2024 Promises a Rise in Outpatient Care
The tail end of 2023 saw a steady uptick in outpatient utilization, specifically elective cardiac and musculoskeletal (MSK) surgeries. While inpatient volumes are relatively stable and at-or-near pre-pandemic levels, a few large payers called out “increased outpatient activity” in earnings calls and other year-end activities. Industry commentary suggests that Medicare and Medicare Advantage members are driving the bulk of the increased utilization – seniors who are finally going in for the procedure they may have delayed during the pandemic. Rather than a quick blip or a rebalancing, Bank of America suggests increased outpatient volumes are “the new normal” and perhaps here to stay. So, what can payers and providers do to prepare? High-complexity surgeries will now be more accessible than ever, so what kinds of surgical outcomes can we expect in this shift?
Driving Factors in the Move to Ambulatory Settings
Advances in cardiac and musculosketal technology have coincided with an increased surgical volume in outpatient settings, like Ambulatory Surgery Centers (ASC’s). Becker’s ASC suggests that smaller devices mean smaller incisions sites – meaning quicker healing time and reduced risk for patients in same-day procedures rather than mutli-day hospital stays. It’s also no secret that Cardiac and MSK procedures bring in the highest and second-highest net revenue per case for payers, even in the outpatient setting, so it stands to reason that this uptick in utilization will stick around for a while. Adding to the sea change, CMS has approved reimbursement for total shoulder replacements and other orthopedic procedures at ASC’s –11 CPT codes in all to the ASC-approved list for 2024, including total ankle replacement, hip tendon incision, and meniscal knee replacement.
Are Outpatient Locations Really Appropriate for Cardiac and MSK Surgeries?
Research comparing outcomes between inpatient and outpatient settings for joint replacements and cardiovascular procedures supports the viability and safety of outpatient care. Not only do ambulatory patients experience shorter hospital stays and lower complication rates, but they also incur significantly lower costs. With projections estimating a substantial increase in joint replacement surgeries by 2030, transitioning a significant portion of these procedures to ambulatory settings could result in substantial cost savings for the healthcare system. Patients are getting wise to this trend, too, often finding that ASC’s offer surgeries at a lower cost and a lower-stress environment than a hospital.
How Can Payers Navigate this Shift?
For payers - medical policies that are current with today’s regulatory and utilization landscape, along with provider network visibility and data will be the keys to navigating the next evolution of healthcare. A condition management partner like TurningPoint offers evidence-based Clinical Policies for comprehensive Musculoskeletal and Cardiac Management. Our market differentiation begins with clinical expertise – a team that has held national leadership positions at the American Academy of Orthopedic Surgeons, North American Spine Society and the American College of Cardiology. That same team has extensive experience working to set national quality & safety standard and craft value-based care policy reform – and considers ASC’s when appropriate. We also work with our health plan partners to design meaningful financial incentives for providers that practice high-quality medicine. Optimizing site of care, like ASC’s, is one the many criteria we use in program design. Just because outpatient cardiac and MSK surgeries are more accessible than ever, it doesn’t always mean they are the most appropriate. There needs to be consistent patient safety and medical necessity protocols in place to ensure patients are receiving the right care, at the right time, in the right care setting.
To see the TurningPoint program in action, download our case study here.
