Inpatient or Outpatient? Which is better for me?

Our concierge coordinators are asked this question quite often

Here’s how we train them to respond to this question. 

“Trust your doctor to advise you on what is best for your body and your medical history.”

Patients with many chronic health conditions or complex medical histories do well in both settings, but a doctor who is familiar with your medical history and condition at the time of surgery may have a clinical concern for your safety that influences their independent medical judgment.  If you are not ready to trust your doctor for any reason, you can always seek a confirmatory second surgical opinion. 

The cost may be about $250, but if you have insurance, your insurance may pay some or all of the cost of the second opinion, or even require a second opinion.  The second opinion surgeon may offer your a different option altogether. The second opinion surgeon may also advise against surgery in your case, or could offer a different approach to treat your concern. Ultimately the decision is between you and your chosen surgeon and the anesthesiologist who will attend you during surgery. 

You may also seek a “remote” second opinion by internet chat, or a second opinion service that instructs you to send your medical records for an “independent review” of your medical records and images at a world renowned health facility in your country or abroad. Johns Hopkins offers this service for about $1600 last time we checked. That expense may or may not be covered by your health insurer.

Sometimes, the deciding factor is that your health condition may be complicated by certain chronic diseases or other conditions.

  • You may be seriously overweight or underweight which poses health risks of its own, unrelated to the surgery that is planned.
  • If you have other serious health conditions – diabetes, hypertension, heart disease, vascular disease, breathing problems, kidney problems, history of blood clots after surgery, cancer, pregnancy, etc. that could influence both your risks both during surgery and after surgery for the first few days.
  • You have a past history of surgical complications.

Sometimes, the deciding factor is that you live alone. 

  • You may need more help of a skilled nature for a few days. 
  • Another reason could be that you live in a setting that requires you to climb stairs, ascend and descend hills, deal with narrow doorways in an older home, have low rise toilets and no grab bars, and /or you may have a primary caregiver that is really not capable to assist you properly at home.  
  • Your doctor may not feel that recovery will be best served without more nursing care than a home care agency visiting nurse can provide. 
  • There may be a shortage or unavailability of a local home care agency visiting nurse where you live.
Sometimes the deciding factor is that the doctor is employed by the inpatient facility.
  • Yes, it can happen. We have read letters sent out to employed medical staff asking them to choose to admit patients and confine them for at least three days. One reason was because the hospital was in a rural / remote area and the hospital had negotiated rates so low that they wanted more revenue. But the letter framed the policy focusing on “prevention or mitigation of the risk of readmission.”  One independent orthopedic surgeon we work with told us that the local full-service hospital refused to admit and canceled his other scheduled cases because he routinely discharged Medicare patients on post-operative day one instead of day three. Since there was no other hospital in the area, it placed him in an ethical bind, and the patient at risk for exposure to hospital-acquired infection and other risks, not to mention additional expense to Medicare and his patient. He could follow the policy and place his patients’ interests second, or the patient and the surgeon would need to travel to another city more than 100 miles away to a different hospital to carry out the surgeries at a hospital that didn’t object to shorter post-operative stays.
Sometimes the deciding factor is that your insurance has established policy about certain surgical procedures and where they may be performed.
  • Another reason may be that Medicare won’t pay for any money at all for the procedure to be done in a same-day, (ambulatory) surgery center or “ASC”. While this policy is changing and the “site of service” rules are currently being revised by Medicare, you must deal with the insurer’s rules and policies if you want your insurer to extend its highest level of in-network benefits. 

So what if all things being equal, you get to choose where you want to have surgery?

First, weigh the options

If all things are really equal, you will be choosing from two or more options that offer, among other things:
  • Accreditation from a highly-recognized accrediting organization (The Joint Commission, DNV, AOA, Medicare Certification, AAAASF, AAAHC). There are a shocking number of accrediting organizations (AOs) that do not require more than payment of a fee and “maybe” a quick site inspection to claim they are “accredited”. Suffice it to say, not all accreditation organizations are equal. (Facilities listed on already meet this criteria as our standard, plus the additional criteria listed below.)
  • Board-certified surgeons and anesthesiologists from the specialty board in the same category as your surgery 
  • Low infection rates (National average is 2.6%)
  • In-network or out of network but also approved by your insurer or employer
  • At an altitude less than 4000′ above sea level for certain procedures, including certain orthopedic procedures
  • If they have overnight stay or 23-hour stay licensing (Not all ambulatory surgery centers are licensed for overnight stays)
  • Have a significant number of recent, favorable feedback posts on all ratings platforms on social media and the internet.
  • Offer a competitively priced bundled surgery package price you can afford or arrange financing. 
When you are in relatively good health and you have an option to choose keep this in mind: The longer you stay around sick people the higher the likelihood you’ll catch something from one of them. 
Many people have some notion that surgery as an inpatient is better than surgery as an outpatient. All things being equal, if you can recuperate safely, comfortably at home or in a hotel, your cost will usually be lower to have surgery in the outpatient setting than as a hospital inpatient where you are not in control of your situation.  
If you are concerned that you’ll need advanced skilled nursing care, ask your surgeon or admission coordinator or case manager to consider home or hotel nursing agency assistance for a few days. The choices are:
  • full time private duty around the clock, or 
  • visiting nurse, one or two times per day, or 
  • a nurse and an assistant combination, or
  • a short stay in a skilled nursing facility. 
Ask about the costs of professional nursing assistance. Together with home or hotel recuperation, you may actually get more personalized attention with a private duty nurse at a home or hotel with less expense than spending the night at the hotel in an unfamiliar bed, with unfamiliar noises, unfamiliar pillows, bells and alarms.
Meals can be pre-arranged and delivered, often with better choices than inpatient hospital food.   
And don’t let the need for an IV put you off. You can be sent home with an IV still connected with the proper nursing or caregiver support.  Home care includes infusion care and home IV therapy these days, whereas decades ago that was not the case. You can also be sent home on oxygen, and for pain management, you can be sent home on a “pain pump” that delivers metered doses of pain medication at a set rate per hour. But there are also new ways of dealing with pain management that your surgeon can use during surgery that reduces your need for opioid medications.  Years ago, patients had to be off IV and ready to manage on oral medication for pain management to be discharged. Much of that has changed in recent years.
We hope that this brief article helps you helps you decide what’s right for you, your unique situation, your pocketbook, your comfort, your safety, and what’s best for the family and friends who will support you during your recovery period.
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