Becker’s Healthcare Podcast: Key CMS Shifts, Site Neutrality Momentum, and ACA Subsidy Uncertainty with Laura Dyrda

Date: November 25, 2025
Host: Scott Becker
Guest: Laura Dyrda

Episode Overview

In this episode, Scott Becker is joined by Laura Dyrda, a healthcare journalist and industry watcher, to discuss the latest trends impacting U.S. healthcare. The primary focus is on key regulatory changes from the Centers for Medicare & Medicaid Services (CMS), the ongoing drive toward site neutrality in payment, and uncertainty surrounding Affordable Care Act (ACA) subsidies. Laura offers insights into how healthcare leaders are responding to these shifts and what it means for the future of the industry.

Key Discussion Points & Insights

1. CMS Ambulatory Policy Changes and the Shift to Outpatient

• Major CMS Announcements:

  • CMS is phasing out the inpatient-only list over three years and expanding the list of covered ambulatory surgery center (ASC) procedures starting next year.
    • "A three year phase out of the inpatient only list and a substantial expansion of the ASC covered procedures list... 285 procedures... will shift off the inpatient only list while 547 codes will be then added to the ASC list." – Laura Dyrda [00:22]
  • Medicare retains the authority to pay for procedures in hospital outpatient departments (HOPDs) when clinically appropriate.

• Historical Context:

  • Policy shifts began under the Trump administration, were reversed under the Biden administration, and are re-emerging with a renewed push in the second Trump administration.

• Market Response:

  • Health systems are adapting by moving more cases to outpatient and ASC settings.
  • Notable activity includes Ascension's acquisition of AMSURG, expanding its ASC footprint to over 300 centers nationally.
    • "Ascension acquired Amsearch earlier this year, which is an ASC operator with more than 250 facilities in 34 states... so the acquisition about... those 250 centers to Ascension's existing 58 ASCs." – Laura Dyrda [01:41]

• CMS Cost-Saving Goals:

  • CMS aims for an estimated $11 billion in savings over the next decade from shifting more procedures to ASCs.

2. Site Neutrality and Payment Realignment

• Site Neutrality Explained:

  • CMS is moving to aligned reimbursement for certain outpatient services, regardless of care site, to address higher copays in HOPDs.
    • "CMS also, you know, advanced some of its site neutral payments, moving to aligned reimbursement for certain outpatient services... to prevent higher co pays based solely on the site of care." – Laura Dyrda [02:20]
  • The goal is to encourage care in lower-cost settings when clinically appropriate.

• Industry Impact:

  • Hospital executives and ASC operators are strategizing as reimbursement rates for hospitals decrease to match ASC levels.
  • Both sectors are concerned about sustainability as margins narrow.
    • “Neither side of care wants to see margins go down so much that it becomes untenable for them to provide care in the outpatient setting.” – Laura Dyrda [07:21]

• Legislative Dimensions:

  • Site neutrality is popular among lawmakers as a cost-saving measure.
    • "It does seem to make a lot of sense in that argument for lawmakers who are serious about it." – Laura Dyrda [06:46]
  • Both hospital and ASC lobbyists are working to shape policy to protect their interests.

3. Health System Concerns and Strategic Responses

• Revenue & Sustainability Worries:

  • Hospital leaders are concerned about revenue loss as procedures shift to lower-reimbursed outpatient settings.
    • “The short answer is yes, there is a lot of concern and it will have an impact on hospital revenues and budgets.” – Laura Dyrda [03:29]
  • Many systems are already developing new budget models and rethinking real estate, technology investments, and care models.
    • “They want to make sure that they are treating patients in the right setting... but in the interim, they're going to need to double down on... leveraging technology [and] what new revenue streams are going to make sense for their organizations.” – Laura Dyrda [03:58]

• Strategic Moves:

  • Partnerships with physicians on ASCs, and focus on outpatient services is becoming a survival and growth strategy.

4. ACA Subsidy Uncertainty

• Upcoming Changes & Political Tension:

  • ACA subsidies are set to expire at the end of the year, with debate on Capitol Hill about their extension.
  • President Trump has proposed the "Health Care Price Cuts Act," extending subsidies for two years with new eligibility and premium requirements.
    • “The proposal... would extend some of these subsidies for two years while adding new eligibility limits, including an income cap... and minimum premium requirements.” – Laura Dyrda [08:40]

• Shifting Stances:

  • President Trump's position has shifted from eliminating insurer payments to supporting renewed subsidies, which is causing political friction.
    • “In this interim, Congress is also considering its own path with the Senate advancing a spending package...” – Laura Dyrda [09:32]

• Public Sentiment:

  • The enhanced ACA tax credits are popular, fueling record enrollment and broad public support.
    • “Polling shows that more than 75% of adults support keeping those tax credits.” – Laura Dyrda [10:24]

Notable Quotes & Memorable Moments

• On Persistence of Outpatient Shifts:

  • “Some health systems had really read the tea leaves and have already started making moves so more cases are in the outpatient setting and in ASCs.” – Laura Dyrda [01:20]

• On Industry Uncertainty and Adaptation:

  • “How do you redesign systems that are more efficient and effective than they ever have been in the past?” – Laura Dyrda [04:52]

• On the Political Drama behind ACA Subsidies:

  • “As President Trump tries to meet in the middle on the ACA subsidies, he's getting a lot of whiplash from his own party and is fascinating to watch the entire thing.” – Scott Becker [10:56]

Timestamps for Key Segments

• [00:22] – CMS policy changes: phase-out of inpatient-only list and ASC expansion
• [01:41] – Ascension’s acquisition of AMSURG and the ASC market outlook
• [02:20] – Site neutrality and payment changes
• [03:29] – Health system budget and revenue concerns
• [03:58] – Strategies for adapting to new payment models
• [05:53] – Discussion on site neutrality’s broader implications
• [08:40] – ACA subsidy uncertainty and proposed legislation
• [10:24] – Public support for ACA tax credits

Summary

This episode provides an incisive look at the regulatory, strategic, and political forces shaping U.S. healthcare in late 2025. Laura Dyrda highlights how CMS policy shifts are accelerating the move toward outpatient care and site-neutral payments, pressing health systems to rethink their financial and operational strategies. The uncertain future of ACA subsidies adds another layer of complexity, with political debate and public opinion playing significant roles in what comes next. Both sectors—hospitals and ASCs—are bracing for change, building new partnerships, and adapting to ensure sustainability in a rapidly evolving landscape.