The outpatient decline was specifically in the number of emergency outpatient visits hospitals delivered in 2018, said Aaron Wesolowski, the AHA's vice president of policy research, analytics and strategy. Other areas of outpatient utilization were stable or up slightly over 2017, he said.
Patients who used to visit emergency departments are now going to urgent care clinics or other settings that may or may not be owned by health systems, Wesolowski said.
Kaufman said it's no different than what's happening in the retail sector.
"In the old days, you had to get in your car and drive around to a bunch of stores to see if you could find what you wanted and you don't have to do that anymore," he said. "The same thing is happening in healthcare. It's going to happen more."
Despite the lower number of visits, hospitals' net outpatient revenue increased 4.5% year-over-year in 2018 on a cumulative basis, even as net inpatient revenue rose 2.1%.
As in prior years, the newest AHA data show the gap between outpatient and inpatient revenue continues to narrow. Hospitals' net outpatient revenue—$494 billion—was 97% of net inpatient revenue—$508 billion—in 2018, compared with 95% in 2017 and 92% in 2016.
"I don't know that I can speculate as to when they will converge, but the trend lines seem to be getting closer," Wesolowski said.
It may be that patients are going elsewhere for primary care but that hosptials are still capturing the more acute services that carry higher reimbursement, said Chad Mulvany, director of healthcare financial practices, perspectives and analysis for the Healthcare Financial Management Association.
"Maybe the trend toward convenience has picked up, and so for all the very low-acuity stuff people are going to the Minute Clinics of the world, and if it becomes more complex than that, they're going to the hospital for a procedure," he said.
The continued pressure on hospitals' budgets pushed profits down 5.2% year-over-year to $83.5 billion in 2018, compared with $88 billion in 2017, which represented a massive, 12.5% jump over 2016.
Wesolowski said that's due to the same pressures that have plagued hospitals for years: continued lower reimbursement from public payers, the shift from inpatient to outpatient care and the increasing costs of drugs and labor. A separate report provided by the AHA said Medicaid paid hospital 89 cents for every dollar they spent delivering care to Medicaid patients in 2018. For Medicare, that was 87 cents.
Total expenses at U.S. community hospitals surpassed $1 trillion for the first time in 2018, up 4.6% year-over-year. AHA's community hospitals definition excludes hospitals that are not accessible to the public, including military and veteran hospitals, prison hospitals and other specialty hospitals. Hospitals' total net revenue surpassed $1 trillion for the second time in 2018.
The AHA also found that hospitals' spent $41.3 billion providing uncompensated care in 2018, or 4.1% of total expenses. That number includes bad debt, unpaid bills hospitals expected would be paid, and financial assistance to low-income patients. That's up from $38.4 billion in both 2017 and 2016.
Wesolowski said the increase is likely due in part to the Trump Administration's repeal of the Affordable Care Act's penalty for not having health insurance and its new Medicaid eligibility policies, both of which increased the number of people without health insurance.
CORRECTION: An earlier version of this story misstated the percentage decline in 2018 outpatient visits, which were down 0.09% from 2017.