CMS’ finalized calendar year 2026 payment rule removed 285 mostly musculoskeletal procedures from Medicare’s inpatient-only list, part of a three-year phaseout the agency plans to complete by 2029.
Outpatient procedures reimburse Medicare an average of $16,334 less than the same case performed inpatient, a $5.3 billion difference in total reimbursement across those 285 codes.
It’s the kind of policy shift Marie Edler, chief growth officer of Optum’s SCA Health, has been watching for years. Ms. Edler joined Becker’s to discuss where she sees the ASC industry heading next, and what’s standing in the way.
Editor’s note: This interview was edited lightly for clarity and length.
Question: Where do you see the ASC industry today, and what shifts is SCA Health preparing for next?
Marie Edler: Most ASC leaders are acknowledging that we’re entering a next phase of maturation from the heyday of the ’90s and the early aughts. The question is no longer whether you can do cases safely in an ASC. It’s whether government and commercial payers will allow it. We’re seeing significant migration generated by payment rules, policy changes and clinical advancements. Today, we estimate that more than 60% of surgeries will be performed in the outpatient setting, and that percentage continues to grow, driven by regulatory changes like the relaxing of the inpatient-only list, along with growth in technology, clinical capabilities and how we manage our care teams.
At SCA Health, we think of it as purpose-driven growth. It isn’t about adding facilities for growth’s sake. It’s about expanding access to quality-driven, cost-effective care and creating alignment with specialists that brings demonstrable value to patients, physicians, health systems, payers and the government.
Question: What obstacles are you facing in that purpose-driven growth?
ME: There are state regulatory requirements that make it harder to access de novo builds or net-new facilities, while other states are relaxing certificate-of-need rules. It’s a balance, and it’s driven mostly at the state level, so it depends on where you are.
There’s also access to specialists. Fewer and fewer specialists are coming out of residency and fellowship programs, so the question becomes how we create the opportunity for them to land in independent practices that drive independent physician ownership inside ASCs, while health systems are thinking about specialist employment models differently. How do we position ourselves to enable their growth inside their specific market or national footprint?
Q: With so much hospital migration in the other direction, what’s actually drawing specialists to ASCs and independent practice?
ME: It’s the same things that have always driven surgeons to want to be in the ASC space: control over their clinical performance, clinical outcomes and clinical teams. The experience physicians and patients get inside an ASC is demonstrably different than at big-box hospitals, which have longer turnover times and emergent cases that can bump or block a schedule. ASCs just run more efficiently, and patients and physicians still appreciate that.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
