The migration of surgical cases from HOPDs to lower-cost sites of care, like ASCs, represents a compelling opportunity for payers to reduce their costs while ensuring their members receive high-quality care and an enhanced experience. While many factors contribute to surgery migration, payers have several strategic approaches they can deploy to drive more surgical cases to ASCs.
1. Implementing Patient-Steerage Policies
Reducing copays for procedures performed in an ASC or removing the pre-authorization requirement for services performed in the ASC can drive more surgeries to ASCs, reducing costs for patients and payers. While reducing costs is an important consideration when developing patient-steerage policies, payers should tailor the policies to ensure quality and patient access aren’t disrupted.
2. Enhancing Physician Reimbursement
Payers can incentivize physicians to move more of their cases from HOPDs to ASCs by enhancing reimbursement for procedures performed in an ASC. Payers should carefully consider which case types would be appropriate for this strategy, understanding the potential impact on its members ability to access ASCs. For example, after a deep market analysis, a payer may choose to apply this strategy to GI cases because it determined local ASCs have the resources to support and absorb these cases.
3. Aligning Incentives Through Value-Based Contracts
Value-based contracts can accelerate surgery migration by rewarding providers and health systems for managing the total cost of care. Under arrangements such as shared savings or bundled payments, shifting appropriate surgical cases directly improves financial performance while maintaining or improving quality. Value-based models naturally encourage the use of ASCs over higher-cost HOPDs.
4. Developing ASC Networks
The potential savings derived from case migration from the hospital to the ASC setting is not going unnoticed by the payers as a possible investment opportunity. The combination of improved premium pricing via improved affordability (resulting from services being performed in the more financially efficient site of service) and financial benefit from ownership presents a win-win opportunity for payers. The most conspicuous example of this is the acquisition of Surgical Care Affiliates by UnitedHealth Group under the Optum Health subsidiary. Increased ownership of ASCs by payers will only accelerate case migration to enhance their investment.
Where is your health plan in its ASC journey?
