FinancialHospitals

Industry Voices—Are surgery centers ready for high deductible health plans?

by David Howerton | July 23, 2019

The rise of High Deductible Health Plans is a big change in patient responsibility, with implications for Ambulatory Surgery Centers (ASCs). 

With the ASC market expected to top $40 billion by 2020, how ASCs handle this sea change has implications for healthcare overall.

From increased patient education efforts to best billing practices, ASCs—with their usual speed—must adapt to the shifting payer/provider landscape.

How Did We Get Here?

Acting on the assumption that HDHPs would stem a rumored over-utilization of healthcare spending, many employers embraced them for the first time in 2006.

In 2007, 85% of adults with employment-based health coverage were enrolled in a traditional plan, with an average deductible of $379 (adjusted for inflation) for single coverage. Today, only 56.6% have a traditional plan, with 43.4% enrolled in a HDHP. The average HDHP deductible stands at $1,350 today, or more than triple the 2006 figure for a traditional plan.  

When patients access healthcare, it’s not likely they have the funds to meet even the lowest deductible before doing some major financial juggling. Wage growth hasn’t followed the increase in insurance premiums, as a study by the Los Angeles Times and Kaiser Family Foundation discovered. Complicating matters, federal data shows that while 61% of adults could cover an unexpected $400 expense, 39% would have to borrow, money, sell something or simply not be able to cover it at all.

The bottom-line impact on ASCs quickly becomes apparent when you examine the patient pay mix. Medicare and Medicaid are growing, but commercial pay still accounts for the majority of ASC payments. The mean percent of gross charges for ASCs, as measured in VMG Health’s 2018 Multi-Specialty ASC Benchmarking Study., breaks down as follows:

  • Commercial 61%
  • Medicare: 20%
  • Worker’s comp: 10%
  • Other: 10%
  • Medicaid: 7%
  • Self-pay: 6%

If the 43.4% figure above is applied to the commercial pay percentage from the VMG study, 26% of the average ASC’s commercial payer mix relies on HDHPs. Physicians may have been worried about how they would be paid by the uninsured; now it’s the patient responsibility portion of any HDHP policyholder that’s keeping them up at night.

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Chris J. Stewart

Chris currently serves as Chief Operating Officer at Ortho Spine Partners. Prior to that, he was the assistant vice president and business unit leader of Medical Device Management for HealthTrust.

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