data available showing favorable outcomes for orthopedic procedures in the outpatient setting.

"Some payers, especially Medicare, have been slow to adapt, which limits ASC access by their beneficiaries. We can advocate for our patients by collecting the data that supports our clinical decisions," Dr. Obermeyer told Becker's.

Suzi Cunningham, administrator of Advanced Ambulatory Surgery Center in Redlands, Calif., told Becker's her biggest roadblock is Medicare's ASC fee schedule.

"If I had to pinpoint one of my biggest struggles, [it] is dealing with so many 'appropriate for outpatient surgery' CPT codes not being on the Medicare ASC Fee schedule. Medicare has got to keep up with the times," she said. "Both patients and surgeons want to have their surgeries performed at a specialty center. There is a much less likelihood of getting an infection, it is a lot less hassle for the patient, and it makes so much sense from a financial aspect. Yet, we are forced to obtain carve-outs, amend contracts, etc. just to be able to provide this care. Waiting year after year for things to change is painful and unnecessary."

CMS has started rolling back some of former President Donald Trump's moves on healthcare and new initiatives under Liz Richter, acting administrator.

Politico also reported CMS' priorities may include:

Ending the short-term health plan and association health plan expansion led by the Trump administration;
Updating rules for ACA marketplace insurance plan enrollment; and
Changing its response to states with Medicaid work requirements.

President Biden issued an executive order in late January to open a special enrollment period for the health insurance marketplace from Feb. 15 to May 15. There are about 15 million uninsured Americans eligible for marketplace coverage, but offering the insurance may not mean access to healthcare if deductibles are too high.

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