Hospitals provide access to critical services that are not otherwise always available in the community and they treat patients with very severe conditions. Payment proposals that attempt to treat hospital outpatient departments the same as independent physician offices and other ambulatory sites of care ignore the very different level of care provided by hospitals and the needs of the patients and communities cared for in that setting. Hospitals need to have emergency stand-by capacity, are open 24/7 to all who seek care regardless of ability to pay, and have myriad regulatory requirements imposed on them – all adding to the overall cost of care.