What Surgery Centers Should Expect in 2012: 15 ASC Market Trends

Here are 15 trends for the ambulatory surgery center industry that will affect how ASCs do business in the upcoming year.

1. More complex and higher-end procedures will move into the outpatient setting.
Sean Rambo, co-founder, Compass Surgical Partners, says 2012 will continue to see more higher-end procedures, including complex orthopedic and spine, move into the ASC setting. He predicts that as smaller procedures increasingly compete with an office- based setting — a move that many payers are driving — more complex procedures will take their place in the ASC.

David Lau, managing partner, Medical Forefronts, a surgery center management company overseeing centers in San Francisco, Las Vegas and New York City, agrees.

"What used to be basic orthopedic and pain facilities are really starting to see an increase in new procedures: partial and even total joint replacement, more advanced spine procedures such as fusions as well as cardiac procedures like pacemaker insertion," he says. “In fact, one of our California ASCs recently became the world's first non-hospital facility to buy a MAKO Rio surgical robot and now offers unicompartmental knee replacement outpatient procedures. Patients used to spend days doing rehabilitation after inpatient surgery at a hospital; they are now literally walking out after the surgery the same day."

2. Healthcare reform will drastically change the ASC environment.
Charles J. Militana, MD, director of NAPA Ambulatory Surgery Centers, says a center's success in the face of healthcare reform will depend on many factors.

"Healthcare costs and their effects on the economy continue to play a significant role on health systems," he says. "ASCs are most certainly not immune from such effects. What we will see over the next year will be the impacts of these economic pressures on ASCs. How ambulatory centers position themselves with respect to such forces will be key to their success. For example, as federal requirements continue to be developed with respect to ambulatory center quality care reporting, factors such as admission rates, patient satisfaction, etc., will have direct and indirect effects on the economic success of the facility.

3. Multi-specialty centers might weather healthcare reform better than single-specialty centers.
Adam Frederic Dorin, MD, MBA, founder and president of America's Medical Society, says assuming that healthcare reform survives, the ASC industry will undergo a big change in the next few years.

"Let's just assume the accountable care organizations take on a life of their own," he says. "I believe there will be some major housekeeping that will be going on. By 2020, a lot of ASCs will likely be closed or bought up by hospitals. Contrary to conventional wisdom, many multi-specialty centers are going to be more vulnerable. Unlike traditionally high-paying single-specialty centers, like orthopedics, where there can be real cost savings through efficiencies of scale, the multi-specialty facilities will become squeezed between less-acute, office-based cases and those procedures reserved for the hospital setting.  ACOs will demand that hospitals be protected and preserved at all costs, as they will form the core of most ACO leadership hierarchies, and thus non-hospital owned ASC reimbursements will shift to favor the hospital masters."

Mr. Lau thinks that while a single-specialty center can improve profitability by tailoring its expenses and understanding its income stream, too much reliance on one specialty or procedure can result in disaster if reimbursement changes drastically. For example, if a center relies heavily on Medicare cataract surgeries, and the reimbursement for that code changes, the center could be in trouble. A multi-specialty center can avoid that by increasing volume in other, more profitable specialties.

"The multi-specialty center is certainly a bigger beast to manage on a day-to-day basis, but I think that diversification in the cases and subsequent revenue might be one of the best strategic defenses against the inevitable changes in reimbursement," he says.

4. Out-of-network reimbursement is becoming harder to obtain. Mr. Lau says getting out-of-network reimbursement from payors is becoming increasingly difficult.

"Without question, payors and insurance companies are getting much trickier when dealing with out-of-network facilities," he says. "They're not only reimbursing less on billed charges, but they're also just making it harder to get reimbursed at all."

The standard accounts receivable cycle for Medical Forefronts' centers used to be as short as 90 days, but Mr. Lau says A/R cycles are lengthening as the centers are increasingly getting letters requesting additional information such as full medical records, even after procedures have been authorized. Payors are putting more pressure on surgeons and patients to stay in network.

Although payors are making it more difficult, Mr. Lau says centers can continue to do out-of-network cases by making some critical changes. Specifically, they need to put more effort into collections, including possibly taking billing in-house to have more control; walk patients through the entire financial process and make sure whoever does the billing is on top of industry trends and changes.

Read more of Mr. Lau's thoughts on out-of-network reimbursement here.

5. Insurance companies are forcing patients and physicians to stay in-network.
Mr. Lau says that insurance companies are changing their policies to restrict certain things, such as out-of-network reimbursement. The impetus behind the change is all about saving money, he says.

"A larger percentage of the insurance base is needing to be seen in network," he says. "There is certainly a growing demand for in-network facilities. Again, it speaks to what institutional payors are trying to do: They are tweaking insurance plans so people aren't able to be seen out-of-network. It's all about the bottom line, and they're going to ultimately steer people to a place where they can maintain the biggest margin for themselves."

Mr. Lau says insurance companies will continue to put pressure on patients and physicians to keep their cases in network. For years, he has seen insurance companies send letters to physicians threatening to kick them out of their professional contracts if they don't stay in network, but just recently he has started seeing insurance companies follow through on those threats.

6. Insurance companies are starting to steer patients toward ASCs.
Healthcare reform has encouraged all aspects of the healthcare system to pinch pennies and cut costs. For this reason, insurance companies are looking for the most cost-effective treatments for their patients. In many cases, this benefits the ASC because they are usually less expensive than procedures done in the hospital. Mr. Lau says insurance companies have begun to approach some Medical Forefronts centers with more favorable contracts.

"This speaks to the fact that certain hospitals are expensive, and insurance companies have started to identify that those folks are making a lot of money on their backs," he says. "For once, insurance companies actually approached us with favorable contracts. We believe that's because they want to steer their patient volume to these more cost-effective ASCs rather than keep them in the hospital systems."

7. Reimbursements will continue to be cut across the board. Jimmy St. Louis, CEO of Advanced Healthcare Partners, says in general, the trend of decreasing reimbursement will continue to shape the industry. There are things ASCs can do to mitigate the damage, such as marketing directly to the consumer and performing out-of-network cases.

Mr. Rambo says that in some markets, the ASC industry has been able to offset some of the Medicare payment reductions and modifications. For example, the ASC industry in New Jersey remained highly profitable due to favorable workers' compensation, personal injury and out-of-network reimbursement. However, he says, that "is being attacked from all angles." In other states, Medicare-based fee schedules are being considered to replace more lucrative workers' compensation fee schedules — a trend that began several years ago across the country. These changes will have a significant impact on the profitability of orthopedic cases in these markets.

"We're beginning to see more and more rate compression and fewer opportunities for ASCs to offset low paying insurance or Medicare reimbursement," he says. "That trend will continue."

8. The ASC market will continue to consolidate. The consolidation trend started to heat up last year with three big deals: Surgery Partners acquiring NovaMed in January 2011, AmSurg acquiring National Surgical Care in August 2011 and United Surgical Partners International acquiring Titan Health Corp. in October 2011. Mr. Rambo believes this trend will continue in 2012 and into 2013.

Mr. Rambo says in many cases, the investors behind these large organizations will be evaluating their exit strategy. This may include IPOs, but to accomplish this many will look toward increased consolidation to drive revenue growth. He says that in most cases, management companies aren't building new centers to fuel growth in large part due to the saturation of ORs in many markets, but rather are looking at acquisitions of individual centers in strategic markets or multiple center acquisitions that really add to the company's portfolio and near term growth targets.

Mr. Lau also sees the trend of consolidation growing as ASCs are under increased pressure.

"As a whole, with all these mounting pressures, many centers out there are in trouble," he says. "But frankly, that's when a company like mine gets approached because we can take troubled centers and help turn them around. Right now, we're busier than ever."

Mr. Lau stresses the importance of finding a partner that can offer not only capital but tested, implementable leadership, such as recruiting and supply chain strategies.

9. ASCs are increasingly partnering with acute-care and nursing facilities. One of the factors keeping some procedures out of the ASC is the inability to keep patients for longer than a few hours. Mr. Lau sees this as something that could change with strategic partnerships.

"Another reason why we could continue to see more complex cases being performed in the ASC is that in our market, we've seen an upsurgence of acute rehab and nursing facility partnerships," he says.

When an ASC partners with this type of facility, the patients can be monitored for longer periods of time if the need arises. Mr. Lau says this is quite common, and he has seen an increase in the past few months, especially in the San Francisco Bay Area.

10. If done right, robotic surgery can be profitable. Mr. Lau says that although purchasing a surgical robot can cost a center upwards of $1 million, if a center has the right cases, there's no reason it can't be successful. Ensuring enough case volume and the correct cases will allow a surgery center to compete with local hospitals that already have the equipment. If a center already does procedures that can be done using surgical robots, it's not a brand new marketing effort and the center doesn't have to bring in a whole new patient base. Another option to save money on surgical robots is to buy a refurbished unit.

"By finding refurbished equipment, an ASC is able to save significantly on capital investment," he says. "The return is quite a bit better."

11. Physician employment threatens innovation. Dr. Dorin says that healthcare reform will bolster the trend toward physician employment by hospitals, and that trend will hurt the healthcare industry as a whole.

"When you squeeze doctors literally or functionally into an employee model, there's less incentive to be creative," he says. "There's actually more incentive to do less cases, and efficiency inherently grinds down. People are still thinking in the mindset of independent players in the healthcare market — such as we have today with insurance companies, hospitals, and doctors/physician groups. If ACOs are allowed to take hold and flourish, there may be cost savings, but the trade-off of effectively rationed care and the creation of government-sanctioned, anti-competitive collusion between the insurance industry and local hospital systems may very well be a dramatic and unpleasant game changer for the American public."

12. Maintaining independence as a physician will be hard. Mr. St. Louis says that one of the biggest challenges facing ASCs will be the ability of the physicians to remain independent. He says the trend of consolidation and acquisitions affects the physicians as well as the centers. Affording the infrastructure demanded by reform can be a challenge. Some things that physicians can do to boost their profit is add patient coordination functions to their services, do more out-of-network cases and market directly to the patients. Patient coordination allows physicians to control their volume and manage their practice more efficiently.

"This can help some of these physicians maintain their independence — financial as well as practice independence," he says. "The physicians want to remain independent, but they can't. That is where our strategies of direct to consumer and efficient patient coordination comes into play. If you can go direct to consumers, you can stay out of network, which allows you to control your financial destiny."

13. Centers will add various ancillary revenue opportunities. Mr. Rambo says ASCs and ASC management companies are also stepping up efforts to target ancillary revenue opportunities such as bringing anesthesia in house, adding an in-house pharmacy or adding a sleep lab.

"The mindset is that as the rate is compressed, they will ask what are other opportunities exist to protect and boost earnings in an ASC," he says. "As an example, I have seen the development of an in-house anesthesia program be very successful, and believe this in particular is a trend that is gaining steam throughout the industry."

14. The slow adoption of EMR will start to pick up. Mr. Rambo thinks large-scale adoption of electronic medical records is still a few years away. Because the ASC industry is still fairly fragmented, he thinks ASCs will be some of the last adopters of EMR. Mr. Rambo says the standards are currently in active discussion, and the industry is likely looking at standard approval in 2014 or beyond.

"We'll hear more about it in 2012," he says. "Things are slowly beginning to heat up, but we're still several years away from active adoption in the industry."

15. To stay independent, ASCs should market direct to consumers. One of the ways centers can stay independent is through direct-to-consumer marketing, Mr. St. Louis says. He says there are four different channels to market a center or service: advertising online through SEO and website optimization, traditional offline marketing, seminars and physician-to-physician marketing.

Online advertising includes paid advertisements and creating relevant and quality content that is placed strategically on the website to enhance a user's experience. Mr. St. Louis says a good social media strategy can go a long way in marketing to patients.

"[It] provides a nice, comfortable environment for people looking to have a surgery done," he says. "For those existing patients, they can talk to people about how their experience is going as well as correspond regarding questions and concerns. Typically, the goal of a seminar is to find the proper geographic location as well as direct-to-patient strategy that are unique to people and then educate them as well as spend personal time with them to maximize their knowledge of our procedures," he says.

For example, one center managed by Advanced Healthcare Partners holds seminars on sleep apnea that looked at the causes and the possible unique treatments. Seminars serve as a way to build trust and credibility, especially if procedures are unique, Mr. St. Louis says. The ultimate goal of a seminar is both to educate people and to convert them to trusting customers at the seminar.

The last marketing strategy is to educate the local physicians on what the ASCs do and build a reciprocal relationship with them. This can generate a high volume of leads. If a center is effective and generating leads, Mr. St. Louis says as much as 90 percent of those the center won't be able to treat. That allows centers to refer patients to other physicians and establish reciprocity.

Related Articles on ASC Turnarounds:
5 Ways to Recruit More Quality ASC Physicians This Year
5 Tips for ASC Turnarounds from ASC Management Companies
10 Surgery Center Physicians in the News

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