The Role Payors Play in Where Patients Seek Care

There are many factors to consider when deciding where to seek care for patients needing a routine or advanced endoscopic procedure. Perhaps it’s urgency for diagnostic or therapeutic care, the ability to travel, a desired physician to see, the convenience of available appointment times, or simply going to the first place found on Google.

But one influence is increasingly difficult to ignore: the bill.

Depending on type of coverage and whether benefits are from private or public sources, patients may unknowingly be directed to select certain locations for care. Increasingly, payors are favoring ambulatory service centers (ASCs) as a cost-effective alternative to hospitals.

“The ASC is usually more efficient, and the patient will benefit by having specialized care in a more efficient manner,” according to Dr. Adam Goodman, a gastroenterologist and professor at NYU Langone Hospital-Brooklyn. “The system benefits by less administrative costs, greater efficiency, and more procedures getting done in a similar amount of time.”

Ultimately, patients receive the same quality of care, but at a much-reduced cost, Goodman said.

It is estimated today that 90 percent of colonoscopies are performed in ASCs, hospital outpatient clinics, or in physician’s offices. Up to 32 percent of the ASC’s in the U.S. specialize in endoscopy alone, while 37 percent of the multi-specialty centers offer endoscopy services, including upper GI endoscopy, sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS).

Since ASCs typically offer specialized care, procedures can usually be performed more efficiently and quickly than at hospitals, resulting in lower costs. Patients seeking care at ASCs are likely also to have fewer complex conditions, requiring fewer resources for care. A recent study in California found colonoscopies cost an average $2,300 less when performed at an ASC rather than a hospital.

In fact, large payors have increasingly created policies that favor ASC care and may put continued pressure on physicians to perform non-urgent procedures in these settings. In some instances, insurance companies won’t pay for a routine colonoscopy in the hospital anymore. For example, United Healthcare now restricts sites available for non-emergent surgeries and Empire Blue Cross Blue Shield in New York began requiring proof of medical necessity for certain procedures to be performed outside of an ASC in 2021. The New York-based company argued procedures they were pushing to ASCs have been safely provided in such settings for many years. This is particularly true for GI endoscopy.

Studies have shown how care provided at ASCs is significantly cheaper than hospitals – with one report from Regent Surgical Health estimating healthcare cost savings up to $38 billion annually. Additionally, combined out-of-pocket expenses for patients could be reduced by roughly $5 million annually, according to the report. Even for advanced GI endoscopy procedures like ERCP or EUS, ASCs can offer a cost-effective alternative to a hospital.

ASCs are becoming increasingly popular throughout the country, and there are more than 5,000 operating nationwide today. If payors continue to drive future care to the centers, that number will only grow.