Opportunities and Hurdles in the ASC Landscape with Alfonso del Granado

Summary

Becker’s Healthcare Podcast: Detailed Summary of "Opportunities and Hurdles in the ASC Landscape with Alfonso Del Granado"

Release Date: June 21, 2025

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Introduction

In this episode of the Becker’s Healthcare Podcast, host Alan Condon engages in an insightful conversation with Alfonso Del Granado, the newly appointed Market Administrator for the North Cypress area in Texas under HCA Healthcare's Surgery Ventures. The discussion delves into the current landscape of Ambulatory Surgery Centers (ASCs), highlighting emerging opportunities, existing challenges, and future growth strategies within the sector.

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Alfonso Del Granado’s New Role

Alfonso Del Granado recently transitioned into his role as Market Administrator, a position that comes with both excitement and its set of challenges.

[00:35] Alfonso: "HCA is a huge company and there's a lot to learn, so I'm drinking from the proverbial fire hose, if you will, but it is really an exciting time to be here."

Despite the steep learning curve, Alfonso expresses enthusiasm about contributing to HCA Healthcare's Surgery Ventures and participating in upcoming events, such as the Spine, Orthopaedic, and Pain Management Driven ASC conference.

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Key Trends in the ASC Landscape

Alfonso identifies three primary trends shaping the ASC environment:

1. Total Joint Surgeries and Robotic Assistance

The ASC sector continues to see robust growth in total joint procedures, particularly knee and hip replacements. The integration of robotic assistance into these surgeries has become well-established, enhancing precision and patient outcomes.

[01:22] Alfonso: "Total joints with knees and hips and with or without robotic assistance protocols by now are really well established and few or if any patients need a 23-hour observation."

The standardization of these procedures allows ASCs to handle them efficiently, fostering growth and attracting patients seeking high-quality care.

2. Minimally Invasive Spine Procedures

Minimally invasive techniques are gaining traction among orthopedic spine surgeons and neurosurgeons. These procedures offer benefits such as reduced recovery times and better patient outcomes, although reimbursement challenges persist.

[03:12] Alfonso: "Minimally invasive procedures... do arguably produce better outcomes for some for appropriately selected patients."

While payers do not offer additional reimbursement for these advanced techniques, they serve as a critical differentiator for ASCs, helping centers attract both surgeons and patients by offering cutting-edge services.

3. Innovations in Pain Management

The latest generation of implantable pain stimulators represents a significant advancement in pain management. These devices can modulate signals based on real-time feedback from a patient's neural responses, offering personalized pain relief.

[02:50] Alfonso: "The newest generation of implantable pain stimulators... can increase or decrease the stimulation based on the patient's neural response."

ASCs equipped to leverage this technology are poised to see increased patient engagement and business growth, positioning themselves as leaders in the pain management field.

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Legislative Hurdles and Advocacy

Navigating the legislative landscape remains a critical challenge for ASCs. Alfonso discusses ongoing efforts and legislative initiatives aimed at creating a more equitable environment for surgery centers.

1. Medicare CO Pay Fairness Act

This proposed legislation aims to ensure that payment caps on Hospital Outpatient Department (HOPD) procedures apply equally to ASCs. The goal is to eliminate financial disincentives for patients choosing ASCs over hospitals for higher acuity cases.

[05:10] Alfonso: "The Medicare CO Pay Fairness act is something that is intended to make sure that payment caps on HOPD procedures apply equally to ASCs."

Alfonso expresses optimism about gaining traction in Congress, which would significantly benefit ASCs by leveling the financial playing field.

2. Anti-Competitive Regulations Task Force

The ASC Association is advocating for fair treatment in regulatory processes, emphasizing the need for transparency when procedures performed safely and frequently in ASCs are denied coverage.

[07:00] Alfonso: "We want to see a little bit more fairness applied to surgery centers... transparency in the process would allow us to make our argument and hopefully impact patients' lives more directly."

This advocacy is crucial in ensuring that ASCs are not unduly restricted, allowing them to perform a wider range of procedures and serve patients more effectively.

3. Site Neutral Payments

While site neutrality—where payment rates are the same regardless of the service location—appears beneficial, Alfonso highlights potential drawbacks.

[10:42] Alfonso: "Site neutrality is a double-edged sword... it may lead to a race to the bottom, disregarding patient acuity and the need for appropriate care settings."

Alfonso cautions that without nuanced implementation, site neutrality could undermine the ability of ASCs to provide tailored care based on patient needs and procedural complexity.

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Growth Strategies in the ASC Sector

Looking ahead, Alfonso outlines strategies for sustainable growth within ASCs, focusing on both organic expansion and strategic partnerships.

1. Organic Growth and Recruitment Challenges

Independent ASCs can achieve growth by expanding within existing service lines and recruiting independent physicians. However, Alfonso notes increasing difficulties in finding physicians who maintain independent practices.

[12:50] Alfonso: "A lot of independent centers are struggling to find independent physicians. I have advocated for reasonable, fair, and balanced joint ventures..."

2. Joint Ventures and Strategic Partnerships

To address recruitment challenges, Alfonso advocates for joint ventures that balance physician autonomy with the resources of larger hospital systems. These partnerships can offer mutual benefits, such as enhanced operational efficiency and expanded service offerings.

[14:46] Alfonso: "A good joint venture is better than just continuing to struggle independently... finding the next opportunity."

By fostering collaborative relationships, ASCs can navigate the complexities of the healthcare landscape more effectively, ensuring long-term viability and growth.

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Conclusion

The conversation between Alan Condon and Alfonso Del Granado provides a comprehensive overview of the current state and future prospects of Ambulatory Surgery Centers. Key takeaways include:

• Technological Advancements: Embracing robotic assistance and minimally invasive techniques can differentiate ASCs in a competitive market.
• Legislative Advocacy: Ongoing efforts to achieve payment fairness and regulatory transparency are crucial for the sustained success of ASCs.
• Strategic Growth: Balancing organic growth with strategic partnerships offers a pathway to overcoming recruitment challenges and expanding service capabilities.

Alfonso’s insights underscore the dynamic nature of the ASC landscape and highlight the importance of adaptability, innovation, and advocacy in navigating both opportunities and hurdles.

[15:07] Alfonso: "Looking forward to seeing everyone in a couple of weeks in Chicago."

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This episode serves as a valuable resource for healthcare professionals and ASC administrators seeking to understand and navigate the evolving challenges and opportunities within the ambulatory surgery center sector.

Transcript

[A]

This is Alan Condon with the Beckers ASC podcast. And today I'm thrilled to be joined by Alfonso Del Granado, Market administrator for the North Cypress area in Texas, which is part of HCA Healthcare's Surgery Ventures. Alfonso, pleasure to speak with you again. I know that you'll be with us again at our Spine, Orthopaedic and Pain Management Driven ASC event this month as well. Really looking forward to that. But before we dive into this conversation, I know you just recently stepped into this position, this new role a couple of months ago. First and foremost, how are things going?

[B]

Well, Alan, I'm really excited with my new role, but I'll tell you, it's daunting. HCA is a huge company and there's a lot to learn, so I'm drinking from the proverbial fire hose, if you will, but it is really an exciting time to be here.

[A]

Exciting, but no doubt challenging. I can imagine. But I'm excited to kind of dive into some of the things that you're kind of following and paying attention to, Alfonso. So, so many things going on in healthcare at any one time, particularly at the given moment. A lot of challenges, a lot of exciting things happen, particularly as it relates to the ASC space. Alfonso, what are two or three kind of key trends that you're paying really close attention to today and why?

[B]

Well, taking into account that we're going to be having our Spine Pain and Orphan Driven conference, Let me focus on that area for a moment. Just broadly speaking, I think the opportunities remain really strong for surgery centers around the country in total joints with knees and hips and with or without robotic assistance protocols by now are really well established and few or if any patients need a 23 hour observation. So I think that that continues to show a strong growth potential for any surgery center that's in that space. And I also see continuing opportunity for orthopedic spine surgeons and neurosurgeons to adopt minimally invasive procedures. They're not reimbursed extra by payers, so there are still some financial hurdles for some ASCs, but they do arguably produce better outcomes for some for appropriately selected patients. And they can be a differentiator for the ASC to drive patients towards its services and away from its competitors. So I think that's a strong area of consideration. And lastly, I guess in the field of pain management, I'm really excited about the newest generation of implantable pain stimulators that are able to modulate the signal based on feedback from the patient's neural response in other words, instead of a fixed signal or at a fixed time, it actually senses the body's response and can increase or decrease the stimulation. I think that these are going to get a lot of traction with patients. And centers that are equipped to take advantage of this technology through their surgeons, of course, are going to see a lot more business.

[A]

Got it. So really, to your point, a lot of big opportunities. The pain management space, the total joint space, spine surgeons, and the spine space specifically, as you'd mentioned, big opportunity for spine surgeons to continue to adopt some of those minimally invasive procedures. The caveat you did explain there, some of these are not reimbursed extra by payers. But what are those as a from an administrator standpoint, someone who's a leader in the ASC space, what are those minimally invasive spine procedures or techniques that you see can really be a differentiator for ASCs offering them?

[B]

I think anytime you use the term minimally invasive and we're talking about endoscopic spine procedures, what you're doing is you're differentiating yourself from your competitors. A lot of patients are looking for the latest and the greatest, and surgeons who are able to provide that are looking for a place to do those procedures. Some of them are going to be done just at the hospital because, again, of the reimbursement model. But for ASCs that can handle the cost, whether through a good reimbursement contract or for that matter, if they're able to run these cases efficiently, the extra volume, even though the margin may not be as good as an open traditional procedure, the extra volume may be something that they can look to use to fill a slot in their schedule.

[A]

Absolutely. No doubt there's a lot of excitement from spine surgeons who I've recently spoken with, obviously ASC administrators as well, migrating a lot of those more complex spine procedures to the ASC setting. And also to your point, using some of these minimally invasive techniques, whether it be robotics, endoscopic spine surgery, safely and effectively perform those procedures in the outpatient setting as well. That's clearly something really exciting for spine surgeon on the surgical end of the standpoint. But for you as an administrator, Alfonso, as a leader in the ASC space, what are you most excited about? When you think about the future of.

[B]

ASCs, it's an interesting thing because obviously a lot of the fundamentals remain the same. We have been struggling for so many years with legislative hurdles that we've had a lot of trouble to overcome. I sit on the board of the Ambulatory Surgery Center Association And I think this year we're finally seeing some real momentum building up in Washington on a couple of fronts. One, legislatively, the Medicare CO Pay Fairness act is something that is intended to make sure that payment caps on HOPD procedures apply equally to ASCs. So that finally for these higher acuity cases that we were talking about, there won't be a financial incentive for the patient to select an hopd because even though the total cost of care may be higher, their actual out of pocket will be kept at hopd, whereas it wouldn't be in the surgery center. I think this is a very exciting front and we have legislation now in Congress that is working its way. So I'm really hoping that this gains more more traction. And then the Anti Competitive regulations Task force has been doing a request for information for. Well, it's a broad area across all industries, but from our perspective we want to see a little bit more fairness applied to surgery centers. I think that for hard to explain outside of. Well, I won't venture a guess, but for reasons that are hard to explain, CMS continues to favor hospitals in areas that are not necessarily beneficial to patients and definitely not beneficial to our national budget. So for example, we want to have procedures added to our ASC covered procedures list that are safely performed every day thousands of times around the country. But asc, the CMS want to explain why they're being denied to be performed in a surgery center. We believe that transparency in the process would allow us to be able to make our argument and to be able to hopefully impact patients lives and patients welfare in a more direct way on the national level. We also believe that if you're going to be able to convert an ASC into an HOPD overnight, well again, fairness, we should be able to convert an HOPD into an asc. I think that a lot of groups that are looking to acquire or partner with hospitals would find this beneficial to be able to walk in tomorrow, take an existing hrpd, turn it into a surgery center and operate the next day as easily as the reverse. So again, we're just fighting for fairness here and I think that this year we are seeing a little bit of traction, a little bit of momentum in that direction. So I know it's a long answer to a simple question, but that's got me really excited this year.

[A]

Yeah. And unfortunately no simple. But I think you laid it out quite perfectly. I'm wondering some of the legislative hurdles. Obviously you sit on the board of aska, as you've mentioned. What has been the turning point from your Perspective from the legislative standpoint, is it increased advocacy changes administrations, or maybe something else that's really kind of helped push some of these legislations along?

[B]

I think we've had a little bit of a breakthrough in having people who are experienced and knowledgeable about the healthcare industry reach certain positions within committees in Congress. I don't want to single anybody out, but education is always a big part of it. It's always been shocking to me on a national level for sure. But even on the state level, when people who are tasked with regulating healthcare services don't even know what a surgery center is or even exist. So being able to find people in key positions in these committees has been a task that ASCA has been working towards for a long time. And I think we finally, just finally may have started to make inroads in, in that educational effort, which again, we're in the surgery center business. Right. So we're, we're not trying to get something for nothing. We're trying to provide value to the patient and value to the nation. And I think surgery centers play a vital role in that process.

[A]

Yeah, I think you bring up such a really important point as well as it kind of plays into a lot of the discussion, a lot of the narrative that was playing out on Capitol Hill at the moment. So Alfonso, just one quick follow up question here before we move on to our last question. You kind of brought up the national budget obviously is something that's been talked about on a daily basis where we're talking about what's going on in Capitol Hill. You brought up potentially how site neutral payments, even in the playing field, might actually play into that, but also benefit ASCs, patients, providers. As we see so much of this complex cases moving to the asc, the outpatient setting. Just from your perspective, is that something that you see potentially, maybe something that might have more of a green light coming down the line? Is that something that. I know it's a big hope for ASCS hospitals, of course, fighting back, hospital lobbies, but is that site neutral payments? Is there any, any movement that you foresee or predict there? Given a little bit of a turning point from the legislative standpoint that you.

[B]

Just talked about, I'm very cautious when it comes to site neutrality because that is a double edged sword and taking away our own interest as a surgery center, I think that the risk is that you'll have a race to the bottom. There are some procedures that can hypothetically in an optimum setting, be performed in the doctor's office where there's no overhead other than the rent and the cost of a medical assistant or nurse, but that would be done more safely in a surgery center. And likewise, there are some procedures that could be done safely in a surgery center, but a patient's complications comorbidities make it advisable to be done in an HOPD or even inpatient. So when we're talking about site neutrality, the downside, the risk there is that people who, as I mentioned earlier, don't really know anything about the healthcare scene will make a decision to push payments down to the lowest possible cost in a way that doesn't take into account patient acuity, patient complications, comorbidities, the need for additional treatment options, the need for higher level technology issues that we as surgery centers are certainly aware of and hospitals of course are as well. I think that we need a system that gives us the appropriate payment for the appropriate site of service for the appropriate patient. And site neutrality unfortunately sometimes is taken as a catch. All that in theory is a good idea, but in practice may not be implemented in an optimal fashion.

[A]

Right? Definitely to your point. I think that an important context to add in terms of that potentially a double edged sword for acs there down the line. Alfonso, fantastic conversations. Always a pleasure to catch up with you. Lots of last question before I let you go. Looking ahead 12 months or so, how are you thinking about growth whether in your current new role or in the ASC sector more broadly?

[B]

I think that for independent centers, same center organic growth within existing service lines is always a given. Continuing to recruit independent physicians of course is always an effort. It can get harder though, and I think a lot of independent centers are struggling to find independent physicians. I have advocated for some time now for reasonable, fair and balanced joint ventures that take into account the need for autonomy and self direction that physicians historically and traditionally have by temperament and by education and balance it out with the larger resources and benefits of the hospital system as well as having a professional management company or educated personnel that can make maximum efficiency decisions in an asc. We have, I'm going to say that a deficit of independent physicians that are truly self directing and even those that are are oftentimes at the mercy of health system referral direction. So that's something that's always plagued us and I think it's getting a little bit more difficult to find physicians who truly have their own independent practices. If they do, great focus on same center organic growth, continue to work hard to recruit independent physicians, find new procedures that are high profile that patients will actively seek out. But for those who are struggling or somewhere in the middle. I think a good joint venture is better than just continuing to struggle independently, trying to figure out what is the next step where we're going to find the next opportunity.

[A]

Yeah, I think some great words of wisdom and great key takeaways to end our podcast today, Alfonso, and really, really looking forward to seeing you again in person, having you speak again at our Spine Orthopedic and Pain Management Driven ASC conference in a couple of weeks. Alfonso, thank you so much for taking the time out of your busy schedule. Congrats again on the new role and always a pleasure. Thank you.

[B]

Thank you so much, Alan. Really love it here and I'm looking forward to seeing everyone in a couple of weeks in Chicago.