Performance Measurement in the Hospital Outpatient Setting. Defining the Hospital Outpatient Setting


The hospital outpatient setting can be an elusive concept to define and the care provided in this setting is not homogenous across hospitals. While hospitals typically consider the Emergency Department (ED) to be part of the hospital outpatient setting, there is no standard classification of other care and services/procedures as “hospital outpatient.” The classification of a service as HOPS reflects the structure and organization of the local health system as well as the location where the service is provided, as opposed to the nature of the service itself. For example, facility charges for a hospital-based physician performing a colonoscopy in a hospital-based outpatient clinic would be billed under the OPPS. Meanwhile, another physician practicing in the same market, but not in the hospital-based outpatient department, and who is performing the same service/procedure may bill for practice expenses using the rates established as part of the Physician Fee Schedule.

For the purposes of our environmental scan, we defined the hospital outpatient setting as visits and/or services/procedures paid for under the Medicare OPPS. This care was further categorized for analyses and discussion in this report as either rendered in: (1) the ED, or (2) any other hospital-affiliated outpatient setting that is paid under OPPS (hereafter referred to as HOPS). We first classified services/procedures that obviously occur in the ED to the ED; all other services/procedures paid under the OPPS were classified as HOPS.

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