Physician groups and surgery centers are increasingly cutting insurers from the care delivery equation and contracting directly with employers and cash-paying patients.
Insurers have increased the administrative burden on physicians and ASCs to approve and receive payment for surgery by disputing more claims and requiring ASCs to spend more time convincing the insurer's medical director that cases are necessary.
But insurers must balance the delicate relationship they have with hospitals and members when developing ASC policies.
"Insurers also are hesitant to approve policies that favor ASCs, for fear it will cause issues with the hospitals," said Greg DeConciliis, administrator of Boston Out-Patient Surgical Suites. "Even though insurers can experience substantial savings through the shift of the site of service to the ASC, they rarely approve pro-ASC policies or directives. Instead of embracing competition, they prevent it from occurring."
About 67 percent of employed, insured workers are covered under self-funded plan arrangements, where the employer contracts directly with healthcare providers and bears financial risk for the cost of care, according to a 2020 Health Affairs report based on the annual Kaiser Family Foundation Health Benefits survey
"Given the difficulty with regulation around government and other third-party payers, the biggest opportunities for growth exist in companies that contract directly with patients and employer groups," said David Hardin, MD, chief medical innovation officer at Healogic in Denver. "Cash-pay surgery centers, disease-specific Centers of Excellence and direct primary care all offer improved outcomes and lower cost by removing much of the administrative cost created through the traditional third-party payer system."
ASCs with the data capabilities to enter into bundled payments also see opportunities with direct employer contracts.
"We're starting to see a lot of employer interest for the self-funded payers in the bundled payment arrangement," said Shannon Yarrow, senior vice president of managed care at Surgery Partners, an ASC company based in Brentwood, Tenn. "And that does put a little bit of risk on ASCs and physicians to make sure that they are giving high-quality care and selecting the appropriate patients for those bundles. But I do think that also leads to opportunities and more growth for volume opportunities, and so saving the health system money."
Surgery centers can also keep prices low by offering cash-paying patients a bundled rate. The Surgery Center of Oklahoma has targeted cash-paying patients since 2009, when the center's founder Keith Smith, MD, posted prices online. He built the cash-paying model after becoming disillusioned with payers and the insurer model.
Cash-paying and concierge practices are uncommon, but they could become more common, especially as large companies see benefits of transparent pricing and patients lose patience with insurers delaying care.
"Companies like Crossover Health, Walmart and the Surgery Center of Oklahoma are addressing these issues," said Dr. Hardin. "Direct primary care, in particular, has built up a large grassroots foundation through organizations like the Direct Primary Care Alliance."