As medical technology advances, physicians are able to shift more procedures from outpatient to inpatient settings. However, hospital procedure prices can be prohibitive for patients, leading to a rise in the popularity of independent outpatient clinics and ambulatory surgery centers (ASCs). These outpatient centers offer patients lower costs and shorter wait times than traditional hospitals, and have caught the attention of federal and private payors.
In August, CMS proposed comprehensive joint replacement (CJR) coverage for total knee and hip replacement procedures at ASCs. The proposal would allow patients greater flexibility in choosing where to receive care, likely saving them time and money. This raises concerns for physicians and hospital executives: the proposal would be an incentive for patients to choose ASCs over hospital outpatient centers, leading to revenue loss. In addition, physicians are wary that some CJR procedures are unfit for the outpatient setting and could lead to more complications and longer recovery times.
Top 10 Outpatient Procedures by Volume (All-Payor)
|HCPCS Code||Description||Avg Payment/Claim|
|G0463||Hospital outpatient clinic visit||$74|
|85025||Complete cbc w/auto diff wbc||$9|
|80053||Comprehensive metabolic panel||$13|
|80048||Metabolic panel total (calcium)||$9|
|99283||Emergency dept visit (moderate severity)||$146|
|99284||Emergency dept visit (high severity)||$281|
Fig 1 Data from Definitive Healthcare
Anthem health care drew criticism in July over their new imaging policy. The payor announced that it would no longer cover CT or MRI scans at hospitals or hospital-owned outpatient clinics, forcing patients to use independent imaging centers or pay out of pocket. Mammograms and X-rays were not included under this policy change. The new program aims to provide Anthem customers with quality care at a lower cost, but could lead to greater frustration and complications for patients.
Now, when Anthem patients are referred to an imaging center for a nonemergency scan, they would have to leave the hospital where they are receiving treatment, find an independent imaging center, have their scans completed and read, and bring the scans back to their provider at the hospital. If the hospital and imaging center don’t have compatible computer systems, the patient would be responsible for bringing their scans to their doctor on a CD, increasing patient stress and chance for a data transmission error.
This extended process also leaves greater room for diagnostic error or oversight. The Spine Journal published a study in 2016 that found unnerving inconsistencies in result findings for one patient across 10 imaging centers. The study undermined the idea that all imaging studies provided by qualified professionals are comparable. Additionally, if there is any miscommunication or obscurity, hospital imaging centers may have to redo a scan, spending more money and effort than if the scan had been done in-house.
Top 10 Outpatient Procedures by Cost (All-Payor)
|HCPCS Code||Description||Avg Payment/Claim|
|J7201||Factor ix fc fusion recomb||$81,361|
|C1841||Retinal prosthetics int/ext comp||$65,244|
|J9600||Porfimer sodium injection||$46,149|
|61886||Implant neurostimulator arrays||$43,278|
|A9543||Y90 ibritumomab, rx||$41,660|
|C9136||Factor VIII (eloctate)||$40,922|
|63685||Insrt/redo spine n generator||$33,221|
|Q9975||Factor VIII FC Fusion Recomb||$32,761|
|Q2043||Sipuleucel-T auto CD54+||$30,911|
|33270||Ins/rep subq defibrillator||$29,762|
Fig 2 Data from Definitive Healthcare
Anthem’s decision could influence other private payors to make similar policy changes, leading to increased incentives to adopt fragmented care paths in order to reduce costs. Though it can be useful to seek multiple professional opinions for diagnoses and treatments, receiving care at multiple, disconnected locations can mean missed details and slower results for patients.
Independent outpatient centers can benefit patients seeking a quality, low-cost procedures and, in some cases, reduce hospital readmission rates. However, as CMS and the healthcare industry continue to emphasize and incentivize comprehensive, streamlined care, it may be best not to rely too heavily on independent centers if hospitals have all necessary resources. If the pattern of incorporating independent centers continues, payors could risk sacrificing integrated care for cost at the expense of patients.
Visit the Definitive Blog to read more about CMS programs and medical imaging centers.
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