Why Health Systems Are Expanding HBOT Services and What Determines Whether a Program Becomes Clinically and Financially Sustainable
Hospital interest in hyperbaric oxygen therapy, commonly abbreviated as HBOT, has grown alongside the development of advanced wound care, limb-preservation services, cancer survivorship programs, reconstructive surgery, and regional emergency referral networks.
The expansion is not driven by one clinical condition or one business model. Some hospitals operate several monoplace chambers within an outpatient wound center. Academic and tertiary hospitals may maintain multiplace chambers capable of treating critically ill patients, diving emergencies, arterial gas embolism, severe carbon monoxide poisoning, or complex surgical complications.
No complete national census describes how many hospital-based hyperbaric programs are currently operating, opening, closing, or changing ownership. The Undersea and Hyperbaric Medical Society, or UHMS, reports that its facility accreditation program has surveyed and accredited more than 267 facilities over nearly 20 years. This cumulative figure includes different facility types and should not be interpreted as the current number of hospital programs. It does, however, demonstrate the development of a substantial clinical infrastructure requiring specialty-specific standards. (UHMS)
The more important question for hospital leaders is not whether hyperbaric medicine is expanding. It is whether a proposed program can meet a defined regional need while maintaining appropriate patient selection, qualified staffing, engineering controls, fire safety, documentation, and measurable clinical outcomes.
Chronic Wounds Are a Major Driver of Program Development
Advanced wound care is one of the most common entry points for hospital HBOT programs. Diabetes, peripheral arterial disease, neuropathy, infection, pressure, renal disease, and impaired mobility can combine to produce wounds that require prolonged multidisciplinary treatment.
Diabetes-related lower-extremity complications remain a substantial health-system burden. The CDC reports that hospitalizations involving diabetes-related amputations doubled between 2009 and 2019. It also emphasizes that vascular assessment, revascularization when appropriate, foot surveillance, and early wound treatment are important components of amputation prevention. (CDC)
This burden has encouraged hospitals to build integrated limb-preservation programs involving:
- Vascular surgery
- Podiatry
- Orthopedic surgery
- Infectious disease
- Endocrinology
- Wound care
- Rehabilitation
- Hyperbaric medicine
HBOT may be useful for selected advanced diabetic lower-extremity wounds, but most diabetic ulcers do not automatically qualify for treatment. Medicare coverage generally requires a diabetes-related lower-extremity wound classified as Wagner grade III or higher, failure of at least 30 days of standard wound therapy, and continued comprehensive wound care during HBOT. (Centers for Medicare & Medicaid Services)
A hospital that estimates demand by counting every patient with diabetes or every chronic wound will overstate the addressable population. Sustainable growth depends on identifying patients who meet clinical and payer criteria after vascular, infectious, mechanical, and metabolic barriers have been addressed.
Cancer Survivorship Is Increasing Demand for Late-Effect Management
As more people live for years after cancer treatment, hospitals are managing a larger population with delayed treatment effects. The National Cancer Institute estimated that the United States had approximately 18.6 million cancer survivors as of May 2025. (Cancer Control)
Radiation therapy can produce late complications months or years after treatment. These may involve the bladder, rectum, jaw, skin, soft tissue, chest wall, or other structures within the treatment field. NCI guidance recognizes that radiation can damage nearby healthy tissue and that late effects depend on the treated region, combined therapies, genetics, smoking, and other patient factors. (Cancer.gov)
Hospitals with active radiation oncology, urology, colorectal surgery, head and neck surgery, dental oncology, and reconstructive services may therefore encounter patients with:
- Radiation cystitis
- Radiation proctitis
- Soft tissue radionecrosis
- Osteoradionecrosis
- Nonhealing wounds in irradiated tissue
- Compromised reconstructive procedures
HBOT is recognized for delayed radiation injury in selected patients and is covered by Medicare for soft tissue radionecrosis and osteoradionecrosis when used alongside conventional treatment. (Centers for Medicare & Medicaid Services)
This referral pathway can be particularly valuable to hospitals because the hyperbaric program becomes part of long-term cancer survivorship rather than an isolated wound service. Patients may require coordinated evaluation by oncology, urology, gastroenterology, oral surgery, plastic surgery, and other specialists before HBOT is prescribed.
Hospitals Can Integrate HBOT With Existing Specialty Services
A hospital has several operational advantages when hyperbaric medicine is integrated with established clinical departments.
A patient with a complex diabetic foot wound may need vascular imaging, revascularization, debridement, antimicrobial therapy, offloading, glucose management, and rehabilitation. A patient with a compromised free flap may require immediate evaluation by the reconstructive surgeon. A patient with necrotizing infection may need repeated operations and intensive care.
Hospital integration can provide direct access to:
- Operating rooms
- Emergency medicine
- Critical care
- Diagnostic imaging
- Laboratory services
- Vascular intervention
- Infectious disease consultation
- Pharmacy
- Respiratory therapy
- Rehabilitation
- Blood bank and transfusion services
This infrastructure is especially important because HBOT is an adjunctive treatment. CMS states that covered hyperbaric therapy should not replace successful standard therapeutic measures. (Centers for Medicare & Medicaid Services)
A chamber located within or closely connected to a hospital may reduce fragmentation, but physical proximity alone does not create clinical integration. Referral pathways, communication responsibilities, emergency procedures, and continued ownership of the underlying disease must be defined formally.
Outpatient Wound Centers Have Become a Common Growth Model
Many hospital hyperbaric programs are developed within outpatient wound centers. This model may use one or more monoplace chambers to treat stable patients during regular weekday hours.
The model can be attractive because it combines:
- Recurring outpatient visits
- Existing wound-care referrals
- Shared nursing and administrative infrastructure
- Hospital outpatient reimbursement
- Coordination with vascular and surgical services
- Predictable treatment scheduling
Medicare’s current claims-processing guidance identifies G0277 as the hospital outpatient facility code for full-body chamber treatment per 30-minute interval. The guidance states that G0277 is not available for use outside a hospital outpatient department in the same manner. Physician attendance and supervision are generally reported separately with CPT 99183. (Centers for Medicare & Medicaid Services)
This reimbursement structure has contributed to the hospital outpatient model, but it does not guarantee profitability. Revenue depends on completed treatments, payer contracts, medical necessity, documentation, denials, staffing expense, chamber utilization, and the number of patients who complete their prescribed courses.
A hospital should not open a program solely because reimbursement exists. It should establish that enough clinically appropriate patients can access and complete treatment without relying on unsupported indications or excessive utilization.
Tertiary Hospitals May Develop Critical-Care Capability
A smaller group of hospital programs is designed to treat emergency and high-acuity indications.
These may include:
- Arterial gas embolism
- Decompression sickness
- Severe carbon monoxide poisoning
- Acute traumatic ischemia
- Necrotizing soft tissue infection
- Compromised replantation or reconstruction
- Exceptional severe anemia when transfusion is impossible
Such capability generally requires more than an outpatient monoplace service. The hospital may need a multiplace chamber, inside attendants, chamber-compatible ventilators, infusion systems, advanced monitoring, respiratory therapy, critical-care nursing, and immediate physician availability.
The program must also coordinate with:
- Emergency medical services
- Regional poison centers
- Diving medicine resources
- Trauma surgery
- Intensive care
- Anesthesiology
- Neurology
- Cardiothoracic and vascular services
Emergency-capable programs may not produce the same predictable treatment volume as outpatient wound programs. Their value may instead involve regional preparedness, patient retention, support for complex hospital services, and access to time-sensitive treatment.
Hospitals should evaluate this strategic role separately from the routine outpatient business case. A program cannot claim 24-hour emergency capability unless a complete chamber team can be mobilized reliably outside normal operating hours.
Regional Hub-and-Spoke Networks May Support Growth
Not every hospital needs its own hyperbaric chamber. In some regions, a hub-and-spoke model may provide better coverage.
Under this model:
- Community hospitals identify possible indications.
- A regional hyperbaric physician provides early consultation.
- Emergency stabilization begins locally.
- Transfer criteria are defined in advance.
- A tertiary center accepts complex or critical patients.
- Stable patients may receive follow-up treatment closer to home.
This approach can be especially useful for carbon monoxide poisoning, diving emergencies, gas embolism, acute traumatic ischemia, and complex radiation injuries.
A regional model requires more than a referral phone number. It should establish:
- Medical acceptance criteria
- Transfer pathways
- Transport altitude considerations
- Required records and imaging
- Stabilization expectations
- After-hours contacts
- Return-transfer and follow-up plans
Hospitals should also map the actual travel burden for outpatient patients. A prescription for 30 or 40 weekday treatments may be clinically reasonable but practically impossible when the patient lives several hours away and lacks reliable transportation.
Accreditation Is Becoming More Important as Programs Expand
Growth increases the need for standardization. Hyperbaric medicine combines medical treatment, pressure-vessel operation, oxygen fire risk, environmental control, and restricted access to patients under pressure.
UHMS accreditation evaluates the facility as a complete clinical system. It reviews staffing, training, equipment, maintenance, safety practices, documentation, patient care, and quality improvement. UHMS states that its accreditation program is recognized by The Joint Commission as a complementary accrediting organization under a cooperative initiative. (UHMS)
Accreditation may help a hospital:
- Structure program development
- Validate safety systems
- Standardize staff competencies
- Strengthen referral confidence
- Prepare for external review
- Demonstrate organizational commitment
- Identify gaps before an adverse event occurs
Accreditation does not replace state licensure, hospital accreditation, FDA requirements, NFPA compliance, ASME pressure-vessel standards, or payer rules. It adds specialty-specific scrutiny to those broader obligations.
A growing program should incorporate accreditation expectations during planning rather than trying to reconstruct policies, staffing files, and maintenance records shortly before a survey.
Fire Safety Is Central to Responsible Expansion
Hyperbaric chambers expose patients and equipment to increased pressure and, depending on chamber design, highly concentrated oxygen. These conditions require strict ignition prevention, material control, grounding, maintenance, and emergency preparation.
In August 2025, the FDA issued a safety communication after receiving reports of fires involving HBOT devices that resulted in serious injuries and deaths. The agency instructed facilities to follow manufacturer requirements, maintain fire-prevention measures, use proper grounding, train staff, supervise patients throughout treatment, follow maintenance schedules, and control electrical, static-producing, and incompatible items. (U.S. Food and Drug Administration)
The FDA also confirmed that HBOT devices are Class II medical devices cleared through the 510(k) process and can be identified under product code CBF. (U.S. Food and Drug Administration)
Program growth should therefore include proportional investment in:
- Hyperbaric safety leadership
- Product and dressing review
- Preventive maintenance
- Fire drills
- Staff competency validation
- Environmental monitoring
- Chamber-approved clothing
- Equipment compatibility
- Adverse-event reporting
Adding another chamber without adding the staff, maintenance capacity, and safety oversight required to operate it can increase risk rather than access.
Workforce Availability Can Limit Expansion
Hyperbaric medicine requires personnel with specialized clinical and technical competencies. A hospital may have sufficient referral volume and capital but still be unable to operate safely because qualified staff are unavailable.
The team may include:
- Hyperbaric medical director
- Credentialed attending physicians
- Advanced practice providers where permitted
- Registered nurses
- Hyperbaric technologists
- Chamber operators
- Inside and outside attendants
- Respiratory therapists
- Hyperbaric safety director
- Program manager
- Revenue-cycle personnel
The challenge is not only recruitment. Staff must complete hyperbaric education, chamber-specific orientation, supervised clinical experience, emergency simulation, and continued competency validation.
Workforce fragility can be significant. A program dependent on one physician, one technologist, or one safety specialist may close temporarily when that individual is ill, resigns, retires, or cannot provide after-hours coverage.
Hospitals considering expansion should evaluate staffing redundancy before purchasing additional equipment. The theoretical chamber capacity has little value when the organization cannot staff every active treatment safely.
Technology Has Made Some Programs More Operationally Feasible
Modern chambers may include digital pressure controls, treatment-profile displays, integrated environmental monitoring, improved communications, and more complete treatment-data capture.
These advances can support:
- Consistent compression and decompression
- Timed oxygen periods and air breaks
- Environmental alarms
- Treatment verification
- Electronic documentation
- Preventive maintenance tracking
- More effective patient observation
Technology has also improved the ability of selected hospital programs to treat ventilated or critically ill patients. Chamber-compatible monitoring, ventilators, infusion systems, and communication equipment can allow necessary organ support to continue under pressure.
These advances do not reduce the need for trained personnel. Automated chamber controls cannot perform a neurologic examination, recognize subtle confusion, manage a seizure, correct a failing airway, or determine whether a treatment should be stopped.
Expansion based on technology should therefore focus on improved safety and clinical capability rather than reduced staffing.
Reimbursement Supports Growth but Also Creates Compliance Risk
Hospital outpatient reimbursement can make a hyperbaric program financially viable, particularly when chambers maintain appropriate utilization. The economic model remains sensitive to reimbursement changes, payer mix, staffing costs, treatment completion, denials, and capital expense.
A 2024 analysis of Medicare payment trends reported that the estimated total Medicare cost of a 40-treatment course decreased from approximately $27,562 in 2013 to $23,834 in 2022. The estimated 2022 cost per session was approximately $596. These figures represent national Medicare payment analysis, not the expected revenue or contribution margin for a specific hospital. (PubMed)
Hospitals must build projections from their own:
- Contractual allowed amounts
- Payer mix
- Collection rates
- Authorization requirements
- Labor costs
- Oxygen and supply expense
- Maintenance contracts
- Cancellation rates
- Chamber capacity
- Capital and construction costs
A high charge per treatment does not establish a high margin. The program must account for preparation time, cleaning, safety checks, compression, decompression, documentation, maintenance downtime, and patients who discontinue before completing the planned course.
Utilization Must Be Clinically Defensible
Hyperbaric services have received sustained federal scrutiny because of concerns about medical necessity, supervision, coding, and excessive treatment.
A CMS prior-authorization demonstration was implemented in three states selected for high HBOT utilization and claims error rates. Approximately 113 providers were affected. The program was designed to review documentation before nonemergent treatment for selected conditions and reduce payment for services that did not satisfy coding, coverage, and medical-necessity requirements.
Federal audits and enforcement actions have also identified improper HBOT payments. One Office of Inspector General audit found that only 5 of 120 sampled outpatient claims reviewed through a Medicare contractor complied with requirements, with an estimated $39.3 million in potential overpayments associated with nonsampled claims. (Health OIG)
Other federal settlements have involved allegations concerning medically unnecessary treatments, excessive units, inadequate supervision, and failure to meet provider-based billing requirements. (Health OIG)
These findings should not be interpreted as evidence that hospital HBOT is inherently improper. They show that growth without strong utilization controls can create repayment, penalty, and reputational risk.
A responsible program should verify:
- The qualifying diagnosis
- Required standard therapy
- Severity and staging criteria
- Medical necessity
- Treatment prescription
- Physician supervision
- Objective clinical response
- Continued-treatment justification
- Correct professional and facility coding
Chamber availability must never become the reason a patient continues treatment.
Outsourced Management Can Accelerate Growth but Requires Oversight
Some hospitals develop hyperbaric programs internally. Others contract with companies that provide program development, staffing assistance, referral support, operational systems, or wound-center management.
Contracted models may offer:
- Startup expertise
- Recruitment support
- Standardized policies
- Revenue-cycle processes
- Data dashboards
- Marketing and referral development
- Accreditation preparation
They can also create governance challenges when the hospital assumes that clinical and compliance responsibilities have been transferred to the contractor.
The hospital remains responsible for patient care delivered under its name, facility billing, medical-staff privileging, life safety, equipment maintenance, and compliance with provider-based requirements. Contract language should define authority, reporting, clinical independence, quality review, and responsibility for correcting deficiencies.
Financial incentives should not reward unnecessary treatment volume. The medical director must retain authority to decline a referral, modify a course, or discontinue HBOT when further treatment is not clinically justified.
Growth Should Be Measured Through More Than Treatment Volume
Chamber utilization is important, but it is not an adequate measure of program quality.
A mature hospital program should track:
- Qualified referrals
- Referral-to-consult conversion
- Authorization approval
- Treatment completion
- Clinical outcome by diagnosis
- Wound closure
- Amputation
- Radiation-related symptom improvement
- Graft or flap salvage
- Treatment complications
- Emergency decompression
- Barotrauma
- Glucose-related interruptions
- Documentation deficiencies
- Denials and recoupments
- Patient travel and treatment burden
Outcomes should be stratified by diagnosis. Combining diabetic foot wounds, radiation cystitis, carbon monoxide poisoning, and compromised flaps into one overall success rate provides little useful information.
The hospital should also examine whether HBOT changes meaningful downstream outcomes. These may include fewer operations, reduced transfusion requirements, preservation of reconstruction, shorter wound-care duration, improved function, or reduced hospitalization.
The Business Case Should Include Downstream Service-Line Value
HBOT may strengthen several hospital service lines even when direct chamber margin is modest.
Potential downstream relationships include:
- Limb preservation
- Vascular surgery
- Podiatry
- Orthopedics
- Infectious disease
- Radiation oncology survivorship
- Urology
- Colorectal surgery
- Plastic surgery
- Trauma
- Rehabilitation
This value should be calculated carefully. A hospital should not attribute every subsequent laboratory test, admission, or surgical procedure to the hyperbaric program.
A useful financial framework separates:
- Direct HBOT revenue and expense
- Attributable downstream contribution
- Documented cost avoidance
- Strategic regional value
This prevents double counting and allows leadership to see whether the program is operationally self-sustaining.
Some Hospitals Should Expand While Others Should Build Referral Partnerships
Not every organization with a wound center needs a chamber.
Expansion may be reasonable when the hospital has:
- Documented eligible referral volume
- Meaningful patient outmigration
- Established vascular and surgical support
- Radiation survivorship demand
- Qualified medical leadership
- Adequate staffing redundancy
- Favorable payer contracts
- Appropriate construction space
- Long-term maintenance resources
- Commitment to accreditation and quality measurement
A referral partnership may be more appropriate when:
- Eligible volume is low
- Another qualified center is nearby
- Staffing cannot be sustained
- Construction or fire-safety requirements are prohibitive
- The hospital cannot support emergencies or complications
- Financial viability depends on unsupported indications
- Patients would be better served through regional coordination
The appropriate growth strategy may be an additional chamber at an established center, a new outpatient service, a regional critical-care hub, or no new chamber at all.
Sustainable Growth Requires Clinical Discipline
The growth of hyperbaric programs in hospitals reflects genuine clinical needs. Diabetes-related limb complications remain substantial, cancer survivors require management of delayed treatment effects, and complex trauma and reconstruction create time-sensitive tissue-salvage problems. (CDC)
Hospital infrastructure can make HBOT safer and more coordinated by connecting the chamber with surgery, vascular care, infectious disease, oncology, emergency medicine, and critical care.
That same infrastructure also creates an obligation. Programs must resist the pressure to fill chambers with marginal indications, fixed treatment courses, or patients whose principal barriers have not been addressed.
The strongest growth model is not the one that produces the most treatments. It is the one that identifies appropriate patients, integrates HBOT with definitive care, measures meaningful outcomes, protects safety, and remains financially sustainable without depending on overutilization.
