Six CSA administrators from California to New Jersey discuss the payer landscape in their region and what they expect next year.
Note: Answers are slightly edited for clarity.
Lynn Winter, RN, BSN St. Louis Advanced Surgical Care Administrator (Florissant, Mo.): The payer landscape for our CSA is very poor. Payers continue to provide low [charges] as well as high deductibles. Often, the entire deductible is paid to the patient’s deductible, and since patients are often unable to pay on the day of surgery, the number of aging-related patient liability claims continues to grow. Patients must pay their premiums to the payer, and the payer in turn applies the authorized charges to the patients liability. For the payer, it is, more often than not, a win-win. For the insured, this is expensive and for the ASC, it means little or no reimbursement.
I don’t see this improving in the future unless payers are held accountable for their actions.
Kris Sabo, RN Executive Director of the Pend Oreille Surgery Center (Ponderay, Idaho): I predict the payer landscape will continue to improve in 2021 and beyond. Contributing factors include COVID; removal of procedures from the CMS inpatient-only list; and the insurance company’s motivation to send beneficiaries to a high-quality, cost-effective site of care. Additionally, patients are contributing to the push for CHWs by stating loud and clear that they want options for their care. Patients willing to pay discounted cash rates and third-party administrators negotiating directly with preferred providers are attracting the attention of commercial payers. I believe that we will have an easier time defending our value with payers. This will ultimately lead to a more realistic refund due to all the factors mentioned.
Dennis Simmons. CEO of the Wayne (NJ) Surgical Center: I think we face a unique opportunity during this pandemic with payers to really show our stuff. Our Wayne, NJ-based center was one of the only ASCs open in New Jersey after the Governor closed elective surgeries [earlier this year due to the pandemic]. We have developed a plan to perform “essential surgeries” and have remained open. We have safely helped a large number of patients during this time.
We were also able to negotiate a small increase with one of the main payers during this time, as many patients were afraid to go to hospital. I still think that’s the case, so we have a great opportunity to work with payers to move more surgeries to an outpatient setting. It’s more cost effective and patients really like the same day service.
Meredith Warf. Administrator of the Mississippi Sports Medicine & Orthopedic Center (Jackson): We have been performing outpatient total joint replacements for several years in ASC, so fortunately most commercial payers have been able to exclude these procedures from contracts. We got a glimpse of what we think the future holds as some payers now require pre-certification to perform certain procedures in a hospital setting. The convenience and cost savings offered by CSA are more evident than ever as total knee replacement moves into the CSA space, saving CMS billions of dollars with a single procedure , and we expect the same result with total hip replacement in 2021.
We believe the future is bright for CSA contracts. As the migration of ASC has only accelerated after the pandemic, payers seem ready to discuss strategies to make ASC a great option for procedures such as lumbar fusions and cardiology. CMS releasing the goal of eliminating the inpatient list within a few years has opened the door for many payers to consider the significant savings in ASC with better outcomes. In addition, advances in technology and knowledge of data will help redefine the quality of care.
We believe risk sharing with bundled care will expand to include arthroscopy among other subspecialties, encouraging multidisciplinary care plans and communication with patients throughout recovery.
Marie Yarborough, CCAC. Administrator of Skyway Surgery Center (Chico, California): I feel like the payer landscape is improving for CHWs. We have major insurance companies finally realizing the cost effectiveness of CSA, lower infection rates and higher quality outcomes, thus adopting new policies to cover procedures in surgery centers. We have CMS working to create policies that will improve our reimbursements and advocate cases away from hospitals. We have hospitals that succumb to our presence in the market. I think the more this is pushed, the more valuable our services will become.
Becky Ziegler-Otis. Administrator of the Stevens Point (Wis.) Ambulatory Surgical Center: Our payer landscape has demonstrated a shift with an increase in government payers. We have been performing outpatient joint replacements since 2010, and surgeons have gradually moved their patient population to the surgical center. With local hospitals limiting elective surgeries due to the COVID-19 pandemic, we have seen an increase in joint replacement cases that might have been more likely to have been done previously in a hospital setting.
We are also seeing more patient financial responsibility, which is not typical for the fourth quarter of the year. Usually, patients have met their franchises throughout the year; however, the COVID-19 pandemic has forced many patients to postpone care until the last quarter of the year and [they are] obliged to pay their deductibles. We also saw a slight decrease in workers’ compensation cases, which could be attributed to unemployment, again due to the COVID pandemic.
I anticipate that the government payer shift will continue through 2021. Patients will be expected to undergo procedures, and word of mouth about the quality and cost-effectiveness of care provided by the surgical center will spread within the community. , pushing the transformation even further.
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