S. A. Brownlee1, D. Dai4, M. Soto4, N. Rosenthal6, E. J. Orav5, A. Frakt4,8,9, J. F. Figueroa4,5, T. C. Tsai2,3,4 1Massachusetts General Hospital, Boston, MA, USA 2Brigham And Women’s Hospital, Department Of Surgery, Boston, MA, USA 3Brigham And Women’s Hospital, Center For Surgery And Public Health, Boston, MA, USA 4Harvard School Of Public Health, Department Of Health Policy And Management, Boston, MA, USA 5Brigham And Women’s Hospital, Division Of General Internal Medicine And Primary Care, Boston, MA, USA 6Premier Inc, PINC AI Applied Sciences, Charlotte, NC, USA 7University Of Chicago, Department Of Surgery, Chicago, IL, USA 8VA Boston Healthcare System, Boston, MA, USA 9Boston University, School Of Public Health, Boston, MA, USA
Introduction: Performing inpatient procedures at lower-cost hospital outpatient and ambulatory surgical center facilities has emerged as a core strategy for value-based care and site of care optimization. However, the decision to perform a procedure in an outpatient or inpatient setting has been largely influenced by Medicare reimbursement policy. During the COVID-19 public health emergency, hospital capacity issues increased pressure to shift procedures out of inpatient centers, and Medicare suspended enforcement discretion to allow for greater flexibility in performing procedures on an outpatient basis. We used the pandemic as a natural experiment to assess the impact of Medicare’s inpatient only list on procedure shifting to the outpatient setting.
Methods: The PINC AI Healthcare Database was used to identify elective procedures performed by 723 hospitals nationally. Our cohort included nine procedures, two of which (hip and knee replacement) had been removed from the Medicare inpatient only list prior to the onset of the pandemic. A facility-fixed effects Poisson model was used to ascertain the relative change in procedures from the baseline year of 2019 to 2020 and to 2021 across all elective surgeries, and across inpatient and outpatient facilities. We also compared changes in adjusted monthly 30-day readmission risks using a patient-level multivariable linear probability model controlling for patient, procedure, and facility-level characteristics.
Results: We included 1,354,187 procedures. In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient procedural volume. The shift towards outpatient procedures was most pronounced for hip replacements where procedural volume increased by 589% in 2021 compared to 2019. The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement volume increased by 271% (95% CI, 241% to 304%) for White patients and 30% (95% CI, 24% to 35%) for Black patients compared to 2019 levels. Risk-adjusted probability of 30-day readmission among outpatient procedures changed by -0.20 percentage points (95% CI, -0.3 to -0.1 percentage points) from 2019 to 2021.
Conclusion: An accelerated shift from inpatient to outpatient elective surgeries occurred chiefly among orthopedic procedures removed from Medicare’s inpatient only list prior to the onset of the pandemic. Enforcement discretion by Medicare to allow for performing procedures on an outpatient basis had a limited effect in shifting care from an inpatient to outpatient setting. White patients had disproportionately higher utilization of outpatient orthopedic procedures compared to minority patients. The shift was not associated with higher readmission risks for outpatient procedures. Surgeons and policymakers should assess whether continued shifting of procedures to the outpatient setting will widen existing disparities.