DISTINCTIVE FEE-FOR-SERVICE PATIENT POPULATIONS
Patients typically have two choices for outpatient surgical care: ASCs or HOPDs. Both are very capable of performing successful surgeries. However, according to the report released by AHA, Medicare fee-for-service beneficiaries at HOPDs:
- Have higher emergency department utilization.
- Have higher prior acute care hospital use.
- May require a greater level of care due to higher complexity.
- Are 1.8 times more likely to be under 65 years of age.
- Are 1.4 times more likely to be 85 years old or older.
The AHA suggests HOPDs have more comprehensive licensing, accreditation and regulatory requirements than freestanding physician offices and ASCs, and therefore require higher reimbursements.
DIFFERENT MEASURES LEAD TO DIFFERENT CMS REIMBURSEMENT RATES
The AHA says hospitals receive sicker patients by design—doctors send patients with the poorest health to HOPDs.
“America’s hospitals and health systems provide around-the-clock care to all who come to us; this includes the sickest patients and those in the most vulnerable communities,” says AHA President and CEO Rick Pollack in a news release. “Physicians tend to refer more complex patients to hospital outpatient departments for safety reasons, as hospitals are better equipped to handle complications and emergencies. Proposals that treat hospital outpatient departments the same as ambulatory surgical centers and other sites of care are misguided, and ignore the health care needs of the patients and communities we serve.”
ASCs perform more than 7 million procedures for Medicare beneficiaries annually, according to an article in Becker’s ASC Review. The article points out that CMS determines reimbursement rates for HOPDS and ASCs using different measures of inflation, which results in significant cost differences. For example, Medicare reimburses hospitals $1,745 for outpatient cataract surgery procedures, while ASCs receive $976 for the same surgery.
“In a fee-for-services world, hospitals received an 81% higher reimbursement rate on services performed in the HOPD over those in an ASC,” says Regent CEO Chris Bishop in the Becker article. “But those days are going fast. As health systems move toward deriving greater percentages of revenue from value-based care, the potential for higher reimbursement in an HOPD is outweighed by the advantages of leveraging a broader ambulatory platform.”