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Outpatient Facility Coding Alert

HOPD/ASC Trends:

Understand How Your Patient Demographics Affect Your Services, Payment

Burdensome HDHPs, migrating physicians—and more—in 2 national studies.

Taking a macro view—rather than a micro view—of who’s using your hospital outpatient department or ambulatory (free-standing) surgery center and for what services is a great way to gauge how you measure up compared to other centers, help you understand more about your patients and their needs, and could serve as useful market research as you think about budgeting and growth.

In 2011, the focus year of a recently-released study, there were 125.7 million patient visits to outpatient departments in the US, with the highest number of patients in the 45-64 age range, according to the Centers for Disease Control and Prevention’s National Hospital Ambulatory Medical Care Survey Factsheet. HOPDs saw more females than males, more African-Americans than Caucasians.

The largest percentage of patients paid with private insurance (39 percent), says the CDC study. The rest used:

  • Medicaid or Children's Health Insurance Program (35 percent);
  • Medicare (20 percent);
  • No insurance (7 percent);
  • Other (7 percent); and
  • Unknown (5 percent)

How HDHPs Affect Your Numbers

The reality of high deductible health plans (HDHPs) means your private pay patients, who comprise your biggest demographic according to the CDC study, are more financially pressured than ever.

The percentage of workers who have HDHP coverage is trending upward, from 10.0 percent in 2006 to 46.0 percent in 2015, according to VMG Health’s Multi-Specialty 2016 Intellimarker, an annual ASC financial and operational benchmarking study. Your patients with HDHPs will likely have minimum deductibles of $1,250 for single coverage and $2,500 for family coverage they have to meet before insurance coverage takes effect,” the study says.

And this means that patient expectations will be higher, given the larger out-of-pocket expenses they’ll have to pay, the VMG Health report indicates.

You could also see a drop in your patient numbers and a sharp rise toward the end of the year, since those with HDHPs are delaying care until their deductibles are met, the study projects.

Tip: Preparing for extra staffing to accommodate extra volume in the last quarter of the year makes sense, given this trend.

“In addition, ensure your financial services representatives are adequately trained in collecting for HDHPs,” Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C, recommends.  

Your Clinic Services Will Increase

While post-op visits (3.3 million) rank third in the list of reasons for visits, overwhelmingly, patients visited HOPDs for physician-practice/clinic services, the CDC study shows. Here’s a snapshot of why they came in:

Progress visit (16.7 million); general medical examination (7.7 million); postoperative visit (3.3 million) medication (2.7 million); counseling (2.7 million); cough (2.6 million); prenatal examination (2.4 million); diabetes mellitus (2.3 million); throat symptoms (2.1 million); well-baby examination (1.9 million).

HOPDs and ASCs are seeing a rise in demand for the types of services that physician practices would have provided in the past for a variety of reasons, including cost factors and shifting office space, observes Goodman.

Physician migration: One reality is the decline in private practice physicians who are increasingly migrating to large health systems, according to VMG Health’s study. And the stats are dramatic: The percentage of physicians in private practice was 57.0 percent in 2000 and dropped to approximately 37.0 percent in 2013, the study indicates. And the downward trend continues, with the projected number at 33.0 percent in 2016.

Editor’s note: Watch for more trend reporting and practice management advice based on those trends in future issues of Outpatient Facility Coding Alert.

Resources: To read the CDC’s report, see https://www.cdc.gov/nchs/ahcd/.

To receive a copy of the VMG Health study, fill out the form at http://vmghealth.com/publications/intellimarker/.