Affiliation models play a major role in whether procedures are performed in higher-cost hospital outpatient departments for lower-cost settings like ASCs and office-based settings, according to a study published in Journal of Market Access and Health Policy.
The study analyzed 32 high-volume CPT codes across cardiology, gastroenterology, orthopedics and urology.
Here are 10 things to know from the study:
1. As of 2022, 41% to 52% of physicians were hospital-affiliated, 23% corporate-affiliated and fewer than 4% worked in PE-backed management services organizations.
2. Hospital-affiliated physicians were least likely to use lower-cost settings, while PE-affiliated physicians were most likely to shift cases to ASCs or office-based sites.
3. The facility fee, rather than professional fees, is the largest driver of higher HOPD costs.
4. Between 2001 and 2021, facility fees grew 60% (2.4% year-over-year) compared to just 11% growth (0.5% year-over-year) for professional fees.
5. ASC payments are about 42% lower than HOPD payments for the same procedure.
6. Across specialties, HOPD reimbursement ranged from 124% to 861% of ASC/office rates for Medicare and 111% to 1,346% for commercial payers.
7. Commercial insurance consistently paid more than Medicare, and the HOPD vs. ASC/office dollar gap was larger in commercial markets.
8. Echocardiogram (CPT 93306):
- Medicare: HOPD $593 vs. office $196 (303% higher)
- Commercial: HOPD $1,100 vs. office $377 (292% higher)
9. Colonoscopy with lesion removal (CPT 45385):
- Medicare: HOPD $1,373 vs. ASC $860 (160% higher)
- Commercial: HOPD $3,428 vs. ASC $1,080 (219% higher)
10. In cardiology, PE physicians used lower-cost sites in 72% of cases compared to 34% for hospital-affiliated. In gastroenterology, PE physicians used the lower-cost sites in 62% compared to 26% for hospital-affiliated.
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