How do the prices of 7 common procedures vary by site of care? 5 insights


Price differentials by site of care for common procedures exist at the national level, and are increasing over time, according to a study published in the American Journal of Managed Care.

The study, which evaluated the prices for seven common services from different clinical categories, found that for individuals with employer-sponsored insurance, prices for services performed at hospital outpatient departments were higher than prices for the same services at other care centers, such as physician offices and ambulatory surgical centers, between 2008 and 2013.

Researchers analyzed 2008 to 2013 claims data from Truven Health MarketScan Commercial Claims and Encounters Database, which contain administrative data for 44 million to 53 million individuals covered by employer-sponsored health insurance.

Here are five key findings from the report.

1. Researchers chose the following CPT codes to analyze across different sites of care: 99213 (office visit, established patient, 15 minutes) and 99215 (office visit, established patient, 40 minutes) for office visits; 70450 (computed tomography scan), 72148 (magnetic resonance imaging ), and 71020 (chest radiography) for imaging services; and, for procedures, 43239 (upper gastrointestinal endoscopy) and 45378 (colonoscopy).

2. The average prices for the seven common services at HOPDs were two to three times more than average prices at POs for the same service, while patient morbidity rates were similar across all sites of care.

3. The study revealed that price differentials by site of care increased over time. Between 2008 and 2013, the price differential index increased by 10 percent for office visits, 15 percent for procedures and 17 percent for imaging services. It also showed the price differential for some services rose more rapidly than others. For instance, the price differential of chest radiography increased by 20 percent from 2008 to 2013, while the price differential for a CT scan of a head remained relatively stable.

4. Across insurance product type — including HMOs, PPOs and consumer-directed health plans — on average, individuals paid between 1.06 and 2.94 times more for care at a HOPD than they would at a PO for the same service. 

5. While the vast majority of office visits occurred in a PO, researchers noted a shift in the volume of office visits to HOPDs, increasing from 5 percent of visits in 2008 to 8 percent in 2013. More people also sought imaging services in an HOPD between 2008, with the biggest shift occurring for MRIs, where the proportion of visits in HOPDs increased from 32 percent in 2008 to 37 percent in 2013.

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