17 things to know about hospital outpatient services & HOPDs

Physicians and surgeons are able to perform more procedures in outpatient settings today than ever before due to technological advancements and new pain management techniques. The focus on value-based healthcare has also encouraged the move from inpatient to outpatient settings for appropriate procedures because there is a reduced risk of infection at outpatient facilities and the overall cost of care is lower.

Here are 17 things to know about hospital outpatient services and HOPDs.

1. Medicare paid for 200 million outpatient service visits at hospitals in 2015, compared to 10 million inpatient admissions. For all outpatient care, Medicare paid around $58 billion, compared to $112 billion for inpatient care in 2015.1

2. Medicare increased outpatient payments by around $4 billion — a 7 percent increase — between 2014 and 2015 due to volume increases, price increases and shifting services from lower cost physician offices to higher cost hospital outpatient settings.

3. Outpatient services volume increased by 2.2 percent from 2014 to 2015, while inpatient service volume increased 0.4 percent over the same time period.

4. Last year, six hospitals converted to stand-alone emergency departments and outpatient centers, and four other hospitals that previously included inpatient services became outpatient-only facilities without ED services.

5. The share of outpatient revenue for hospitals increased over the past half-decade. In 2010, 21 percent of hospitals' Medicare revenue was from outpatient care; in 2015, it grew to 28 percent. At the same time, the share of Medicare revenue from inpatient care decreased from 71 percent in 2010 to 60 percent in 2015.

6. Medicaid beneficiaries made up 21.6 percent of Medicare patients treated at HOPDs and 13.3 percent of Medicare patients treated at ASCs in 2015.

7. The majority (83.2 percent) of Medicare patients treated in HOPDs in 2015 were, while 10 percent of the patients were African American and 6.5 percent were another ethnicity or race.

8. Among the Medicare patients treated at HOPDs, 70.7 percent were between the ages of 65 and 84 years old.

9. Patients receiving care at HOPDs were more medically complex than those receiving care at ASCs, according to the risk scores from the CMS-hierarchical conditions category. Patients at HOPDs had average risk scores of 1.57 in 2014, compared with 1.13 for ASC patients.

10. Medicare's rates for HOPD reimbursement are 85 percent higher than reimbursement for ASCs in 2017.

11. There were 3,360 Medicare certified HOPDs as of December 2012, based on the most recent data available.2

12. In 2014, the top 10 hospital outpatient procedures by volume among Medicare patients, excluding procedures that don't receive Medicare reimbursement in ASCs, were3:

• Subcutaneous tissue debridement: 841,517
• Esophagogastroduodenoscopy with biopsy: 628,900
• Aspiration/injection of a joint: 578,407
• Cataract surgery with IOL implant: 512,191
• Colonoscopy and biopsy: 472,886
• Colonoscopy with lesion removal: 350,001
• Spine epidural injection lumbar, sacral: 326,956
• Insertion of temporary bladder catheter: 308,614
• Application of multi-layer venous wound compression system: 303,026
• Diagnostic colonoscopy: 253,350

13. The states with the most outpatient hospital visits per 1,000 people in 2015 were4:

• Maine: 5,418
• Vermont: 5,049
• District of Columbia: 4,099
• New Hampshire: 4,062
• West Virginia: 4,054
• Missouri: 3,807
• Michigan: 3,600
• Iowa: 3,541
• Montana: 3,535
• Idaho: 3,514

14. The states with the fewest outpatient hospital visits per 1,000 people in 2015 were:

• Nevada: 1,045
• Arizona: 1,293
• Florida: 1,293
• California: 1,462
• Texas: 1,523
• Maryland: 1,569
• Oklahoma: 1,581
• Colorado: 1,617
• Georgia: 1,639
• South Carolina: 1,688

15. Blue Cross Blue Shield Association released a study in February 2016 comparing costs of inpatient and outpatient procedures. The study covered four common procedures and found consumers save when those procedures are performed in the outpatient setting:

• Angioplasties: Patients saved $1,062 on average in 2014
• Gallbladder removals: Patients saved $924
• Hysterectomies: Patients saved $483
• Lumbar spine surgeries: Patients saved $320

16. Between 2010 and 2014, the three of the four procedures Blue Cross Blue Shield Association studied reported a shift toward the outpatient setting. While the 80 percent of gallbladder removal procedures performed outpatient in 2010 remained consistent in 2014, here is the breakdown for the other three procedures:

• Angioplasties: 43 percent were outpatient in 2010; 50 percent were outpatient in 2014
• Hysterectomies: 36 percent were outpatient in 2010; 64 percent were outpatient in 2014
• Lumbar spine surgeries: 61 percent were outpatient in 2010; 82 percent were outpatient in 2014

17. The Medicare payment structure for HOPDs has changed over the past few years. President Barack Obama signed the Bipartisan Budget Act of 2015, which stipulates off-campus provider-based sites that began billing under the Outpatient Prospective Payment System on or after Nov. 2, 2015 won't be paid for most services under OPPS after Jan. 1, 2017. The facilities are now paid under the Physician Fee Schedule unless services are provided in a dedicated emergency department, which will still be paid under the OPPS.

However, last year there were revisions to the Act addressing facilities that were in the planning phases when the bill was signed to exempt them for the site-neutral payments. Hospitals must have had a binding written agreement for the construction of the off-campus site before Nov. 2, 2015, and then submitted the required attestation and certification to its Medicare Administrative Contractor by Feb. 13, 2017, to receive the exemption.

1. MedPAC: "Report to the Congress: Medicare Payment Policy." March 2017

2. CMS: "Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS)." Aug. 9, 2016

3. Definitive Healthcare: "Top 10 Outpatient Procedures at ASCs and Hospitals."

3. The Henry J. Kaiser Family Foundation: "Hospital Outpatient Visits per 1,000 Population by Ownership Type." 2015

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