To expand patient access to care, the Centers for Medicare and Medicaid Services (CMS) has begun asking ambulatory surgery centers (ASCs) to screen patients for “social drivers of health” (SDOH) that hinder access to care. However, groups that represent ASCs and surgeons, including those in ophthalmology, argue the measures are misplaced, citing insufficient staff and resources to assess and address these barriers.

“Health equity and understanding the communities that we serve are important from a community health perspective,” says Kara Newbury, JD, chief advocacy officer for the Ambulatory Surgery Center Association (ASCA). “It has just not been demonstrated to us that ASCs are the appropriate sites of service to collect and use this data.”

So, what exactly is “health equity?” CMS defines it as “attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes (www.cms.gov/priorities/innovation/key-concepts/health-equity).

Measuring Quality of Care

ASCA is one of many groups, including the Outpatient Ophthalmic Surgery Society (OOSS) and others in ocular surgery, that are seeking elimination of, or major revisions to, the CMS’ Ambulatory Surgical Center Quality Reporting (ASCQR) program, which requires all ASCs to abide by 3 measures of health equity:

1. 1. Demonstrating facility commitment to health equity
      
      
   2. Screening for social drivers of health (SDOH)
      
      
   3. Screening positive rate for social drivers of health

While the ASCQR was initiated in July 2024, the first measure became mandatory this year; the other 2 become mandatory in 2026. All 3 cover 5 major social drivers of health (SDOH): food and housing instability; transportation and utility access; and interpersonal safety.

Facilities must attest, or affirm, that they are screening each Medicare patient for SDOH issues to comply with this measure, implement a structure for screening, and report on the number of positive responses received each year. Facilities that fail to participate face a 2% reduction on their annual fee schedule update.

Insufficient Staff and Technology

ASC group leaders, however, argue that the facilities don’t have the staffing levels or technology capabilities necessary to collect or act on the data.

The American Academy of Ophthalmology (AAO), the OOSS, the American Society of Retina Specialists (ASRS), the American Society of Cataract and Refractive Surgery (ASCRS), and the Society for Excellence in Eyecare (SEE) sent the CMS a joint letter covering their concerns about the program.

The groups argue the ASCQR places an unfair burden on personnel already tasked with completing the CAHPS Outpatient and Ambulatory Surgery survey. Consisting of almost 40 questions, the survey was initiated in 2024 and asks adult patients about their care experience with communication, preparation, and postsurgical care. Facilities that fail to administer and report on the CAHPS OAS survey also face a 2% reduction on their annual fee schedule update.

“It is simply unreasonable to add another measure to the ASCQR program at the same time that ASCs will be commencing compliance with OAS CAHPS,” the letter reads in part. “It would be challenging for the ASC to attest that [it] inputs demographic and/or social determinants of health collected from patients and transmitted via EHR technology. Many ASCs have not adopted robust EHR technology.”

Apryl McElheny, MBA, MSN, RN, CIC, CASC, senior consultant at VMG Health—which advises ASCs on strategic, regulatory, or operational challenges that affect quality of care, profitability, and growth—agrees the program could put a strain on ASCs. This is especially true of small facilities with just 1 or 2 operating rooms.

“There are entire departments in hospitals and larger organizations that facilitate programs like ASCQR,” says Ms. McElheny. “We have nurses, receptionists, technicians, the surgeon. We don’t have additional employees to be collecting, analyzing, and building the strategic plans that the measures require.”

Another objection to the program is that SDOH data in many cases is already being collected by other, upstream referrers such as primary care physicians, ophthalmologists, and optometrists. Issues relating to SDOH are likely to be discovered and addressed by these providers, well before the patients reach the ASC.

“It doesn’t really make sense for a facility providing elective surgery,” says Ms. Newbury. “We’re opposed to anything that is duplicative.”

No Ability to Act

Even if ASCs can collect the required SDOH data, there are concerns surrounding their ability to act on the information. According to Ms. Newbury, the program “technically” does not require ASCs to act on SDOH information shared by a patient. However, in her view, that raises ethical concerns over what personnel can or should do with the information.

“If [the patient] indicates that they need support, and you’re not in a position to provide that support, in my mind it’s worse, because they’ve shared something very personal, and we have to say, ‘I’m sorry about that, but we can’t do anything for you,’” she says.

“We don’t have the infrastructure to collect the data, let alone take action on it,” agrees Ms. McElheny.

She cites the hypothetical example of a patient who reports feeling unsafe at home. Because healthcare providers are considered “mandatory reporters,” ASC personnel would be required to alert authorities. While that might not be unreasonable, Ms. McElheny says, she questions whether the ASC is the appropriate setting for the screening in the first place.

“It’s one thing when it’s just the patient and their primary care doctor behind a closed door. But it’s different when you’re in a pre-op area that has 6 bays…separated by curtains, and there are people coming in and out. It’s just not an appropriate place to ask the questions,” Ms. McElheny says.

Noncompliance More Financially Feasible?

In their letter to the CMS, the ocular surgery groups state that while “substantial resources” are required to meet the objectives of the program, “the rule does not propose to provide compensation to ASCs for…the adoption and operation of the screening for the SDOH measures.”

Indeed, Ms. Newbury says some ASCs may find it more financially feasible to take the 2% hit to their rate update than to participate in the program as it currently stands.

ASCA and other organizations remain engaged in an ongoing dialogue with the CMS over ASCQR, Ms. Newbury says. Some would like to see the health equity measures removed or delayed until they can be revised and vetted in surgery centers.

“I want to emphasize that we feel adoption of the facility commitment to health equity and screening for social drivers of health and screen positive rate for social drivers of health measures should be delayed until the measures have been tested in the ASC setting,” says Vance Thompson, MD, president of ASCRS.

Ms. Newbury notes that ASCA anticipates at least part of the program “could be removed or at least delayed due to different priorities” of the Trump administration.

Proceed with Caution

In the meantime, ASC leaders are advised to take a cautious approach.

“Find good resources to learn about the measures and learn what is being asked of you,” says Ms. McElheny. “Educate yourself about what you’re being asked to do, and network with other ASCs to exchange ideas. You’ll find that you’re not functioning in a silo.”

Ms. Newbury strikes a similar tone, observing that many questions remain to be answered in the months ahead.

“When people call, I’m not telling them not to start looking into it, but we’re not necessarily encouraging them to start operationalizing those measures,” she says. “There are still a lot of discussions to be had and things to be worked out.” OM

For more information about SDOH, visit www.odphp.health.gov/healthy
people/objectives-and-data