ASC leaders are becoming increasingly frustrated with the reimbursement disparity between hospital outpatient departments and surgery centers.
Here are 10 key considerations on HOPDs and ASCs:
1. Common medical procedures can cost as much as 58% more when they take place at HOPDs when compared to a physician office or ASC, according to an analysis by Blue Health Intelligence, the Blue Cross Blue Shield Association's data analytics company.
2. Colonoscopy screenings cost 32% more in a hospital than in an ASC, according to the Blue Cross Blue Shield analysis. Diagnostic colonoscopies cost 58% more and cataract surgery costs 56% more.
3. In February, lawmakers reintroduced legislation that aims to close reimbursement gaps between HOPDs and ASCs. The bill would permanently align CMS' update factors to move to a more complete alignment of the ASC and HOPD payment systems. The bill, which has bipartisan support, has remained stagnant in Congress.
4. In November, CMS finalized its extension of the interim period using the same pay update factor for ASCs and HOPDs through 2025. This means ASC payment rates will align with the the hospital market basket rate for the next two years
5. It is estimated that more than 80% of HOPD cardiovascular procedures could be allowed in ASCs from Medicare's covered procedure list inclusion, according to a report from Cardiovascular Business.
6. UnitedHealthcare's 2023 site-of-service policy, which went into effect April 1, stipulates that 1,041 codes for commercially insured patients and 167 codes for Medicare Advantage patients require pre-authorization for the surgery to be performed in an HOPD.
7. The average cost of a knee arthroscopy with cartilage removal at an ASC is $3,412, compared to $5,226 at an HOPD, according to data from Sidecar Health's care price calculator.
8. Many ASC leaders said this reimbursement disparity between ASCs and HOPDs is one of the biggest threats to ASC migration.
"Our costs are increasing, especially salaries and benefits, which need to be competitive with HOPDs and hospitals, yet reimbursements still sit at 50% of the HOPD rates," Andrew Weiss, administrator of Vorhees, N.J.-based Summit Surgical Center, told Becker's.
9. The most commonly performed ASC procedure is an extracapsular cataract removal with insertion of intraocular lens prosthesis, according to data from Sidecar Health's care price calculator. The average cash price of a cataract eye surgery is $2,733 at ASCs versus $3,995 at hospital outpatient departments.
10. Despite the cost-saving opportunities, HOPDs are still outpacing ASCs in the number of procedures performed, according to an analysis from Blue Health Intelligence. Here are counts for six procedures performed at ASCs versus HOPDs in the U.S. in 2022, according to Blue Health Intelligence:
Mammography
ASC: 1,086
HOPD: 3,069,370
Colonoscopy screening
ASC: 62,768
HOPD: 85,295
Diagnostic colonoscopy
ASC: 443,335
HOPD: 489,409
Cataract surgery
ASC: 110,372
HOPD: 41,312
Ear tympanostomy
ASC: 25,733
HOPD: 48,343
Clinic visit
ASC: 8,672
HOPD: 6,485,708