Inpatient versus outpatient cleft lip repair and alveolar bone grafting: a cost analysis
Senior Scholars Program; School of Medicine; Department of Surgery, Division of Plastic Surgery
Janice Lalikos, MD/Plastic Surgery
Medical Subject Headings
Alveolar Bone Grafting; Ambulatory Surgical Procedures; Cleft Lip; Cleft Palate; Health Care Costs; Hospitalization; Humans; Insurance, Health, Reimbursement; Reconstructive Surgical Procedures; United States
BACKGROUND: The lifetime cost of a child with an orofacial cleft is estimated at $101,000, which amounts to $697 million total for those born each year with orofacial clefts. There has been a trend toward outpatient procedures for cleft lip repair (CLR) and alveolar bone grafting (ABG), and studies have shown no disparities in safety or outcome between inpatient and ambulatory treatment. The financial implications of outpatient versus inpatient procedures have not been compared.
METHODS: Financial data were collected for outpatient (n = 33) and inpatient (n = 2) CLR, as well as outpatient (n = 7) and inpatient (n = 5) ABG during a 5-year period at our institution. We examined hospital charges and reimbursement for these procedures by private insurance plans and Medicaid Managed Care (MMC) plans.
RESULTS: The average total reimbursements for inpatient and outpatient CLR were similar at $6848 and $5557, respectively. Average facility reimbursement for CLR was greater for inpatient ($5344) than outpatient ($4291) procedures. Average professional reimbursement was similar between inpatient ($1504) and outpatient ($1266) CLR.For ABG, the average total inpatient reimbursement was $14,573, whereas outpatient was $8877. Average facility reimbursements were greater for inpatient ($12,398) than outpatient ($7183) ABG. Average professional reimbursement was similar between inpatient ($2175) and outpatient ($1693) ABG, with 35% and 31% of charges reimbursed, respectively.A substantial difference existed between reimbursements based on insurance types for both outpatient CLR and outpatient ABG. On average for CLR, commercial payers reimbursed 52% ($7344) of overall charges, whereas Medicaid and MMC reimbursed 9% ($1447). For ABG, commercial payers reimbursed an average of 78% ($11,950) of overall charges, whereas Medicaid and MMC reimbursed 10% ($1192).
CONCLUSIONS: Fewer patients' insurance companies are reimbursing for inpatient stays; in many cases, even patients who remain hospitalized up to 48 hours are treated as "day surgery" from a reimbursement perspective. For outpatient surgery, a greater percentage of CLR and ABG charges were successfully recouped compared to inpatient surgery. Awareness of higher payment for inpatient surgery and potential savings through use of the outpatient setting is crucial for hospitals and the US health care system as a whole.
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Citation: Ann Plast Surg. 2014 Dec;73 Suppl 2:S126-9. doi: 10.1097/SAP.0000000000000149. Link to article on publisher's site
Albert, Mark Graham; Babchenko, Oksana Olegovna; Lalikos, Janice F.; and Rothkopf, Douglas Miller, "Inpatient versus outpatient cleft lip repair and alveolar bone grafting: a cost analysis" (2014). University of Massachusetts Medical School. Senior Scholars Program. Paper 222.