Generally, the care you receive from your doctor is either inpatient or outpatient care. So how do you know which one you're getting? Sometimes, it's easy because the facility will have "outpatient" right in the name. But other times, it's not as clear.
Inpatient and outpatient care
It's important to know what kind of care you're getting because it affects how much you will have to pay. Outpatient services are by far much cheaper than inpatient services.
♦ Inpatient care refers to being admitted to the hospital. Having the care performed in the hospital and staying in the hospital to recover.
The hospital stay usually must be overnight to be called inpatient care.
♦ Receiving treatment in the hospital's emergency room and then being sent home would not be inpatient care. These charges will go against your plan's emergency room benefits.
There is a confusing gray area. It usually comes down to one question: were you admitted? If so, then you're an inpatient.
• To be admitted, your doctor has to write an order to admit you.
• If your doctor doesn't write an order, you're are usually considered an outpatient even if you stayed overnight.
Outpatient care may take place in a hospital but many procedures are now done in outpatient surgery centers that may or may not be affiliated with the hospital.
After the treatment, the patient is sent home to recover.
♦ Inpatient care is usually a more invasive procedure like complicated surgeries. Heart surgery and hip replacement are two examples.
Outpatient care can include surgery, but it is usually less invasive and requires less recovery time. Cataract and hernia surgery are examples.
Outpatient procedures could include testing such a MRI’s or biopsy tests. Procedures that are less invasive, less time consuming and have faster recovery times than inpatient procedures.
♦ Outpatient care is usually a fraction of the cost of inpatient care.
Many health insurance plans favor the use of outpatient facilities as a cost control method.
It is common to have a lower copay or a lower coinsurance for an outpatient facility compared to an inpatient setting.
If you have Medicare … the situation is less clear.
Are you a hospital inpatient or outpatient ?
Even if you stay in a hospital overnight, you might still be considered an outpatient.
♦ Your hospital status (whether the hospital considers you an inpatient or an outpatient ) affects how much you pay for hospital services like X-rays, drugs, and lab tests.
How your hospital stay is classified may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay.
♦ You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.
♦ You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.
• Observation services are hospital outpatient services given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged.
Observation services may be given in the emergency department or another area of the hospital.
• The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care.
• An inpatient admission is generally appropriate when you’re expected to need 2 or more days of medically necessary hospital care, but your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.
Outpatient Surgery Centers
Outpatient Surgery Centers are also called Ambulatory Surgery Centers. These are surgical facilities where patients can receive minor surgical procedures and testing that does not require an overnight stay in the hospital.
Over time, the types and complexity of surgical procedures have increased significantly. A lot has to do with improvements in techniques and technology.
Among the most common procedures performed at outpatient surgery centers are:
• Colonoscopy (27%)
• Upper gastrointestinal endoscopy (10%)
• Cataract surgery (10%)
• Pain management procedures (5%)
♦ The purpose of outpatient surgery is to keep medical costs down, as well as saving the patient time that would otherwise be wasted in the hospital. The cost savings is attractive especially for Medicare.
♦ Outpatient surgery has grown in popularity to the point where 55% of all surgical procedures are now done on an outpatient basis.
To add to the confusion, many outpatient surgeries are performed in a hospital setting. Just like the surgery centers the patient does not stay overnight. The procedure is billed as an outpatient procedure just like a surgical center would bill.
• Most standalone surgery centers involve physicians as owners.
However, more and more hospitals want to play in this market. To that end, hospitals are either establishing their own or purchasing surgery centers.
What this will do to the costs is not clear, yet. But markets with a dominate provider tend to result in higher costs for the patient.
Are outpatient surgery centers safe ?
Complications related to surgery occur less than 1% of the time in outpatient settings. However, in terms of patient safety, non-hospital settings are not as regulated as hospitals are.
Most outpatient surgery centers aren’t required to report infections or other complications, like hospitals are. This makes it difficult for the patient to compare facilities. To add to the confusion, states have different licensing requirements.
♦ The death of Joan Rivers during a common procedure performed at an outpatient surgery center brought a lot of attention to this question. Joan Rivers’ death has been classified by the medical examiner as a 'therapeutic complication.'
♦ A concern is that when a medical mistake is made and a patient's life is threatened, can it be addressed quickly and thoroughly enough given the level of staffing and equipment at a smaller center?
The patient has very little information available to decide these questions.
It is hoped that data being collected by the Centers for Medicare and Medicaid Services (CMS) will shed more light on this subject.
• The CMS is requiring ambulatory surgery centers that receive Medicare payments to document and report on a series of safety related issues.
They are also being asked to report on the use of safe surgery checklists.
A facility that fails to report can have its Medicare payment reduced. It is only a 2% potential loss if they don’t comply.
The CMS will publish the data and the public can then peak behind the curtain.