Shift to ambulatory care centers seen lowering costs, improving outcomes

Injured workers who need surgery are increasingly going to ambulatory surgical centers instead of hospitals for treatment as experts say that such procedures can produce better, less expensive outcomes with fewer complications for most patients.

“The ambulatory care centers are a cost-effective way to manage certain types of surgeries,” said Andrea Buhl, Jersey City, New Jersey-based senior vice president of clinically integrated medical programs for Sedgwick Claims Management Services Inc.

The centers are known in the industry as medical facilities that can provide same-day surgical care and are specialized in certain types of procedures — at a fraction of what hospitals charge in some instances. For workers compensation patients, knee, shoulder and back surgeries are common examples, according to the Workers Compensation Research Institute, which has confirmed the trend in recent reports.

Specifically, the Cambridge, Massachusetts-based institute found that care in the nonhospital setting is typically 40% less expensive than that at hospitals and highlighted an overall shift away from hospital care in workers comp systems across 18 states, with most patients receiving care at less-expensive ambulatory surgical centers and other nonhospital settings, according to the report issued Nov. 16.

Using data from 2002 to 2016, virtually all study states saw a downturn in the percentage of claims with both hospital services, according to Rebecca Yang, a senior public policy analyst with the institute who spoke about her research during a webinar Thursday. Her data showed declines of up to 3%.

“Part of the shift follows the trend in general health care and part of it might be influenced by states,” which have enacted workers comp medical payment reforms, Ms. Yang said during the webinar.

With more group health plans being high-deductible plans, health care consumers are generally seeking less expensive treatment options, said Joe Vonderhaar, Cincinnati, Ohio-based senior vice president in the national healthcare practice for Valhalla, New York-based USI Insurance Service Services LLC.

The surgical centers often “bundle” services so that a patient can see the same doctor from diagnosis to physical therapy and the patient and insurer can see a price tag, he said.

“You can get an all-in cost from soup to nuts of your injury,” he said.

This shift to nonhospital settings is also attractive to payers and providers working with another trend in workers comp: fee schedules. 

That several states such as California and North Carolina have introduced medical fee schedule changes in recent years is also fueling the shift, as payers are rethinking the more-expensive hospital care as a first resort, according to Ms. Yang.

WCRI researchers also found that in 2016, 14 of the study states saw payments for knee surgeries done at surgical centers at least 21% lower than that performed in the hospital outpatient setting, according to a batch of reports released in November. In 11 of the study states, payments for shoulder surgeries done at surgical centers were at least 10% lower than payments for hospital outpatient surgeries in 2016, according to the findings.

For this “surgery centers are the popular model,” said Mr. Vonderhaar.

Overall, rising health care costs are a factor, according to William Prentice, chief executive officer of the Alexandria, Virginia-based Ambulatory Surgery Center Association.

“As health care costs continue to rise, more insurers, employers and patients are questioning the amounts they are paying for that care and seeking lower cost providers that won’t force them to compromise on quality,” Mr. Prentice wrote in an email to Business Insurance. “(Ambulatory surgical centers) provide the outstanding patient experience and high-value care that consumers are looking for.”

Outcomes are another driving force: highly-specialized centers can often provide better service without the problems that arise in a hospital setting, according to Mr. Vonderhaar, who noted that fewer infections are reported at surgery centers.

“One of the key reasons is (there is) not a patient mix of the sick patients, (who) have an illness that can spread, coming in and sitting next to the person (who) is getting an orthopedic surgery,” he said.

The U.S. Centers for Disease Control and Prevention reports one in 31 hospital patients has at least one health care-associated infection every day.

Because of fewer infections, patient satisfaction can be higher at a surgical center, said Ms. Buhl. “This trend definitely will continue; people are still able to have good outcomes at a lower cost,” she said.

One area to manage are comorbidities and others who are at-risk for complications during surgery, she added.

“When you get into invasive or multilevel (surgery), or someone with a pre-existing cardiac condition, you want to monitor them more post-op,” she said.

But hospital settings are often the better choice for some patients who might require overnight care or monitoring, she added. “They may require a higher level of nursing care post-op.”  

Patients with heart issues or those who are overweight may require more post-op care, according to Ms. Buhl.