The government is getting out of the way of surgery site-of-service decisions, but some experts fear insurers could be stepping in.
In a recent article, ASC News examined the potential impact of the U.S. Centers for Medicare & Medicaid Services’ (CMS) plan to phase out the Medicare inpatient-only (IPO) list. Although the move has been applauded for reducing regulatory barriers for outpatient surgery, it has also raised concerns about payer pressure, administrative burden and patient safety.
To follow up, ASC News spoke with Dr. Thomas Tsai, a minimally invasive gastrointestinal and bariatric surgeon at Brigham and Women’s Hospital and a health policy professor at Harvard T.H. Chan School of Public Health. Dr. Tsai is also the American College of Surgeons’ inaugural medical director for health policy research, a role created in May 2025 to help the College support evidence-based policy as the health care landscape evolves.
Highlights from that conversation are below, edited for style, length and clarity.
ASC News: You are the American College of Surgeons’ first medical director for health policy research. What does this new role entail, and how does it shape the College’s engagement with federal policymakers?
Dr. Tsai: The vision really is to generate actionable evidence at pivotal moments to inform surgical delivery models that deliver excellent outcomes for our surgical patients. I think of myself as a bridge tender, connecting the academic world, clinical expertise, surgical registry programs like the ACS National Surgical Quality Improvement Program (NSQIP), and a policy perspective so we’re asking the right questions at the right time.
From that vantage point, how do you view CMS’ proposal to phase out the inpatient-only list?
As the goal of any clinician or surgeon is to practice evidence-based medicine, our goal is to practice evidence-based policy. The phaseout could have potential advantages in increasing access to outpatient surgery and helping the transition from hospitals to outpatient and ambulatory settings. But it can also have unintended consequences, including less visibility into quality of care outside the hospital. We’ve made two decades of progress in improving surgical quality on the inpatient side. The question from a research perspective is how we set up the studies and use data to monitor these changes as they’re happening.
Your JAMA Surgery editorial argues that eliminating the IPO list represents a departure from an incremental approach. Why does that distinction matter?
Surgeons historically have been very good at triaging patients who may be safe for inpatient versus outpatient settings. The real worry is not so much about the surgeon-patient relationship. The real worry is that you take a decision out of the surgeon and the patient’s hands, and then private insurance companies or Medicare Advantage plans will default coverage only to out-of-hospital settings, and require prior authorizations and potentially denials after the fact. … That turns it into an insurance algorithmic rule about where procedures should happen or should not happen.
CMS frames the policy shift as expanding flexibility and choice for surgeons. Do you agree with that framing?
I think that’s the intent of CMS. You could argue that CMS historically has been too conservative, that procedures should only be inpatient and then need specific evidence before they’re approved in outpatient or ASC settings. But the alternative, if you remove every procedure from the inpatient-only list, is that commercial insurance companies will make the default that they can only happen in the outpatient setting. That is what we are experiencing day to day as surgeons already.
Can you give a real-world example of that?
A month or so ago, a patient came into the emergency room with acute cholecystitis [gallbladder inflammation]. The patient was admitted to the medicine service because she needed antibiotics and had a lot of other medical issues — diabetes, high blood pressure — and needed a little bit more monitoring. We ultimately evaluated that she would benefit from gallbladder surgery. She was already an inpatient, so we performed the gallbladder surgery while she was in the hospital and she was able to leave the next day, which saved her from having to come back and see the surgeon and schedule a gallbladder surgery after finishing a course of antibiotics. We got a denial from the insurance company because they said gallbladder procedures should only happen as outpatient procedures. This patient was already an inpatient from the emergency room! This happens every day to surgeons and patients all across the country.
Are there certain patient populations where a push toward outpatient care warrants greater caution?
Patients with chronic diseases, patients with obesity, patients with more complex care needs, both medically and socially. Hospitals provide not just physiologic and medical recovery, but also a lot of the kind of nursing support that patients need to recover — services like physical therapy and dietitian services and consultation to other medical specialties, a chaplain. The worry is that there are just more hoops to jump through, because now you have to justify why you need an inpatient stay after a surgery where that was previously not questioned. … We need to make sure that what we’re doing is actually improving surgical care for patients.
You and your co-authors of the JAMA Surgery article point to increased administrative burden following prior IPO removals. What does that look like in practice?
We’re alluding to the increasing burnout physicians are facing around prior authorizations: … submitting the paperwork that’s involved, working with the insurance companies, and if there is a denial, appealing. It adds a lot of wasted time and effort that is not contributing to better care. It’s time that is not compensated — and that is really important — but it’s also taking time away from providing care to our patients.
Assuming CMS moves forward with the IPO phaseout, what should surgeons, health systems and ASC leaders be watching most closely?
We need more data. One, evidence on the administrative burden — are we seeing more denials. Two, what this means for access for patients — are patients not getting surgeries because they’re being denied on prior authorization? Three, we need evidence on the quality of care that is happening. We don’t have as robust clinical registries on the outcomes of surgeries that happen in the outpatient setting, and there’s likely significant variation in care across ASC settings and hospital outpatient settings. We need investments by CMS and regulators to observe outcomes as this shift is happening.
Could ACS help fill those data gaps, perhaps through quality programs like the ACS NSQIP?
The ACS NSQIP has historically been hospital-based, but there are opportunities to continue to evolve and reimagine what surgical quality improvement looks like as care moves out of the hospital into outpatient and ambulatory surgical settings. That will require new partnerships not just with hospitals, but also with ASCs and hospital outpatient departments.
