Editor’s note: Responses have been lightly edited for clarity and length.
Question: What are the biggest obstacles ASCs face when trying to expand their market share, and how do hospital lobbying efforts influence these challenges?
Dr. Shakeel Ahmed: The ASC industry continues to face multiple obstacles in their expanding market around the country and worldwide in general. In the U.S., our biggest hurdles are regulatory barriers, including political opposition from special interest groups, worsening payer dynamics and difficult physician-owner recruitment around the country. As far as political issues go, ASCs continue to struggle with highly restrictive certificate-of-need laws around the country, with an uphill battle to overcome these hurdles. Medicare also has failed to keep pace with inflation. Reimbursement disparities are progressively unsurmountable for most surgery centers, especially the smaller ASC.
Lastly, hospital-employed physician referrals have all but disappeared. While we all know that is an egregious assault on the antitrust laws, there is no recourse for small businesses but to absorb those losses and continue to work with the dwindling referral sources that they have. Hospital lobbies continue to work aggressively to maintain hospital dominance around the country by pushing rules, regulations and policies that limit our growth. We continue to see weakening Medicare reimbursement rates and private commercial insurers continue to adopt payment structures that favor hospitals over surgery centers, making market expansion difficult for us.
Q: How have hospital lobbying groups, such as the AHA, shaped policies or regulations that make it harder for ASCs to compete
SA: Groups like the American Hospital Association continue to play a pivotal role in shaping federal and state policies that overwhelmingly favor hospitals at the expense of ASCs. This blatant abuse of power, which compromises patient care, is a travesty — yet it continues largely unnoticed.
Through relentless lobbying, hospitals ensure that hospital outpatient departments receive significantly higher reimbursement rates than ASCs, while also discouraging hospital-employed physicians from referring to these lower-cost outpatient facilities — even when they are located just steps away from the hospital.
Physicians, even in independent practices, face behind-the-scenes pressure and resistance from hospitals when attempting to shift cases to outpatient surgery centers. Meanwhile, hospitals continue to use their lobbying power to uphold certificate-of-need laws, which restrict ASC expansion in many states. In some states, surgery centers must apply for a CON for each new specialty they add — an already burdensome process that hospitals frequently obstruct by pressuring surgeons to withhold letters of support.
Q: What strategies have ASCs and their advocacy groups used to counteract the influence of hospital lobbies, and have any of these efforts been successful in securing policy changes or leveling the playing field?
SA: Surgery centers and their advocacy groups, such as the Ambulatory Surgery Center Association, have fought for site-neutral payments and against restrictive CON laws in more states. While progress has been made, it has been slow and incremental. We continue to push for legislative changes that would allow greater physician investment in ASCs.
One of our most significant successes in recent years has been Medicare’s gradual expansion of covered ASC procedures, enabling more complex surgeries to be performed in outpatient settings. It has been encouraging to see the addition of numerous orthopedic and spine CPT codes to the ASC roster over the past few years. Additionally, the rollback of certain CON laws in a few states has opened the market for new surgery centers.
However, despite these efforts, hospital lobbies remain the dominant force, and our victories have been modest at best. The reimbursement disparities continue to be the greatest challenge, making it difficult to compete on a level playing field. These financial constraints also make it increasingly difficult to keep pace with rising costs for instruments, equipment and staff salaries.
