The Shift in Care Is Real

Scenario mapping creates an appropriate response strategy

As experts have predicted for some time now, the healthcare market has seen an acceleration in the shift of care for surgical procedures, from inpatient to outpatient sites. However, there is still a lack of understanding and agreement on the speed with which this shift will more broadly occur and the implications for how various stakeholders should effectively respond.

Historically, patients have primarily received care in a hospital setting. But advances in medical technology and innovative care delivery models have ensured certain specialty procedures can be safely performed in the outpatient setting. Factors contributing to the shift to hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) are changes in reimbursement structures, improved access to care, convenience, quicker recovery times, lower out-of-pocket costs and enhanced overall patient experience. With consolidation of provider networks, high-deductible health plans and the recent pandemic, consumers are more selective about where to receive medical care.

To meet patients where they are and effectively manage this shift, its essential for healthcare organizations to understand the key factors and strategize for a response.

Identifying & illustrating possible scenarios

In quarters one and three of 2022, HealthTrust hosted Shift of Care Summits to better understand the nature and timing of this shift in surgical care. Participants were pulled from the membership, representing 13 acute care health systems and two ASC groups, and included individuals in both clinical and supply chain leadership roles.

A brainstorming exercise identified 72 possible key factors or signposts associated with the shift of surgical procedures. They were organized into two high-level themes: market dynamics and influencers.

Examples of signposts related to market dynamics include:

Staffing availability
Technology advances
Customer preference & experience
Physician interest in ASCs & clinical evidence to support the outward shift

Examples of signposts related to influencers include:

State & federal policy
Payer mix
Patient steerage
Consumer interest

Following are four scenarios that illustrate the continuum of the shift of care. During the second Summit, participants reviewed the four scenarios and explored provider implications and possible solutions for each. The outlines of scenarios demonstrate unique properties that require individualized, targeted responses. Providers should understand which scenario exists within their market in order to strategically employ an appropriate response strategy.

Scenario A | An environment where conflicting forces toward the shift of surgical procedures exists. Market dynamics are accelerating the outward shift; however, influencers are slowing the outward shift, or remain flat.

In scenario A, acute care providers will see divergent trends. Within market dynamics, providers will find trends demonstrating a proliferation of HOPD or ASCs, high physician interest in ASCs, strong clinical evidence supporting safety and efficacy of care in the outpatient setting, and plentiful, skilled staff. These trends accelerate the outward shift of surgical procedures. At the same time, providers will find signs that influencers are inhibiting the outward migration, such as restrictive Medicare regulations, certificate of need (CON) laws, an unfavorable payer mix, unfavorable patient steerage, and low consumer interest for undergoing surgical procedures in an ASC setting.

Response to Scenario A:

Strategically deploy capital &/or new construction
Leverage physician contracts to increase percentage of employed physicians
Repurpose acute care hospital beds
Utilize Centers of Excellence for strategic service lines to improve payor steerage
Ensure the Triple Aim of care: high quality, efficiency & reduced cost (aka, cost, quality, outcomes)
Adopt standardized orders, pathways & protocols to ensure standardized care
Invest in artificial intelligence & technology
Explore joint-venture ASCs
Improve HOPD functionality & appeal to customers (physician & patient)
Explore alternative payment models with market payers (e.g., bundled payment models)
Improve care coordination & collaboration with post-acute facilities
Continually monitor signposts to anticipate change

Scenario B | An environment where shift of care is occurring at a fast rate due to aligned market dynamic and influencing forces.

In scenario B, acute care providers will see aligned trends for market dynamics and influencers with both accelerating the outward migration. Market assessment will show a proliferation of HOPD or ASCs, high physician interest in ASCs, strong clinical evidence supporting safety and efficacy of care in the outpatient setting, and plentiful, skilled staff. Additionally, providers will find regulations allowing more procedures in the outpatient space, relaxed or no CON laws, a favorable payer mix, active patient steerage to the outpatient setting, and high consumer interest for undergoing surgical procedures in an ASC setting.

Response to Scenario B:

Strategically deploy capitol &/or new construction
Expand footprint into ASCs (own or joint venture)
Improve HOPD functionality & appeal to customers (physician & patient)
Ensure retention of high-quality physicians & staff
Leverage physician & staff relationships
Offer competitive perks, scheduling & salaries
Utilize Centers of Excellence for strategic service lines to improve payer steerage
Ensure the Triple Aim of care: high quality, efficiency & reduced cost (aka, cost, quality, outcomes)
Adopt standardized orders, pathways & protocols to ensure standardized care
Conduct market analysis for new inpatient service lines or inpatient service line growth
Repurpose vacant acute care hospital beds
Ensure public persona excellence & advertise to educate community on high quality
Lobby with state &/or federal regulators to modulate shift of procedures
Continually monitor signposts to anticipate change

Scenario C | An environment where shift of care is occurring at a very slow rate due to both market dynamic and influencing forces remaining flat or inhibiting the outward shift.

In scenario C, acute care providers will see aligned trends for market dynamics and influencers again; however, these forces inhibit outward migration of surgical procedures. Market assessment will show minimal presence of HOPD or ASCs, low physician interest in ASCs, little to no change in inpatient procedure volumes, and inadequate staffing. Additionally, providers will find regulations inhibit migration to the outpatient space, stricter CON requirements, an unfavorable payer mix, little to no patient steerage to the outpatient setting, and low consumer interest for undergoing surgical procedures in an ASC setting.

Response to Scenario C:

Ensure retention of high-quality physicians & staff
Ensure the Triple Aim of care: high quality, efficiency & reduced cost (aka, cost, quality, outcomes)
Adopt standardized orders, pathways & protocols to ensure standardized care
Improve HOPD functionality & appeal to customers (physician & patient)
Explore on-campus ASC/hybrid model that focuses on relevant procedures/populations
Ensure public persona excellence & advertise to educate community on high quality
Continually monitor signposts to anticipate change

Scenario D | An environment where conflicting forces toward shift of care exist. Market dynamics are flat or inhibiting the outward shift, while influencers are accelerating the outward shift.

In this scenario, acute care providers will see divergent trends again, but for opposite reasons as in Scenario A. When assessing market dynamics, providers will find a nominal HOPD or ASC presence, low physician interest in ASCs, little to no change in inpatient procedure volumes and inadequate staff. These trends inhibit the outward shift of surgical procedures. At the same time, providers will find regulations allowing more procedures in the outpatient space, relaxed or no CON laws, a favorable payer mix, active patient steerage to the outpatient setting and high consumer interest for undergoing surgical procedures in an ASC setting. These trends pose to accelerate the outward shift of surgical procedures.

Response to Scenario D:

Improve physician & staff retention & satisfaction
Ensure the Triple Aim of care: high quality, efficiency & reduced cost (aka, cost, quality, outcomes)
Adopt standardized orders, pathways & protocols to ensure standardized care
Explore on-campus ASC/hybrid model that focuses on relevant procedures/populations
Enable multispecialty stays in the acute care setting
Ensure high-quality, consistent staff that are versatile
Educate & advertise the acute care facility’s good works to promote loyalty, trust & relationships
Lobby with state &/or federal regulators to modulate shift of procedures
Utilize Centers of Excellence for strategic service lines to improve payer steerage
Continually monitor signposts to anticipate change

Experts predict the popularity of ASCs and HOPDs will continue to accelerate. However, the pace for these site of care shifts may vary from market to market and procedure to procedure. As a result, hospitals will need to adjust their strategies based on market dynamics and influencers to ensure the Triple Aim of Care is achieved. Standardized care models, strong physician relationships and staff recruitment and retention are top priorities for sustained, high levels of care.

How is your organization managing the shift of care? Email thesource@healthtrustpg.com to share your story or post your experience on the HealthTrust Huddle.