Image by Gerd Altmann from PixabayOutpatient surgeries at ambulatory surgery centers (ASCs) are more cost-efficient than those at hospital outpatient departments (HOPDs).
That’s according to a study recently published in the American Journal of Managed Care.
Outpatient surgery remains a sizable and expanding sector in the U.S. Between 2017 and 2021, per-capita spending on outpatient facilities for commercially insured individuals rose by 19%, according to the Health Care Cost Institute.
This trend is likely to persist, especially as the Centers for Medicare & Medicaid Services (CMS) seeks to eliminate more procedures from Medicare’s inpatient-only list.
Performing surgeries at ASCs rather than HOPDs reduces costs for insurers and consumers, as ASCs often charge up to 50% less than HOPDs. The primary reason, according to researchers, is the disparity in facility fees between the two settings.
Researchers noted that previous studies found that performing more cases at ASCs rather than HOPDs led to lower medical spending without a loss of quality and with improved patient results. Because of this, many health plans have created programs directing members to ASCs for care.
For example, the Massachusetts Group Insurance Commission and the Minnesota State Employee Group Insurance Program use tiered networks to direct patients to lower-priced providers, according to the study. Related programs use financial rewards to incentivize the use of lower-cost providers.
“A limitation of these programs is that they may leave some providers out of their networks, potentially exposing patients to high costs,” the authors noted.
The study examined how the site of care and insurance network affect price differences for common adult outpatient surgeries covered by commercial insurers, based on a 50-state sample of medical claims data.
Researchers compared insurer-paid amounts, patient out-of-pocket costs and balance billing for four common outpatient surgeries — arthroscopy, cataract surgery, colonoscopy and upper gastrointestinal procedures — based on site of care and insurance network status. They found that patients saved money by choosing in-network facilities regardless of the care location, while insurers benefited from increased use of ASCs.
Prices were substantially higher for procedures at out-of-network ASCs and in-network HOPDs compared to an in-network ASC — $886 and $ 1,227 more, respectively. Procedures at out-of-network HOPDs were $1576 more than at an in-network ASC.
Regarding charges, in-network HOPDs billed $1,194 more than in-network ASCs. Out-of-network facilities billed significantly higher amounts than in-network facilities. Specifically, out-of-network ASCs and HOPDs charged $2,385 and $3,540 more than in-network ASCs, respectively.
Researchers found that insurers paid 32% more to an out-of-network ASC, $306 more to an in-network HOPD and $1,041 more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, and both had lower cost-sharing rates than out-of-network facilities.
Estimated differences in price and payments for all procedures.
Findings suggest that insurers and plan sponsors can lower health care costs by offering greater incentives for patients to seek care in ASCs instead of HOPDs.
“If insurers pass part of the savings from using ASCs on to patients, patients will be better incentivized to use ASCs,” researchers wrote. “Meanwhile, insurers and plan sponsors could also benefit from the increased use of ASCs.”
Overall, the study concluded that patients lowered costs by choosing in-network facilities regardless of the care site. At the same time, insurers saved money by increasing the use of ASCs for common adult outpatient surgeries covered by commercial insurers.
Additionally, researchers found that insurance models that better align patient and insurer incentives could encourage greater ASC use and decrease total outpatient surgery costs.
“The most straightforward strategy is to include more ASCs in provider networks and lower patients’ cost share for ASCs,” researchers recommended. “Therefore, patients will have a higher willingness to go to the lowest-cost option – in-network ASCs.”
