Pricing and insurance networks in outpatient surgery markets.

OBJECTIVE

To examine how site of care and insurance network contribute to price differences for common adult outpatient surgeries paid by commercial insurers.

STUDY

DESIGN

Observational study using a 50-state sample of commercial medical claims data.

METHODS

We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network).

RESULTS

Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities.

CONCLUSIONS

Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.