ASC Industry Awareness
Educating the Public on ASC Benefits
The American public has come to know more about ASCs over the past few years due to conditions surrounding the pandemic. However, misconceptions remain, such as their value proposition and innovations that allow for more advanced procedures in ASCs. Surgery centers are consistently helping to reduce patient cost and stress. Across the northern border in Canada, ASCs are a solution to the chronic elective procedure wait time problem. Since ASCs are increasingly able to perform more complex procedures and utilize robotic technologies at a lower cost with ultra-low infection rates, the future for most patients now lies with ASCs rather than hospitals.
What Is the Most Common ASC Specialty?
By a whisker, orthopedics is the most common ASC specialty. Unsurprisingly, the most frequently performed ASC orthopedic procedures are knee arthroscopies. Knee arthroplasties are on the rise with a 304% increase in ASC knee replacement claims from 2018 to 2022. Orthopedic and spine organizations are in expansion mode across the country in 2023. Innovative orthopedic practices and surgery centers are cropping up even in less urban areas, such as this one in Warsaw, IN, which takes advantage of its location as an orthopedic device center. In Rochester, NY, a large orthopedic surgery center and practice is helping to revitalize a struggling suburban mall. How is that for innovation?
Healthcare Industry/Trends
Increasing Scrutiny on Health Insurer Tactics
Hospitals are feeling financial pain induced by payer mischief seen in denials, pre-authorizations, and downcoding – and they are making their pain known. AdventHealth filed a lawsuit against Multiplan, alleging that it colludes with health insurers to underpay significantly for out-of-network claims. With wider use of automation in healthcare insurance, denials of health insurance claims are rising in number and incongruity as evidenced by Cigna’s alleged denials of health insurance claims without a physician review. Bon Secours is suing Anthem, Virginia’s largest health insurer, over slow pay and no pay tactics. In California, the state medical association has won legal standing to sue Aetna Health of California over a PPO plan policy that depresses the number of patients that network physicians send to out-of-network physicians.
U.S. Hospital Challenges
Tough decisions are in the offing for a rising number of hospitals and health systems in 2023 with over eighty known to be cutting jobs. Losses have grown for Cano Health in Miami so it cut 17% of its workforce and is seeking to sell. Rural hospitals are struggling the most and are closing service lines to cope. In order to stay afloat, a financially struggling rural hospital in Pennsylvania is seeking to raise $1.5 million through a GoFundMe page. Finances are not the only worries, as dozens were arrested in Los Angeles over Labor Day during a labor protest, striking nurses in New Jersey had their health insurance dropped, and concerns are growing over the impact of hospital mergers.
Healthcare Digital Transformation Watch
New Cyber Trust Mark for Smart Device Security
Healthcare cybersecurity is a large and quickly growing concern. Healthcare tops all industries in money lost in data breaches with the average costs of a healthcare breach reaching almost $11 million. According to a 2023 survey, nearly 80% of healthcare organizations experienced a cyber incident in the past year. Cybersecurity experts, who safeguard sensitive protected health information, are in high demand, among other healthcare IT specialists. In response to cybersecurity issues, the Biden Administration has announced a US Cyber Trust Mark, which is a labeling program for smart devices intended to make them less vulnerable to cyberattacks.
Healthcare M&A, Valuation, Revenue Cycle
ASCs and Physicians Attractive to Investors
The volume of healthcare deals is 41% lower year over year. Private equity is no longer a reliable resort for troubled hospitals and has pivoted to targeting orthopedic ASCs. Physician practices and ASCs have become very attractive for investors, accounting for 42% of all healthcare deals in Q2 2023. In the last year, Optum (parent of SCA Health) and Tenet Healthcare (parent of United Surgical Partners International), have together made seven moves to consolidate ASCs and physicians further. In response to growing healthcare mergers, a bipartisan group of congressional members has sponsored a bill to require HHS to produce annual reports to Congress examining regulations’ effects on mergers.
Out-of-Network Watch
NSA Concerns… Not Just the IDR
In August, Health and Human Services, the Dept. of Labor, and the Dept. of Transportation collectively suspended the Independent Dispute Resolution (IDR) process (again) following a decision by the US District Court for the Eastern District of Texas, which compelled them to do so. However, the IDR process is not the only No Surprises Act (NSA) woe. Ground ambulances were an exception in the NSA law, because many ground ambulances are public sector entities. Ground ambulance billing under the NSA has become such a solution-less issue to date that pointed viral videos like this one have lampooned.
Legal
Federal Health Care Legislation as Congress Returns from August Break
From the office of Jon Sistare, JD, Attorney at Law
Following is an overview of the federal health care legislative landscape and potential scenarios as Congress returns to business this month. These are the issues related to health policy.
- Mental and Behavioral Health: An expiring measure is a 2018 law, known as the SUPPORT Act, which contained multiple policies to respond to the opioid crisis. For example, this law included a Medicaid option to allow for limited inpatient substance use disorder treatment. The House Energy & Commerce Committee has advanced the Support for Patients and Communities Reauthorization Act out of committee and it awaits floor action with more than 60 bipartisan cosponsors. The bill would reauthorize many of the original SUPPORT Act programs and contains additional provisions intended to combat arising issues with fentanyl and xylazine.
- Other Reauthorizations or Expiring Measures: Congress also has other expiring health-related laws or policies on its agenda. These include laws to reauthorize programs for community health centers (CHCs) as well as the training of pediatricians and the law to reauthorize the Food and Drug Administration’s Animal Drug User Fee Act (ADUFA). Reauthorization of the historically highly bipartisan Children’s Hospital Graduate Medical Education (CHGME) program has become another divisive issue this year as part of larger debates about gender-affirming medical care for children. This threatens reauthorization of the law though Congress could still appropriate funding for the program as it has done in the past when its reauthorization lapsed. Additionally, Congress needs to act to prevent a reduction in funding to hospitals, known as Disproportionate Share Hospitals, which treat high percentages of Medicaid beneficiaries or underinsured persons.
- Insulin: Another popular and bipartisan topic is legislation that would cap the cost of insulin at $35 a month for enrollees in group and individual plans, similar to the benefit the Inflation Reduction Act (IRA) included for Medicare Part D beneficiaries. However, competing bipartisan Senate insulin bills and differing approaches and scopes — as well as the price tag of such a measure — have kept the legislation from advancing. Moreover, while Senate support for insulin legislation is bipartisan, that same level of support has not emerged in the House.
- Physician Payments: Physician advocates continue to voice that Congress must act on legislation to blunt planned reductions in payments to physicians, currently set to go into effect in the calendar year (CY) 2024 Medicare Physician Fee Schedule (proposed rule). Congress acted in late 2022 to partially (but not completely) address proposed cuts as well as extend bonus payments for providers in alternative payment arrangements.
- Health Care Transparency: Congress is interested in policies to increase health care price transparency for consumers. The Centers for Medicare & Medicaid Services (CMS) published hospital price transparency enforcement updates earlier this year, and a phase-in of health plan price transparency (transparency in coverage) requirements began in 2022. Congressional committees have held numerous hearings on the topic. This Congress is considering legislation to codify and amend CMS hospital pricing regulations – extending such requirements into other services including imaging, clinical lab tests and outpatient surgeries. Congress will also consider requiring transparency in insurance provider networks with the intention of avoiding “ghost networks” in which providers on the list are not actually available.
At a Glance
Payer Mix in Nation’s Largest For-Profit Health Systems
Share of Payers and Percentages Grows over Time
Bureau of Labor Statistics’ Jobs to 2031
Nurse Practitioner the Fastest Growing Occupation
Arrests in Several States in Bizarre Harvard Remains Trade
Nationwide Network Connected to Harvard Med School
Some Hospitals Embracing RV Living for Patient Families
RV Life on Campus Makes Stay Easier for All Involved
American Fitness Index Measures 100 Fittest American Cities
How Did Your City Fare?
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