Reimbursement policy changes have the potential to shift more procedures to ASCs, and with that comes a need for new approaches in ASC quality measurements, Hari Nathan, MD, PhD, said.
Dr. Nathan, an associate professor of surgery at the University of Michigan in Ann Arbor, discussed what changes in reimbursement policies will do to the healthcare landscape in an Oct. 17 panel at Becker’s 31st Annual Meeting: The Business and Operations of ASCs, which took place in Chicago.
Editor’s note: This response has been lightly edited for clarity and length.
Question: How are you thinking about the reimbursement policies that are coming forth, whether it’s CMS or commercial payers? What’s top of mind for you there, and how does quality factor into the mix from your perspective?
Dr. Hari Nathan: I think one thing that we’ve learned over the last five to six years as procedures have come off the inpatient only list is that alone does not shift procedures to ASCs. In fact, most of those procedures have parked themselves in HOPDs … There’s the safety reason, and I think it will just take time for surgeons to wrap their heads around the idea that some of these procedures can be done outpatient with a 23-hour stay. But there’s also financial implications for that. As long as HOPDs continue to be reimbursed at a higher rate, there’s always going to be this built-in incentive to keep those procedures there. I would just distinguish [a procedure] coming off the inpatient only list from actually [being] covered at ASC and then add on top of that the difference in reimbursement rates, which obviously will impact the decisions.
Site neutrality is really the key nudge that’s going to be necessary in order to really level that playing field and make these decisions happen based on patient safety and appropriate triage … without regard to which one pays more. Certain systems are going to be better positioned to do that than others. The more of these different types of sites you have at your disposal, the more you can accommodate different levels of case complexity and do that in a way that is most cost efficient for your institution and therefore results in a favorable margin.
[Turning to] quality, I think we obviously have some ASC quality reporting programs in place, but they’re limited. For instance on CMS’ website, almost no ASCs are distinguished from the average. I think that’s a combination of [factors]. No. 1, currently the healthiest of the healthy are getting their procedures done in ASCs, and so the complication rates and the ER visit rates and hospitalizations are appropriately very low. But also because CMS metrics are based on Medicare patient data only, where you are limited by the number of patients whom you can use in order to come up with those estimates. One of the things we’re doing in our state is we’re coming up with an all payer metric. A lot of these patients are not on Medicare. So we’re going to start measuring some of these outcomes across payers, which I think will give us just more statistical power to assess which ASCs are performing at higher quality than others.
From a policy perspective, my guess is that everything that we’ve seen happen over the last 15 to 20 years in the hospital setting is eventually going to be tried in all these other settings, including ASCs. One of the few payment models that has shown real success at the federal level with respect to hospital reimbursement is prior authorization. It’s no surprise that that’s been brought up as a possible solution for ASCs. I think we’re going to see more links between payment and quality, starting with reporting and benchmarking and in a pattern that will replicate what happened in hospitals. As more patients come off the inpatient only list, and as more patients with slightly more complexity potentially go to ASCs, you’re not going to see that everybody has a less than 1% ER visit rate within seven days. That’s not going to happen, because you’re going to be doing slightly more complex patients at these facilities. It’s the combination of quality of care, appropriateness of triage and having the facilities and the staff available to deal with problems for the small minority of patients when they arise. I think we’re going to see a lot of that play out over the next five to 10 years.
