After 25 years of growth, the future looks bright — but brace for changes
Challenges include technology, reimbursement, regulations, and staffing
What should outpatient surgery managers be prepared for as we celebrate a quarter-century milestone and look to the future? To put it plain and simple: Expect more growth, with all the joys and headaches that go along with it. The news isn’t good for everyone, however. Many procedures are moving from hospitals to surgery centers to physician offices. Surgery centers should prepare to lose many cases that have served as the "bread and butter" of their caseload, warns Scott Becker, JD, CPA, partner with Ross & Hardies in Chicago. "This may include, for example, gastroenterology cases, [ear, nose, and throat] cases, and pain management cases," he says. (For more on the move of procedures into physician offices, see Same-Day Surgery, November 2000, p. 133.)
Also, new therapies involving minimally invasive techniques and pharmaceuticals will change the need for surgical intervention, says Eric Zimmerman, JD, MBA, an attorney at McDermott, Will & Emery in Washington, DC. One example is a new gastrointestinal diagnostic tool that is swallowed like a pill, he says. "Whereas patients used to, and still do to a large extent, need to be treated in a surgical environment to image the [gastrointestinal] tract, they now can receive the same service without surgery," he says. (Look for more information on this pill in upcoming issues of Same-Day Surgery.)
Technology and reimbursement have influenced the shift of cases to offices, sources says. "Sometimes the staff will go there, too," warns Kay Ball, RN, BSN, MSA, CNOR, FAAN, educator/consultant/author in Lewis Center, OH, and past president of the Denver-based Association of periOperative Registered Nurses.
Offices will perform more procedures and perform them more frequently, says Jennifer Marks, MPH, acute care product manager at SMG Marketing in Chicago. "We expect continued growth in office-based surgery, although not in the exponential arena," she says. (See Projections of Surgical Procedures on our web site: www.same-daysurgery.com. Click on "toolbox" and look under "projections.")
On the positive side for freestanding facilities, technology advancements will move more complex procedures into freestanding centers and surgical hospitals, many sources predict. Becker says, "This includes general surgery cases, neurosurgical lower spine cases, and other cases for which reimbursement will be higher and the technological requirements of the surgery center also will be higher, but achievable." Expect to see a significant larger number of surgical hospitals, because they allow for profitability from imaging and more complex inpatient and outpatient procedures, he says.
The line between outpatient and inpatient surgery is becoming blurred, several sources point out. "As more and more ASCs [ambulatory surgery centers] mature into surgical hospitals," says Zimmerman, "the definition of outpatient surgery will continue to change, and the range of services that can be performed on an outpatient basis will continue to grow." (For more information on surgical hospitals, see "Your facility does what procedures? Surgical hospitals expand limits," Same-Day Surgery, March 2002, p. 29.)
Competition from traditional hospitals won’t go away, however, Marks predicts. "We anticipate hospitals will reposition themselves somewhat in marketing their outpatient surgery in order to make more headway in competition with the growth of the surgery center market," he says. For example, hospitals have started explicitly marketing their outpatient departments, she says. "They’re seeking patients who probably would go to an alternative care site," Marks says. "They’re not necessarily assuming they will go through the hospital."
Expect to see more joint ventures with hospitals, predicts Beverly Kirchner, RN, BSN, CNOR, executive vice president of Surgical Synergies Inc., a St. Louis-based company that develops and manages freestanding surgery centers. "Hospitals are starting to get smart," she says. "Physicians are going to build surgery centers. [Hospitals] can own a piece of the pie or none of it."
Rick Wade, senior vice president of the Chicago-based American Hospital Association, says that technology is one of the primary factors driving hospital-physician partnerships. "Physicians will find it very attractive as partners, and hospitals will find it a very good long-term move, in terms of stability, to be in partnership with their physicians," he says. The long-term outlook is strong for hospital-based and hospital-affiliated outpatient surgery, Wade says. In addition to technology, he points to two factors: hospitals’ longtime experience with quality oversight and the increasing headaches associated with professional liability, including rising premiums. "Coverage is going to be an issue for all outpatient surgery," he says. "Freestanding, doctor’s office, and hospital-affiliated programs are going to have to have coverage, and the market for that coverage is shrinking, not expanding."
Overall, however, outpatient surgery managers have reason to be optimistic, Zimmerman and others say. "The same pressures that led the migration of more and more surgeries from hospitals to freestanding facilities in the last 25 years — i.e., (1) increasing cost pressures from employers and third-party payers; (2) the rapid pace of technological advancement; and (3) physician interest in regaining control over patient care — are all still present and strong, and therefore, will continue to push more procedures to the outpatient setting," Zimmerman says.
Driving the growth of the field will be a continued boom in computer technology, endoscopic devices, and communication technology, Ball predicts. "Anything that helps the patients get back to their activities of daily living quicker will be what is accepted," she says.
Stay updated on the current technology by reading journals, newsletters, recommended practices, and benchmarks, because they will discuss practices that will become the standard of care, Ball suggests. "The standard of care will no longer be defined as having most practitioners or facilities doing something one way or another," she says. "The standard of care will be what is available that’s been shown to be safer. There-fore, the more expensive device may be chosen because it has been shown to be safer."
One side effect of the focus on safety is that surgery centers and hospitals will begin to specialize in different procedures, Ball predicts. For example, if a surgery center is able to provide safe technology, such as active electrode monitoring (AEM) for gall bladder removals, then they will be the ones who perform the procedures, she says. "The others who can’t afford the safer technology will be forced out of doing specific procedures from the high number of lawsuits they’ll experience," Ball predicts. (See more on AEM in upcoming issues of Same-Day Surgery.)
What’s the manager’s role?
As the same-day surgery field grows, so do managers’ responsibilities, such as keeping up with technological changes. "Managers need to stay current on what is new and innovative in surgery, including surgical instruments, drugs, and surgical techniques," Ball says. For example, managers are being held accountable for devices that have been available, such as AEM, and not been used in the OR, she says. The Federated Ambulatory Surgery Association in Alexandria, VA, is developing a credentialing program and certification test for outpatient surgery administrators that may be helpful, sources say. "It’s negligence to know that these devices are out there but not being purchased," Ball says. "It requires a considerable amount of time to keep up with regulatory changes."
That’s the manager’s job, says Lawrence Pinkner, MD, immediate president of the San Diego-based American Association of Ambulatory Surgery Centers and president of the SurgiCenter of Baltimore. "Someone has to know the rules and how they limit what you can possibly do," Pinkner says.
And don’t expect federal regulation to lighten up anytime soon, Zimmerman predicts. "New quality pressures, for example, are likely to lead to a new layer of federal and state regulatory requirements," he adds. "Moreover, as more and more ASCs mature into surgical hospitals, they will be incurring the vast array of additional regulatory requirements applicable to hospitals."
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