Performance Measurement in the Hospital Outpatient Setting. Overall Finding


As noted previously, we examined E&M visits separately from services/procedures to assist us in identifying measures that are relevant to each category, given that different types of measures apply. Additionally, all data analyses were performed separately for the ED and the HOPS, given the distinct type of care provided in these two settings.

Based on our analysis of the 2005 Medicare OPPS facility data, CMS was billed for 15,325,267 E&M encounters and 78,538,882 services/procedures in the HOPS. In the same year CMS was billed for 11,426,386 E&M encounters and 22,494,724 services/procedures in the ED. Thus, in 2005, services/procedures represented a significant volume of the care provided in the hospital outpatient setting. More specifically, the top 20 most frequent services/procedures accounted for 58 percent of total services/procedures in the HOPS, and 94 percent of total services/procedures in the ED.

In terms of cost, had 2007 payment rates been applied in 2005, CMS would have paid $19.1 billion for services/procedures in the HOPS, and $1.7 billion for services/procedures in the ED.19 The top 20 services/procedures as a fraction of total costs would have accounted for 44 percent of total dollars in the HOPS, and 83 percent of total dollars in the ED. In both the HOPS and ED, a relatively small share of the services/procedures represented a significant proportion of costs — especially in the ED.

  Hospital Outpatient Setting Emergency Department
Table 3.1. Volume and Expenditures Related to Visits and Services/Procedures in the Hospital Outpatient Setting and Emergency Departments20
Evaluation and Management (E&M) Visits21    
Total E&M Visits 15,325,267 11,426,386
Total Cost of E&M Visits $1,000,166,031 $1,774,375,562
Total Services/Procedures 78,538,882 22,494,724
   Top 20 Services/Procedures by Volume 45,806,040 21,227,715
   Top 20 Percent of Total Volume 58% 94%
Total Service/Procedure Expenditures $19,055,431,864 $1,709,238,878
   Top 20 Services/Procedures by Expenditure  $8,420,413,916  $1,424,886,799
   Top 20 Percent of Total Expenditure 44% 83%

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