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Inpatient Versus Outpatient Cleft Lip Repair and Alveolar Bone Grafting: A Cost Analysis.
Mark G. Albert, M.D., Oksana O. Babchenko, B.S., Janice F. Lalikos, M.D., Douglas M. Rothkopf, M.D..
University of Massachusetts, Worcester, MA, USA.
Cleft lip and palate are among the most common birth defects in the United States, occurring in approximately 1 in 940 and 1,574 live births, respectively. 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 and alveolar bone grafting, and studies have shown no disparities in safety or outcome between inpatient and ambulatory treatment. While the outpatient benefit of recovery in a familiar home environment, and earlier resumption of daily life may be apparent, the financial implications of outpatient versus inpatient procedures have not been compared.
Financial data was collected for outpatient (n=33) and inpatient (n=2) cleft lip repair (CLR), as well as outpatient (n=7) and inpatient (n=5) alveolar bone grafting (ABG) over 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. We compared facility and professional/surgeon fee reimbursement. Facility charges include operating room, anesthesia, recovery room, pharmacy, and inpatient room and board fees.
The average total reimbursement for inpatient and outpatient CLR were similar at $6,848 and $5,557, respectively. Average facility reimbursement for CLR was greater for inpatient ($5,344) than outpatient ($4,291) procedures; a greater percentage of outpatient facility charges (45%) were reimbursed than inpatient facility charges (34%). Average professional reimbursement was similar between inpatient ($1,504) and outpatient ($1,266) CLR.
For ABG, the average total inpatient reimbursement was $14,573 while outpatient was $8,877. Average facility reimbursements were greater for inpatient ($12,398) than outpatient ($7,183) ABG; outpatient was reimbursed at a greater percentage (80%) than inpatient facility charges (30%). Average professional reimbursement was similar between inpatient ($2,175) and outpatient ($1,693) 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% ($7,344) of overall charges, while Medicaid and MMC reimbursed 9% ($1,447). For ABG, commercial payers reimbursed an average of 78% ($11,950) of overall charges, while Medicaid and MMC reimbursed 10% ($1,192).
Fewer patients’ insurance companies are reimbursing for inpatient stays; in many cases, even patients who remain hospitalized up to 36 hours are treated as “day surgery” from a reimbursement perspective. Hospitals are paid significantly more when CLR and ABG are actually reimbursed as “inpatient” cases. For outpatient surgery, a greater percentage of CLR and ABG charges were successfully recouped compared to inpatient surgery. With increasing cost consciousness in contemporary healthcare, awareness of higher payment for inpatient surgery and potential savings through use of the outpatient setting for these common pediatric procedures is crucial for hospitals and the US healthcare system as a whole.
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