Search Results

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Using April 2025 Transparency in Coverage data, the researchers examine how negotiated allowed amounts for common cardiology services vary across four major commercial insurers. They find greater variation in facility fees than in professional fees for cardiology services, as well as significant differences in negotiated facility prices across payers. The researchers also find substantial variation in median professional and facility fee rates across states for coronary angiography.

Topic Areas: Payment Differentials, Vertical Integration, Facility Fees

Publisher/Organization: Yale Health Care Affordability Lab

Payer: N/A

Summary: The review explores literature on hospital acquisition of physician practices, largely finding that consolidation leads to higher health care prices and spending. On average, acquiring hospitals increase their prices by 3–5%, while acquired physician practices increase their prices by 14–15%. The researchers identify site-of-service payment differentials, in addition to reduced competition, as key drivers of these price increases. The evidence also does not show that hospital-physician integration leads to improvements in quality.

Topic Areas: Vertical Integration, Payment Differentials

Publisher/Organization: Center on Health Insurance Reforms

Payer: Commercial Insurance

Summary: The resource highlights that the same services are often more expensive in hospital outpatient departments (HOPDs) than independent provider offices. Outpatient facility fees and rising hospital prices driven by the increasing market power of consolidated health systems contribute to higher payments for HOPDs. To address this, the resource covers 16 decision points across four domains to help policymakers develop a policy solution that best fits their local needs, circumstances, and priorities.

Topic Areas: Vertical Integration, Payment Differentials, Policy Reforms, Site-Neutrality, Facility Fees

Publisher/Organization: N/A

Payer: Medicare, Commercial Insurance

Summary: Using 2013-2021 Medicare claims and 2015-2018 commercial claims, the study evaluates Optum’s acquisition of physician practices and ambulatory surgery centers (ASCs). It finds no meaningful change in referrals from hospital outpatient departments to ASCs in Medicare after acquisitions. Instead, Optum acquired practices that already had high ASC use, consistent with strategic selection. In commercial markets, prices at acquired ASCs rose by 11%, driven by higher facility fees and increased professional fees for Optum-employed physicians.

Topic Areas: Facility Fees, Vertical Integration, Payment Differentials

Publisher/Organization: Progressive Policy Institute

Payer: Commercial Insurance, Medicare

Summary: This report reviews the impact of hospital-physician integration on prices across Medicare and commercial markets. Examining 70 economic studies, the authors find hospital acquisitions of physician practices are consistently associated with higher prices and increased spending, with average price increases of about 14%. Approximately 45% of the price increases are linked to site-of-service payment differentials, as hospitals can bill higher rates in outpatient settings than in physician practices. Evidence on utilization and quality are mixed. The report identifies site-neutral payment reform as a key strategy to reduce financial incentives for vertical integration, limit price inflation, and curb shifts toward higher-cost care settings.

Topic Areas: Vertical Integration, Site-Neutrality, Payment Differentials

Publisher/Organization: Center on Health Insurance Reforms

Payer: Commercial Insurance

Summary: The blog explains how facility fees result in unexpected out-of-pocket costs for consumers with commercial insurance receiving routine care, including checkups, lab tests, and outpatient visits. High deductibles and complex benefit designs leave many patients particularly exposed to these fees. The researchers highlight that hospital acquisitions of physician practices and payment differences between hospital and non-hospital settings contribute to the growth of facility fees and higher overall costs. The blog also discusses state policy responses aiming to limit patient cost-sharing, prohibit certain facility fees, and improve transparency to help consumers better understand and compare prices.

Topic Areas: Facility Fees, Payment Differentials, Policy Reforms

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Using 2024 Transparency in Coverage data for three commercial insurers, researchers compare payments for thirteen common procedures across settings. Overall, commercial prices were $1,489 (78%) higher in hospital outpatient departments (HOPDs) than in ambulatory surgical centers (ASCs). However, site payment differentials varied substantially across payers. Cigna had the lowest differentials between HOPDs and ASCs ($327), and UnitedHealthcare had the highest ($1,673). Cigna achieved lower price differentials through provider selection, contracting with only 14% of HOPDs in applicable markets compared with an average of 76% for United and Blue Cross Blue Shield. If United and Blue Cross Blue Shield paid Cigna’s average HOPD rates for the procedures, they would save about $1.4 billion per year together. The results suggest that payers can reduce site differentials through provider selection. They also imply that larger insurers with broader networks may continue to reimburse sites differently in the absence of either government action or a shift in market dynamics.

Topic Areas: Payment Differentials

Publisher/Organization: Health Care Cost Institute

Payer: Commercial Insurance, Medicare

Summary: Using 2018-2022 data from patients with commercial insurance, Medicare fee-for-service, and Medicare Advantage, researchers examine whether hospital participation in the 340B program was associated with shifts in site of care, payments, and patient out-of-pocket costs for commonly used physician-administered drugs for blood cancers and autoimmune diseases. Authors found that site of care for physician-administered drugs increasingly shifted from physician offices to hospital outpatient departments, with faster growth at 340B hospitals than non-340B hospitals. Additionally, 340B hospitals received higher reimbursement rates for commercial insurance patients receiving blood-cancer physician-administered drugs, resulting in higher patient out-of-pocket costs.

Topic Areas: Payment Differentials

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Using 2023 Transparency in Coverage data on commercial negotiated rates, researchers examine specialist practice affiliation and its relationship to prices for cardiology and gastroenterology services. They find that hospitals employed about 72% of cardiologists and 57% of gastroenterologists, while private equity entities employed a smaller share of specialists who tended to be concentrated in certain regions. Hospital-affiliated specialists negotiated prices that were 16.3% higher for cardiology procedures and 20.7% higher for gastroenterology procedures than specialists in independent practices. Private equity-affiliated specialists also negotiated higher prices, though to a lesser extent. The authors estimate that if hospital- and private equity-affiliated specialists charged the same prices as independent practices, annual commercial health care spending would decrease by about $2.9 billion and $156 million, respectively.

Topic Areas: Vertical Integration, Payment Differentials

Publisher/Organization: Center on Health Insurance Reforms

Payer: Commercial Insurance

Summary: The authors review state efforts to collect and analyze outpatient facility fee data. Facility fees often make care delivered in hospital settings more expensive than in physician offices, but limitations in claims data can obscure where and how hospitals bill these fees. Colorado, Maine, Connecticut, and Washington have implemented data reporting requirements to better identify facility fee billing patterns and trends. These efforts reveal rising facility fee charges and highlight challenges such as inconsistent data across claims. Monitoring provides insight into site-of-care price differences and informs potential policy responses to improve affordability.

Topic Areas: Payment Differentials, Facility Fees, Policy Reforms

Publisher/Organization: Government Accountability Office

Payer: Commercial Insurance, Medicare

Summary: This report synthesizes published research on the trends and effects of physician consolidation through 2024. It notes that hospitals employ or affiliate with a growing share of physicians. While less common, provider affiliations with private equity are also increasing in certain specialties and markets. The literature indicates that vertical integration between hospitals and physician practices is associated with higher health care spending and prices for both Medicare and the commercial payers. The shift of delivering services in more expensive hospital-based settings contribute to increased prices and costs. Evidence on the quality effects of hospital-physician vertical integration is mixed and limited. The literature on how consolidation affects access to care is also sparse. The report highlights evidence gaps on consolidation involving private equity or insurers and reinforces concerns that reduced competition may contribute to cost pressures in health care markets.

Topic Areas: Vertical Integration, Payment Differentials

Publisher/Organization: Health Care Cost Institute

Payer: Commercial Insurance

Summary: This blog analyzes 2018-2022 commercial claims for services MedPAC identified in its June 2023 report as being safely and routinely provided in ambulatory surgical centers or physician offices. Authors compare prices for these services when delivered in hospital outpatient departments (HOPDs) and physician offices. For every service in every year, prices were higher in the hospital outpatient setting. Prices in HOPDs increased over time for all services, while prices in physician offices did not always increase, particularly for some diagnostic tests and related services.

Topic Areas: Payment Differentials

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Using 2022 commercial claims, researchers analyze 32 procedures across cardiology, gastroenterology, orthopedics, and urology, excluding evaluation & management and drug-related services. They focused on services with at least 10% volume in hospital outpatient departments (HOPDs) and at least 10% volume in ambulatory surgery centers or physician offices. Hospital-affiliated physicians were least likely to provide these services in lower-cost settings, while physicians affiliated with private equity-backed management services organizations were most likely to do so. Across all services, total reimbursement at HOPDs ranged from 111% to 1,346% of the reimbursement at lower-cost settings.

Topic Areas: Payment Differentials

Publisher/Organization: US of Care

Payer: Commercial Insurance

Summary: This report analyzes how three payment policies—site-neutral payments, facility fee prohibitions, and commercial hospital price caps—could affect consumer costs and hospital finances in Indiana, Massachusetts, and North Carolina in 2022. The authors find that setting commercial site-neutral rates at 100% of the Medicare non-hospital payment rate for the 57 services MedPAC identified could reduce consumer premiums and out-of-pocket costs by over $840 million. Hospital operating margins in the states would also remain positive after the site-neutral reform. They also find that banning facility fees for evaluation and management, preventive, and telehealth services in hospital outpatient departments could save consumers $121-$323 million per state, while hospitals would continue to maintain positive operating margins. Finally, the report estimates that capping commercial hospital prices at 200% of Medicare rates could save over $5 billion per state without leading to negative hospital operating margins. The authors conclude that policies aimed at curbing excessive hospital payments could lower costs without threatening hospital financial viability.

Topic Areas: Payment Differentials, Site-Neutrality, Policy Reforms, Facility Fees

Publisher/Organization: Health Care Cost Institute

Payer: Commercial Insurance

Summary: This issue brief explains what facility fees are and uses visual examples to compare the cost components of a primary care office visit and a pediatric wellness visit in 2022 across care settings for patients with commercial insurance. It shows that when these services are delivered in hospital outpatient departments, facility fees make up roughly half of the total cost, significantly increasing overall prices compared to physician offices. While the professional fee in hospital settings may be slightly lower than in an office—for example, $13 less for a primary care visit—the addition of a $114 facility fee results in a higher total cost. The analysis highlights how site-of-care billing practices and facility fees drive payment differentials and increase spending for routine outpatient services.

Topic Areas: Payment Differentials, Facility Fees

Publisher/Organization: Maine Health Data Organization

Payer: Commercial Insurance

Summary: This dataset from the Maine Health Data Organization uses commercial claims from Maine’s All-Payer Claims Database and represents about 73% of commercially insured individuals in the state. It includes facility and professional payments for 109 outpatient procedures across 197 healthcare settings from July 2023 to June 2024. The dataset contains claims from 16 commercial payers, including detailed breakouts for the five largest insurers, and organizes services into categories. For each CPT code, care setting, and payer, it reports median payments, the number of episodes, and the share of total payments attributable to institutional versus professional claims. It also includes a “split billing” analysis that identifies instances where both institutional and professional claims were submitted for the same service, enabling comparisons of how payments are distributed across settings and claim types.

Topic Areas: Payment Differentials, Facility Fees

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: This study analyzes 198,097 primary care physicians and 226.6 million negotiated prices for office visits across three large commercial insurers. Researchers examine trends in hospital and private equity affiliation and assessed how affiliation relates to commercial prices. From 2009-2022, hospital-affiliated primary care physicians increased from 25.2% to 47.9%. During the same period, the share of primary care physicians affiliated with private equity firms increased from 0% to 1.5%. Relative to independent primary care physicians, negotiated prices for office visits were $14.91 (10.7%) higher for hospital-affiliated primary care physicians and $9.56 (7.8%) higher for private equity-affiliated primary care physicians.

Topic Areas: Vertical Integration, Payment Differentials

Publisher/Organization: RAND

Payer: Commercial Insurance

Summary: This study uses 2020-2022 commercial claims data from self-insured employers, state all-payer claims databases, and private health plans to analyze hospital prices. It finds that average private insurer prices were 254% of Medicare rates in 2022, with prices exceeding 300% of Medicare in some states. Hospital outpatient procedure prices averaged 263% of Medicare rates, and facility fees accounted for about 87% of outpatient spending. The researchers also find that prices at ambulatory surgery centers averaged 171% of Medicare rates. In addition, prices for private insurers averaged 281% of average sales price for hospital administered drugs, compared with Medicare's payment rate of 106% of average sales price.

Topic Areas: Payment Differentials, Vertical Integration, Facility Fees

Publisher/Organization: Colorado Hospital Facility Fee Steering Committee

Payer: Commercial Insurance, Medicare

Summary: The Colorado Hospital Facility Fee Steering Committee analyzed outpatient facility fee trends in Medicare and the commercial market using 2017-2022 data. Total outpatient facility fee reimbursements for the commercial market and Medicare grew by 6.5% per year on average. In the commercial market, professional fee payments for the 25 most frequently billed, high-reimbursement CPT codes were nearly identical for hospital-affiliated and independent providers. However, hospital outpatient departments (HOPDs)charged additional facility fees for these codes. Variations in billing practices across providers—along with incomplete facility fee data for self-funded plans—prevented the Committee from calculating total costs of care for HOPD services, limiting direct comparisons with office-based settings.

Topic Areas: Payment Differentials, Facility Fees

Publisher/Organization: Health Care Cost Institute

Payer: Commercial Insurance

Summary: By analyzing a commercial claims dataset, the authors compare prices for clinical laboratory tests across hospital outpatient departments (HOPDs), physician offices, and independent laboratories. Prices in HOPDs were three times higher than in physician offices or independent labs. Although HOPDs accounted for 29% of lab tests for commercially insured patients, they represented 60% of total lab spending in 2022. From 2012 to 2022, lab prices declined at independent laboratories but increased in HOPDs.

Topic Areas: Payment Differentials

Publisher/Organization: N/A

Payer: Commercial Insurance, Medicare

Summary: This survey study of 1,069 clinicians in 2021, combined with 2019 claims data, assesses how much care delivered in hospital settings could be shifted to lower-cost care sites without compromising clinical outcomes. Respondents evaluated more than 300 care activities and indicated that about 10.3% of commercial care volume and 10.9% of Medicare volume in hospital settings could safely occur elsewhere. Based on 2019 reimbursement rates, shifting this care would be associated with annual savings of approximately $113.8 billion to $147.7 billion for the overall health care system.

Topic Areas: Payment Differentials, Patients & Quality

Publisher/Organization: Center for Advancing Health Policy through Research

Payer: Medicare

Summary: Researchers review the evidence on site-neutral payment reforms, including the history of federal site-neutral policy reform in Medicare as well as the challenges and concerns that hospital groups have raised. The researchers present five policy options to decrease the site-of-service payment differential: uniform payment rates, evidence-based payment adjustments, monitoring and evaluation, enhanced transparency and accountability, and enhanced sustainability of rural and marginalized access to care.

Topic Areas: Payment Differentials, Site-Neutrality, Policy Reforms

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: This study analyzes the volume and prices of colonoscopy, knee or shoulder arthroscopy, and cataract removal in hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). Using national commercial claims data from Blue Cross Blue Shield insurance plans in 2019-2020, the researchers find the average volume of the procedures were 44-134% higher in ASCs compared to HOPDs. Additionally, prices paid for the services in HOPDs were 44-55% higher than in ASCs. Complications within 90 days of the procedures were more common for procedures in HOPDs for colonoscopy and similar across settings for arthroscopy and cataract removal.

Topic Areas: Payment Differentials, Patients & Quality

Publisher/Organization: Blue Health Intelligence

Payer: Commercial Insurance

Summary: Using national commercial claims data for roughly 123 million people between 2017 and 2022, researchers found that allowed costs for thousands of outpatient services were consistently higher when provided in hospital outpatient departments (HOPDs) than in ambulatory surgery centers (ASCs) or physician offices. HOPD prices also grew more rapidly over time than prices in ASCs or offices. The brief concludes that implementing site-neutral payments would generate substantial savings for patients, employers, and insurers by reducing these price disparities.

Topic Areas: Facility Fees, Payment Differentials, Site-Neutrality

Publisher/Organization: Yale Tobin Center for Economic Policy

Payer: Medicare

Summary: The review synthesizes literature on Medicare’s site-neutral payment policies. It shows that payment differences for the same outpatient services across hospitals, ambulatory surgical centers, and physician offices increase spending and beneficiary costs. Eliminating these differences could lower costs without harming quality. The authors find that payment differentials have encouraged hospital-physician vertical integration, but peer-reviewed evidence has shown that hospital-based care does not yield better patient outcomes for comparable services. Because commercial payers often follow Medicare’s lead, these payment disparities extend into the commercial insurance market. The review also discusses site-neutral policies and proposals as of 2023.

Topic Areas: Payment Differentials, Vertical Integration, Policy Reforms, Site-Neutrality, Patients & Quality

Publisher/Organization: Blue Health Intelligence

Payer: Commercial Insurance

Summary: Analyzing commercial insurance claims from 2017 to 2022, researchers compare allowed costs for six outpatient procedures across hospital outpatient departments (HOPDs), ambulatory surgery centers (ASCs), and physician offices. The study finds that allowed costs for the same procedures were consistently higher at HOPDs than other settings and that these costs have grown faster over time. The findings suggest that site-neutral payments across care delivery settings would result in substantial savings for employers, employees, and patients.

Topic Areas: Site-Neutrality, Payment Differentials

Publisher/Organization: Committee for a Responsible Federal Budget

Payer: Commercial Insurance

Summary: The report estimates that implementing site-neutral payment policies in the commercial insurance market from 2024 to 2033 could reduce total national health expenditures by $458 billion, lower commercial insurance premiums by $386 billion, decrease patient cost sharing by $73 billion, and reduce the federal budget deficit by $117 billion. It attributes these savings to narrowing site-of-care payment differentials, particularly by lowering payment for services billed in hospital outpatient departments (HOPDs). To achieve these savings, the report outlines a three-step policy approach: requiring unified billing to improve transparency, capping total payments for services delivered at off-campus HOPDs, and extending price caps to selected services at on-campus HOPDs. The analysis also illustrates substantial price variation across sites of care for common services.

Topic Areas: Payment Differentials, Site-Neutrality, Policy Reforms

Publisher/Organization: Massachusetts Health Policy Commission

Payer: Commercial Insurance

Summary: Using commercial data from the Massachusetts All-Payer Claims Database, researchers find that from 2018-2020, annual price growth per encounter grew 1.5-1.7% in office-based settings and 3.2-3.9% in hospital outpatient departments (HOPDs). Looking at seven different common ambulatory services, researchers find that the average price at HOPDs was 0.9-3.3 times higher than in office settings.

Topic Areas: Payment Differentials

Publisher/Organization: RAND

Payer: Commercial Insurance, Medicare, Medicaid

Summary: The authors reviewed ten studies examining the price impact of vertical integration between hospitals or health systems and physicians. Eight studies reported price increases, one found no significant effect, and one reported mixed results. A major factor driving higher prices in vertically integrated entities is the shift of services to higher-cost settings where systems can bill both professional and facility fees. Similar to most of the studies on the price effects of vertical integration, nine studies found increases in medical spending associated with vertical integration.

Topic Areas: Vertical Integration, Facility Fees, Payment Differentials

Publisher/Organization: RAND

Payer: Commercial Insurance

Summary: This report uses 2018-2020 commercial claims data from self-insured employers, state all-payer claims databases, and private health plans to analyze amounts paid to hospitals by private insurers across the United States. It finds that, on average, private insurance payments to hospitals were much higher than the amounts Medicare would have paid for the same inpatient and outpatient services, with variations across states and hospitals. Specifically, average private insurer payments were 224% of Medicare rates in 2020, with certain states above 300% of Medicare rates. The study highlights significant geographic and facility-level price variation that is not explained by patient mix or payer mix, pointing instead to hospital market power and negotiated pricing dynamics. It also finds that ambulatory surgery centers tend to have lower relative prices than hospital outpatient departments. Private insurance payments for administered drugs in hospital settings are also much higher than Medicare rates.

Topic Areas: Payment Differentials, Vertical Integration

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: This study analyzes 2018 commercial claims data to compare payments for outpatient services across sites of care. It finds that total payments, including facility and professional fees, were on average 145% higher in hospital outpatient departments (HOPDs) than in physician offices. Price differences between settings were highest for pathology and laboratory services. It also finds that patient out-of-pocket spending was 109% higher in HOPDs. Additionally, patients treated in HOPDs had higher risk scores and received more same-day services. However, it is unclear whether this reflects true differences in patient complexity or coding practices.

Topic Areas: Payment Differentials, Patients & Quality

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Researchers find that in 2019, Blue Cross Blue Shield health plans nationally paid hospital outpatient departments (HOPDs) about twice as much as physician offices for biologics, chemotherapies, and other infused cancer drugs and 68% more for infused hormonal therapies. Excluding HOPDs from networks and directing all infusions to physician offices could have reduced plan spending by $1.28 billion annually, or 26%. Alternative cost-sharing designs also would have lowered plan spending, but substantially increased patients’ out-of-pocket costs for receiving care at HOPDs.

Topic Areas: Payment Differentials

Publisher/Organization: Employee Benefit Research Institute

Payer: Commercial Insurance

Summary: The brief explains how the cost of physician-administered specialty drugs differs by site of care in the commercial market. For the 72 physician-administered drugs studied, allowed payments were higher in hospital outpatient departments (HOPDs) than in physician offices for all but two drugs. Given that the drugs examined were more likely to be delivered in an HOPD setting, authors estimate that eliminating price differentials for these drugs between HOPDs and physician offices would save employers and workers approximately $10.3 billion annually. Expanding site-neutral payment or shifting care away from HOPDs for all physician-administered outpatient drugs examined would increase estimated savings to $14.1 billion per year.

Topic Areas: Site-Neutrality, Payment Differentials, Policy Reforms

Publisher/Organization: RAND

Payer: Medicare

Summary: This report summarizes findings on vertical integration from a series of RAND studies. Studies have found that hospital-physician vertical integration shifted care from lower-cost settings to hospital outpatient departments, raising Medicare spending and prices. Increased hospital-based imaging and lab use added $73.1 million in Medicare costs for selected services over the study period. Hospital-integrated physicians were less likely to use ambulatory surgery centers, directing patients to higher-reimbursed hospital settings. The volume of outpatient services stayed roughly the same, but prices rose by up to 29%, reflecting site-of-care differences.

Topic Areas: Vertical Integration, Payment Differentials

Publisher/Organization: N/A

Payer: Medicare

Summary: Using 2010-2016 Medicare payment data, the study estimates that the average physician working in an independent physician office would have earned about $114,000 more in 2016 by billing services through a hospital outpatient department (HOPD) than an independent practice, with substantial variation by specialty. The analysis also finds that payment incentives from annual Medicare payment updates for HOPD services may have contributed to greater physician-hospital integration over time. The authors suggest that Medicare site-neutral payment reforms could reduce incentives to shift care toward more expensive sites of care and have a “cooling effect” on vertical integration. However, hospitals’ motivation to acquire physician practices may persist due to the advantage integration provides in negotiating higher prices with commercial payers.

Topic Areas: Vertical Integration, Policy Reforms, Payment Differentials, Site-Neutrality

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: This study examines more than 5.2 million outpatient surgeries among commercially insured patients to assess trends in total payments, facility fees, professional fees, and out-of-pocket (OOP) expenses. Total payments for surgical encounters increased by 29%, primarily due to a 53% rise in facility fees, while professional fees remained stable. Patient OOP expenses grew by 50%. Predicted payments for procedures in ambulatory surgery centers and hospital outpatient departments were higher than office-based procedures, adding $2019-$2649 in total payments and $302-$324 in OOP expenses per procedure.

Topic Areas: Facility Fees, Payment Differentials

Publisher/Organization: N/A

Payer: Medicare

Summary: Using 2017 Medicare Physician/Supplier Procedure Summary data, researchers analyze where otolaryngologists provide outpatient clinic visits and estimated the financial impact of site-neutral payment reforms for off-campus hospital outpatient departments (HOPDs). The study finds that 91.9% of the 5.1 million clinic visits occurred in physician offices, while only 8% took place in HOPDs, and just 2.2% occurred in off-campus hospital settings. As a result, applying site-neutral payment rates to off-campus HOPD visits would have produced a relatively modest overall payment reduction of about $12.2 million in 2017 for this specialty, with some variation among specialties.

Topic Areas: Payment Differentials, Site-Neutrality, Policy Reforms

Publisher/Organization: Health Care Cost Institute

Payer: Commercial Insurance

Summary: Using 2009-2017 commercial claims data, the blog compares utilization and prices for selected services delivered in hospital outpatient settings versus physician offices. It finds that the share of these services performed in hospital outpatient settings rose from 11.1% to 12.9% over the period. For every service studied, the average price was higher in hospital outpatient settings than in office settings, and price growth was faster in hospital outpatient settings for many services.

Topic Areas: Payment Differentials

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: Using negotiated rates from three commercial insurers from 2007 to 2014, the study compares price growth for the hospital and physician components of hospital-based outpatient services. The price of the hospital component grew by 25% over this period, and the price of the physician component grew by 6%. The hospital component comprised 79.5% of the total price for outpatient procedures. Because hospital prices grew faster and accounted for a larger share of costs, the hospital component accounted for 93.5% of the increased total price for outpatient services.

Topic Areas: Payment Differentials, Facility Fees

Publisher/Organization: Green Mountain Care Board

Payer: Commercial Insurance

Summary: Using commercial claims and payment data, the Green Mountain Care Board documents significant payment differentials for identical services that favor hospital settings (especially academic medical centers) over independent physician practices in Vermont. This contributes to higher overall costs and creates financial incentives for hospital-physician consolidation. These payment disparities can affect patient access, distort competition, and drive up insurance premiums. To address these issues, the report recommends strengthening hospital budget review authority, enhancing insurer rate review processes, increasing price transparency, and enacting site-neutral payment reforms.

Topic Areas: Payment Differentials, Policy Reforms

Publisher/Organization: N/A

Payer: Commercial Insurance

Summary: This study analyzed commercial claims data from 2009-2013 to assess payment differences across settings for seven common services, including office visits, imaging, and procedures. They found that prices for all seven services were higher when delivered in hospital outpatient departments (HOPDs) than in physician offices, with the greatest price differentials for imaging and procedures. Combined with a shift in service volume toward HOPDs, the growing price differential contributed to a 44% increase in total spending for these services over the study period.

Topic Areas: Payment Differentials