Our research focused on which services are prone to shift out of hospitals based on current market conditions.

• We broke down this research into four questions:
• What proportion of national subservice line volumes have already shifted out of the hospital?
• How does shift vary across geographies?
• How much volume is at risk if volumes across the country shifted to resemble more advanced markets?
• Based on historical trends, at what stage of shift is each procedure?

We then analyzed claims from 2017 to 2022 from Optum’s¹ de-identified Clinformatics® Data Mart Database to identify historical shifts across sites of care and regions. We grouped data by health referral regions to understand prevalence of and variability in use patterns across markets. We excluded services with fewer than 100 encounters in 2017.

To calculate the percentage of HOPD revenue that is at risk, we calculated per-case revenue benchmarks adjusted for national payer mix based on demographics. Volume in at-risk subservice lines is multiplied by the corresponding subservice line revenue per case to calculate at-risk revenue. This value is divided by total revenue to understand percentage of revenue at risk.

Moderate and aggressive shift scenario figures are based on national volumes moving to resemble markets with low HOPD market share. Moderate scenarios represent the 25th percentile market, and aggressive scenarios represent the 10th percentile market. We distinguished the stage of each procedure by looking at a combination of historical shift, HOPD share, and ASC volumes.

Services at risk of shifting away from the hospital outpatient department span 92 subservice lines, comprise 43% of hospital revenue, and account for 36% of HOPD volume. The greatest number of services at risk of shift are concentrated in the spine, ENT, and orthopedics service lines.

These procedures, including joint replacement, spine fusion, and cardiac catheterization, are more complex than most procedures performed in ambulatory settings today.

Some examples include nasal procedures, sports medicine, and electrophysiology. The pace of shift for these services is often inhibited by local market variables, including the absence of ambulatory sites.

Many markets may already be at shift maturity for services such as bariatric procedures, urolithiasis, and CT, as most of their out-of-hospital shift has already occurred.

Stage of shift

• Not shifting: little shift since 2017 and high HOPD share.
• Early: meaningful shift since 2017 and high HOPD share; expected to shift based on qualitative factors and indicators from competitive markets.
• Intermediate: meaningful shift since 2017 and low HOPD share; moderate shifts identifiable in historical data with significant room for further HOPD market share loss.
• Advanced: little shift since 2017 and low HOPD share.