Need to get a colonoscopy or a mammogram? The procedure could cost you—and your insurer—more depending on where it takes place.
A new report found that common medical procedures can cost up to 60% more when they occur in an hospital outpatient department (HOPD) setting instead of at a doctor’s office.
The Blue Cross Blue Shield Association (BCBSA) analysis of insurance claims data for six common outpatient procedures—mammograms, colonoscopy screenings, diagnostic colonoscopies, cataract surgeries, ear tympanostomies (ear tubes), and clinical visits—found that HOPDs charged more for the same services, with prices increasing faster than physician offices and ambulatory surgery centers.
The report partially attributes the high costs to more hospitals acquiring physician practices over the last two decades. The consolidations have contributed to higher payment rates in provider contracts and higher commercial insurance premiums. Providers can also bill Medicare more for care delivered in HOPDs, including facility and physician fees.
The findings
Diagnostic colonoscopies cost 58% more when performed in an HOPD versus an ambulatory surgery center, and come out to be more than double the cost compared to a doctor’s office, according to the analysis. Colonoscopy screenings cost 32% more in an HOPD than in an ambulatory surgery center—and they cost twice as much as in a doctor’s office.
The report further found that cataract surgery cost 56% more in an HOPD than in an ambulatory surgery center; mammograms cost 32% more in an HOPD than in a doctor’s office; and ear tympanostomies were 52% more expensive in an HOPD versus an ambulatory surgery center. Even clinical visits were 31% more expensive in an HOPD setting than in a doctor’s office.
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Researchers noted that the findings—which are based on claims covering 133 million Blue Cross Blue Shield members from 2017 to 2022—are consistent with studies released in 2021 and 2016.
Policy implications
David Merritt, BCBSA’s SVP of policy and advocacy, added that the analysis underscores the savings that could come from implementing site-neutral payment policies. He pointed to a January BCBSA analysis suggesting that federal site-neutral legislation could lead to just over $470 billion in savings over 10 years.
“The cost of a procedure shouldn’t be determined by the setting where the care is delivered,” Merritt said in a statement. “Lowering the cost of care, regardless of the site, is common sense.”
The federation of 34 Blue Cross and Blue Shield companies, which together cover about one in three people in the US, has backed federal bills—i.e., the Facilitating Accountability in Reimbursements Act (FAIR) Act and Site-based Invoicing and Transparency Enhancement (SITE) Act—that would overhaul hospital billing policies.
BCBSA in January released a set of proposals that the association argued could reduce healthcare costs by $767 billion over 10 years. The suggestions included expanded site-neutral payments for outpatient services, among other things. Site-neutral payments for Medicare took effect in 2017, but researchers noted that “little is known about price trends for outpatient services in the commercial insurance sector.”