Is the ASC industry in need of an image makeover? Yes, and an extreme one at that, many would say.

"We're either not well known or, where we are well known, we're not well liked," says Marian Lowe, executive director of the ASC Advocacy Committee, a newly formed lobbying alliance of the ASC Association and 13 corporate partners that hopes to fix what she calls the industry's "brand-identity crisis" — the perception among federal policymakers that surgery centers are the leeches and lepers of the healthcare system, fly-by-night factories that siphon all the quick, easy and good-paying cases from 24/7/365 hospitals and pad the pockets of rogue surgeons who put profits above patients.

This, of course, is more myth than reality, the finely honed spin of the American Hospital Association, which, despite its legion of lobbyists and river of resources, has succeeded only slightly in slowing the migration of surgery into less expensive yet clinically appropriate settings (read: ASCs).

"Hospitals and their lobbyists portray ASCs as the bad guys to government and the public is relatively oblivious to this, even though the public really likes ASCs in terms of service, convenience and cost," says Bryan R. Smith, BSEE, MBA, vice president of operations at National Surgical Care in Roswell, Ga.

Where the AHA has succeeded is in giving ASCs a bad name and in generally making life miserable. Misery has taken many forms — attacks on physician ownership and an inequitable payment system are symptomatic of the growing reimbursement and regulatory pressures on an industry that is slowly but surely stripping hospitals of their most profitable service line: outpatient surgery.

"?"?"?

"The most important thing we can provide our industry is our advocacy," says one ASC facility manager. "If the hospitals' voice is louder, then ASCs' must be clearer."

"?"?"?

The sole purpose of the ASC Advocacy Commit-tee is federal advocacy, which many would argue is the ASC industry's most glaring deficiency. Steven Gunderson, DO, the CEO and medical director of the Rockford Ambulatory Surgery Center in Rockford, Ill., speaks for many when he says, "I am not certain we have the ability to compete against the strong lobby of the hospital industry."

Don't tell that to the strait-laced and studious Ms. Lowe, 33, a precocious and personable policy wonk who graduated high school a year early (yes, she's one of them) and mastered the arcane world of Medicare policy as a lobbyist for the now-defunct AAASC (American Association of Ambulatory Surgery Centers). Her mission is now as she described it nearly 5 years ago: "To both Congress and CMS, I help give voice and visibility to an industry that has tremendous potential to improve the lives of Medicare beneficiaries and save money for patients and the Medicare program."

Today, however, she adds the 2 R's: "My job is to ensure that ASCs are not constrained by government regulation and rate-setting." To do that, she says she'll focus on "telling a concise and compelling story about what ASCs bring to the healthcare delivery system."

Ms. Lowe is a partner at Strategic Health Care, a healthcare consulting firm in Washington, D.C. That she has been chosen to do the industry's most important and difficult work is hardly surprising. She once described herself like this: "Whether figuring out the nuance of a complex regulation or deciphering why my herb garden flourishes while my tomato plants languish, I never give up on a problem until the solution is in hand."

Ms. Lowe reasons that the meteoric rise and popularity of ASCs has left the industry exposed to criticism. "People look at ASCs and volume in silos," she says. "They see rapid volume growth as a bad thing instead of a sign of tremendous success. Part of it is physician ownership. Part of it is rapid growth. Both of those things for many in the policy community are red flags for the misalignment of the payment system."

The ASC Advocacy Committee is preparing to launch a public relations campaign aimed at policymakers on Capitol Hill, in the Obama administration, and with CMS, MedPAC and other important groups. It has retained Spectrum (www.spectrumscience.com), a communications agency that specializes in science and health, and 3 lobbyists.

"We have a job to do, and that's to make sure policymakers understand the benefits of ASCs," says John McManus, president of The McManus Group, one of the 3 lobbying firms working on ASCs' behalf. "First, we want to put the ASCs on more equal footing with hospitals in terms of payment updates and quality data that's reported. Second, we want to raise the profile of the industry as an important component in constraining healthcare costs and providing high-quality care."

Spectrum will create a Web site for policymakers that touts the positive influence of ASCs ("We will create a clear, concise message to communicate," says Ms. Lowe) and an internal communications portal ("a clearinghouse of resources") to help the industry coordinate its grassroots lobbying efforts.

"The PR campaign will be much more oriented toward changing policymakers' perceptions than the general public's," says Ms. Lowe. "These are the folks who have the power to create a more or less favorable environment for ASCs to operate in the Medicare space. These are the folks where the ASC story is not well understood."

Ms. Lowe is taking a favorable, forward-looking approach to her new duties, careful not to criticize who or what's gone before her.

"My role here is to do the best job possible to coordinate the efforts of a bevy of policy and regulatory professionals as well as PR and media experts, to craft the best message that communicates the ASC story as best we can, and coordinate the delivery of that message to the target audience — to the policymakers that have the power to improve the payment and the regulatory environment," she says.

"?"?"?

"We've been very happy being a mom-and-pop industry. Nobody touched us or did anything to us. We were below the radar. What we didn't know was that, all this time, the hospital association was painting us as greedy and not safe," says the president of a state ASC association who spoke on the condition of anonymity.

"?"?"?

There was hope, when the Federated Ambulatory Surgery Association and the American Association of Ambulatory Surgery Centers merged 2 years ago to form the Ambulatory Surgery Center Association, that a single group representing an industry in its adolescence would bring strength and unity to lobbying efforts. The numbers suggest that hasn't happened.

The ASC Association claims 2,500 members — well fewer than half (42%) of the 6,015 ASCs in the country. And 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. In 2000, there were 3,101 ASCs, about half as many as there are today. Today there are 300 more U.S. state-licensed or Medicare-certified ASCs than hospitals — 6,015 ASCs compared to 5,708 hospitals, according to Outpatient Surgery Magazine data.

Despite this critical mass, hospitals still perform more outpatient surgery than ASCs. Hospitals hosted 19.9 million outpatient surgeries in 2006 compared to 14.6 million for ASCs, according to 2006 data from the National Survey of Ambulatory Surgery. Sooner than later, however, it's inevitable that ASCs will host the lion's share of outpatient surgery.

It's not unlikely that ASCs will be reimbursed half of what hospitals are paid for hosting the same surgery. 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.

Despite being "more friendly, more efficient and more cost-effective," as Dr. Gunderson puts it, ASCs are up against it when it comes to changing their unfavorable perception with lawmakers, CMS, the administration and MedPAC. Yes, physicians, patients and payors clearly prefer surgery centers for their efficiency, safety, convenience and economy. And yes, ASCs have a great story to tell. But they are seemingly powerless to tell it.

"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.

There's a growing sense that those inside the ASC industry have grown tired of this woe-is-me loser's lament. "The ASC Association does a really good job with what they have to work with, but the ASCs themselves need to get involved and not stand idly by waiting for someone to do it for them. We need to get our congressional delegations to visit and to make our own case on a local level," says Stuart Katz, FACHE, CASC, the executive director of the Tucson Orthopaedic Surgery Center in Tucson, Ariz. "The ASCs need to decide what they want to be when they grow up and put up the funds necessary to wage the war."