For all it's done to advance the cause of ASCs, the ASC Association has fallen woefully short where it matters most: preserving and protecting what 5,208 U.S. surgical centers get paid to do cases faster than hospitals, at close to half the cost. Medicare ASC payment rates have sunk like a stone over the last 6 years, diving lower and lower as the number of ASCs and the number of cases they perform grow higher and higher. It hasn't been for lack of effort, but the numbers tell a disturbing story and point to an uncertain future:

• 2003. Medicare paid ASCs 86.5% of the rate it pays to hospital outpatient departments.
• 2009. A 6-year payment freeze and additional cuts reduced ASC payments to 59% of HOPDs' rates. Add to that the indignity of Medicare payments for the 10 most frequently performed ASC procedures all falling from last year to this year.
• 2014. ASCA President Kathy Bryant predicts that payment rates will dip below 50% of HOPDs' rates within 5 years unless Congress passes the ASC Access Act, legislation that would lock in ASC payments at the current 59% rate. Ms. Bryant apologized to hundreds of ASCA members when she dropped the 50-and-falling bombshell at last month's association conference in Nashville.

"It's incredibly frustrating," says Ms. Bryant of her years of strenuous objections, relentless lobbying and bar graphs showing the inequity and absurdity of it all. "More importantly, it's frustrating for the ASCs to provide high-quality care at a cheaper cost and to have to deal with CMS. Without legislation, we are in trouble. We'd like to see a higher percentage, but if we can stop the bleeding at 59%, we will have taken a significant step for the industry."

The idea that deeply discounting surgeries performed in ASCs would have the unintended consequence of forcing more outpatient surgeries into more expensive hospitals is just one of the many oddities in how the government pays ASCs. Here are 3 more, none of which CMS is required to do by statute, all of which would needlessly harm ASCs:

• CMS is adopting a "secondary rescaling" calculation that annually reduces ASC payments when volume increases at ASCs.
• CMS wants to update ASC payments by the Consumer Price Index, which represents economy-wide inflation, not by the market basket that every other Medicare provider receives.
• CMS is requiring ASCs to provide patients with information at least a day in advance of surgery, effectively sealing off same-day access to ASCs.

"ASCs have exactly the right message and they're doing all the right things and we still seem to get hit over the head every time we turn around," says Ms. Bryant. In that case: ASCs, put on your helmets and buckle your chin straps.