ASC Industry Awareness
Accelerated Surgery Shift from Inpatient to Outpatient
Demonstrating a pandemic-accelerated trend, data analysis on 12 million commercial insurance members from 2019-2021 found that inpatient surgery utilization dropped 7.33% while ASC utilization rates rose by 10.26%. A significant aspect in that commercial shift for elective surgeries is the ASC’s lower cost. For example, the cost of a total knee arthroplasty in outpatient settings, such as ASCs, was 22% lower than the cost for the same procedure at inpatient facilities. The surgery shift to ASCs and outpatient facilities is becoming so prominent that ten states now have more ASCs than hospitals. Wise to the trend, US Senators Cassidy (R-LA), Blumenthal (D-CT), Wenstrup (R-OH), and Larson (D-CT) want to eliminate outpatient copay penalties and have introduced a bill to increase access to ASCs for Medicare beneficiaries.
ASCs Growing in Number and Uses
Becker’s ASC reported 186 new ASCs in 2022. Click here for a state-by-state breakdown. Orthopedics was the most common ASC specialty in 2022. Orthopedics, spine, and now cardiology are benefitting from the higher-acuity case shift in outpatient services. Mastectomies, lymph node excisions, intravascular vena cava filter removals, and laparoscopies are the four procedures finalized by CMS for ASCs in 2023 of the 47 procedures proposed by the ASCA. The advent of higher acuity cases in ASCs makes for more varied growth opportunities for inpatient services. Reimbursements, inflation, labor costs, and supply disruptions are issues ASC leaders are watching in 2023.
Hospital Hardship and Hope
The past few years have been hard on US hospitals; multiple challenges within and without continue to wear on them. Nearly half of US hospitals finished last year in the red, struggling to keep revenue up and costs at bay. Closing departments or ending services have become commonplace ways for hospitals to adapt. Workplace violence in various forms has also found hospitals, leaving 25% of critical care workers considering an exit, which at least 25 healthcare CEOs did in January. However, on the side of renewed hope, hospitals are leading a fresh hiring boom, counteracting job cuts in the technology sector.
What Is Happening in Insurance in 2023?
Insurtechs, like the well-known Oscar Health and Clover Health, continue to have difficulty scaling to profitable sustainability, but profitability is their goal in 2023. The Blue Cross Blue Shield Association believes its’ newly published affordability solutions, which emphasize site-neutrality, would reduce patients’ healthcare costs by $767B over ten years. Big commercial insurers are continuing their move toward vertical integration with PBMs, providers, pharmacies, and supporting technology, but vertical integration does not always favor patient interests. Marketplace insurance costs are rising in 36 states and Tricare plan costs are rising for active duty military personnel, their families, and retirees.
Healthcare Digital Transformation Watch
Digital Healthcare Advances
Private insurer payment for telehealth is on par with in-person care in 2020, but there is a catch – telehealth payment parity is currently only guaranteed through 2023. Telehealth is a service that patients and providers both want, but the question remaining is how reimbursements will be worked out long term. Another benefit to telehealth is that seeing a virtualist, when appropriate, can help to offset doctor and staff shortages. Albertsons Companies, the food and drug retailers, have found yet another way to advance digital healthcare with the launch of their Sincerely Health™ digital health and wellness platform for their customers.
Healthcare M&A, Valuation, Revenue Cycle
Mergers Continue Apace, PE Slows
Cardiovascular Associates of America expands to Florida in a new partnership that enables the retention physician ownership. Two Chicago orthopaedic powerhouses, Midwest Orthopaedics at Rush and OrthoIllinois, have now become one while operating as autonomous divisions. On the insurance front, Elevance Health (Anthem) acquires BCBS of Louisiana. CVS/Aetna is adding to its vertical integration by planning to buy Oak Street Health, a primary care provider for mainly senior adults with 160 clinics in 21 states. Grab a quick overview comparison of the competition between CVS Health/Aetna and UHC/Optum here. Healthcare private equity slowed toward 2022 year’s end and focus narrowed.
IDR Goes to Court, CMS to Update IDR Guidance
It has been a busy month for the No Surprises Act (NSA). On February 6, US District Court Judge Jeremy Kernodle ruled in favor of the Texas Medical Association’s challenge to NSA’s Independent Dispute Resolution (IDR) process for out-of-network claims. Medical societies call the ruling a victory for patients and providers because it restores balance and fairness to the arbitration process. In response, on February 10, CMS notified certified IDR entities to stop issuing payment determinations and to recall any determinations made after February 6. CMS stated that the certified IDR entities may continue other aspects of their work but they must await further CMS guidance before issuing determinations and payments.
Telehealth to Go Back to Original HIPAA Requirement as Public Health Emergency Ends (Unless Amended)
From the office of Jon Sistare, JD, Attorney at Law
Telehealth providers should prepare to comply with the HIPAA health privacy law once the federal public health emergency ends, the Department of Health and Human Services said in June of 2022.
Healthcare providers, health plans, and healthcare clearinghouses that transmit electronic health records were previously exempt from complying with the Health Insurance Portability and Accountability Act of 1996 “in connection with the good faith provision of telehealth using non-public facing audio or video remote communication technologies” during the pandemic.
Telehealth usage exploded at the beginning of the pandemic, when many practices closed their doors and patients were hesitant to receive in-person care. HHS exercised enforcement discretion to remove barriers to telehealth care from the many patients and doctors who had never had an online appointment.
The federal public health emergency is set to last until May 11, 2023. The emergency, which was originally declared in January 2020, was renewed every 90 days. The agency committed to a 60-day notice, but gave states a 90-day notice before letting it expire.
When the public health emergency expires, many regulatory flexibilities across the industry will expire. “This guidance will help ensure that individuals can continue to benefit from audio-only telehealth by clarifying how covered entities can provide telehealth services and improving public confidence that covered entities are protecting the privacy and security of their health information,” HHS said.
Healthcare providers should deliver telehealth services “in private settings to the extent feasible,” according to the HHS. If they cannot find privacy, they should speak quietly and not use a speakerphone. The HIPAA Security Rule, which requires doctors to protect patients’ electronic medical information, does not apply to audio-only telehealth using a landline “because the information transmitted is not electronic,” HHS said. Smartphone apps would be covered by the rule.
At a Glance
Federal Trade Commission Fines GoodRx $1.5M
For Sharing Health Data with Facebook & Google
1,085-Day Wait for Surgery in Australia and Getting Worse
500,000 Predicted to Be Waiting by Summer
Juries Need to Know that Bad Health Outcomes
Are Not Always Due to Physicians’ Negligence
Two Years into Price Transparency Rule
Only 25% of Hospitals Have Managed Compliance
HHS Issues 90-Day Notice of Final COVID-19 PHE Renewal
Public Health Emergency to End May 11, 2023
To subscribe or unsubscribe to ASCs in Motion, simply send an email request to firstname.lastname@example.org.
To inquire about Contego’s expert reimbursement solutions:
Call 855.505.8346 x1245 or Email email@example.com
Contego Solutions, LLC