Inpatient vs. outpatient care costs and how to choose

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You've been dealing with knee pain for months. After a few appointments with your doctor, you decide it's time to have that knee replacement surgery you’ve been putting off. The next big decision: Where should you have the procedure done? Inpatient vs. outpatient facility?

What you decide can affect your costs, care experience and recovery. Understanding your options and benefits can help you feel more confident choosing the care that's right for you, especially when many procedures like knee or hip replacement surgery, cataract removal or rotator cuff repair, can be done in either inpatient or outpatient settings.

The difference between inpatient vs. outpatient care

You've probably seen the terms inpatient and outpatient care in your benefits documents, but what is the difference? Both refer to where and the way a service or surgery is provided. Here's a rundown of inpatient vs. outpatient care:

• Inpatient care refers to care when you've been admitted to a hospital. A few examples of common inpatient surgeries and procedures include hip fracture repair, giving birth or heart surgery. Inpatient care requires one or more overnight stays in a hospital or surgical center.
• Outpatient care, on the other hand, rarely requires an overnight stay at a hospital. Outpatient care is usually done in a hospital, clinic or surgery center. Along with outpatient hip replacement surgery, other services typically handled in an outpatient setting include tonsillectomies, the placement of ear tubes or colonoscopies.

Both inpatient and outpatient care have benefits and risks. When deciding which is best for your situation, you’ll want to consider which option will give you the best health outcome, compare costs and be aware of your health coverage.

Comparing costs of inpatient vs outpatient care

Outpatient surgery usually costs less than inpatient surgery. When deciding between an inpatient or outpatient procedure, consider these factors that may impact your costs.

By understanding these factors, you’ll be able to ask informed questions and compare your options before scheduling care. You can also use tools like myWellmark to check your coverage, estimate costs and find in-network facilities before making your decision.

Factors that impact the cost of inpatient surgery

• Procedure complexity: Some surgeries require more support staff, nurses, specialists and supplies. A complex inpatient surgery like a transplant will typically cost more than an inpatient hip replacement.
• Facility fees: When you receive care in a hospital, you typically receive two bills: one from the health care practitioner(s) and other clinicians for their professional services and one from the hospital. The hospital bill includes charges associated with the care provided by the hospital (e.g., room and board, procedures, evaluation and management), and overhead costs (e.g., equipment, space, and support staff).  One part of the hospital's overhead cost is a "facility fee." This fee is designed to support the emergency room and other services that the hospital must provide, even if they are not directly related to your care.
• Length of care: The longer you stay in a facility, the more resources you use. Your costs increase with longer inpatient stays.

Inpatient vs. outpatient surgery — how to decide which is right for you

While cost is definitely a factor when deciding between inpatient and outpatient care, there are a few other things to consider. Take these steps when deciding between inpatient vs. outpatient care.

1. Talk to your provider. They may recommend one care setting over the other based on your health history, risk for complications, surgery complexity or other concerns.
2. Check your health insurance benefits and costs. Knowing how your health plan covers inpatient vs. outpatient care can help you feel more confident in your decision and avoid unexpected bills.
3. Assess your support system. Regardless of where you receive surgery, you’ll need to have a recovery plan. Do you have a way to get home after surgery and follow-up appointments? Will you need help bathing, getting dressed or preparing meals? Will you need help remembering to take your medication? If you may struggle with any of these or don’t have support you can rely on, your provider may recommend inpatient care.

Check your inpatient and outpatient care benefits in myWellmark

myWellmark has the tools, resources and insights to help you manage your health care spending and live a healthier life. By simply logging in to myWellmark, you can estimate your inpatient and outpatient surgery costs, track and organize your family's medical expenses, search for in-network facilities and much more.

Start getting more from your health insurance benefits, log in or register today!