ASC Industry Awareness
Trends Leaning in Favor ASCs
ASCs are garnering attention from nearly every direction: physicians, corporate entities, patients, health systems, administrators, and private equity groups. A newer entrant is making news as a medical equipment manufacturer-cum- medtech group invests to create and equip ASCs. All of the attention creates opportunities for shake-ups and adjustments in the industry including percentages of ASC-based cases, certificate of need laws, and patient cost-consciousness. ASC leaders are also hoping for Medicare neutral site payment reforms to align more strongly with the forward lean of the market toward ASCs to enable more equitable reimbursements as more empowered and informed patients seek outpatient surgery in ASC settings.
Procedure Growth for ASCs
We nearly take for granted now the amazing growth in types of outpatient procedures that can be performed safely in ASCs. It was just two years ago that CMS reversed its decision to end the inpatient-only list to create a more calculated assessment for determining outpatient procedures. More spinal, plastics, and total joints procedures are regular features of ASC’s surgery schedules. Cardiology is now one of the biggest opportunities for ASC growth. As of May, Florida began allowing cesarean section procedures to take place in outpatient centers, though there is still healthy debate about complication risks. ASC leaders are generally enthused by the opportunities with procedure growth but questions of whether reimbursements will catch up to the opportunities tempers that eagerness.
Healthcare Industry/Trends
Motley Movements in Medicare
Medicare is a curious chameleon experiencing several alterations over time due to background conditions. One of the most enduring curiosities for providers is the calculation of commercial insurance estimates per state to the Medicare benchmark. See here to capture how that reptile works. That, along with the diminished role of the Medicare Economic Index has contributed to an effective physician payment decline of 29% since 2021. Medicare Advantage is the latest to flirt with reptilian ways. Insurers have sunned themselves by it, pocketing $50 million for diseases no doctor treated. In the shade, Medicare Advantage plans are paring back for 2025 and are no longer a gold mine for private insurers.
States Making Healthcare Moves in the First Half of 2024
Federal government action sucks up all the news oxygen, but in 2024, states have been making a variety of healthcare moves. In June, Minnesota Governor, Tim Waltz, signed the Emergency Medical Rural Services Bill to create one-time aid for rural ambulance services. Washington State has also taken action on ambulance services, driving more patient protections against surprise bills. This spring, Vermont ratified aggressive reform on prior authorization and step therapy coverage to enable more timely treatments for patients. Georgia loosened certificate of need rules in the state to shorten the timeframe for review of new hospital applications. In February, Connecticut became the first state to cancel medical debt for eligible residents.
Healthcare M&A, Valuation, Revenue Cycle
AI in Healthcare RCM
Artificial Intelligence and automation have the potential to help to address challenges in the healthcare revenue cycle like rising costs, eroding financial margins, labor shortages, insurance verification, and collections though there are barriers to adoption. At this stage in the game, human intervention in RCM AI overcomes shortfalls in efficiency and rigor of design to keep outcomes safe. The promise of RCM AI means the availability of cash, as a New York-based RCM intelligence and automation company found in securing $31 million in Series B funding. Advances in automation, AI, and digital technology are also enabling payer-provider, or “payvider,” organizations to bud and blossom.
Out-of-Network Watch
When the Saints Go Marching Out
Historically religious nonprofit hospitals and health systems are having a challenging season with regard to insurance networks. Indiana’s St. Joseph Health System, which is now a member of Trinity Health (also a non-profit healthcare system) has been nudged out-of-network with UHC. As of July 1, Schenectady, New York’s, St. Peters Health Partners is also no longer in-network with UHC. St. Mary’s Hospital in Athens, Georgia (also a member of Trinity Health), is still negotiating with UHC after their contract expired June 30, so the hospital is out-of-network while some physicians and practices remain in-network. BaylorScott&White, a Texas faith-based non-profit system, just negotiated a three-month extension to October 1 with BCBS of Texas, so talks can continue toward finalizing a longer-term agreement.
Healthcare Digital Transformation Watch
AI in Healthcare RCM
Artificial Intelligence and automation have the potential to help to address challenges in the healthcare revenue cycle like rising costs, eroding financial margins, labor shortages, insurance verification, and collections though there are barriers to adoption. At this stage in the game, human intervention in RCM AI overcomes shortfalls in efficiency and rigor of design to keep outcomes safe. The promise of RCM AI means the availability of cash, as a New York-based RCM intelligence and automation company found in securing $31 million in Series B funding. Advances in automation, AI, and digital technology are also enabling payer-provider, or “payvider,” organizations to bud and blossom.
Legal
40 Years’ Worth of Deference to Federal Agencies Is Over
From the office of Jon Sistare, JD, Attorney at Law
A landmark Supreme Court decision that reins in federal agencies’ authority is expected to hold dramatic consequences for the nation’s health care system.
The June 28 decision overturns a 1984 precedent, known as the Chevron Doctrine, which said courts should give deference to federal agencies in legal challenges over their regulatory or scientific decisions. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law.
The ruling will likely have seismic ramifications for health policy. A flood of litigation — with plaintiffs like small businesses, drug makers, and hospitals challenging regulations they say are not specified in the law — could leave the country with a patchwork of disparate health regulations varying by location.
Agencies such as the FDA are likely to be far more cautious in drafting regulations, Congress is expected to take more time fleshing out legislation to avoid legal challenges, and judges will be more apt to overrule current and future regulations.
Health policy leaders say patients, providers, and health systems should brace for more uncertainty and less stability in the health care system. Even routine government functions such as deciding the rate to pay doctors for treating Medicare beneficiaries could become embroiled in long legal battles that disrupt patient care or strain providers to adapt.
At a Glance
Catholic Medical Center, Manchester, NH Ready to Deal
HCA Ready to Make Partnership Offer
Mental Health Claims Increased 83% from 2019-2023
Claims Increased 11% from 2022-2023
Letter to HHS Detailing Egregious Insurer Denials
20% of Claims Denied, Some without Even Opening Patient File
Argument: Thank Private Equity and Consolidation for Large Bill
Healthcare Costs Rising Mostly Due to PE
Rebuttal: Government Thumb on Scales Leading to Cost
Government Intervention and Insurer Market Dominance
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