Keep your eye on these hot stars in surgery
Cardiac care, noninvasive diagnostics to grow
How healthy is the outpatient sector of health care? At least one new report on the state of ambulatory care forecasts continued robust growth in new clinical services, particularly in outpatient surgery. And forecasters predict that barring any unforeseen circumstances, such as a severe economic downturn, ambulatory care facilities can expect years of new opportunities ahead.
The trend caps a nearly decade-long wave of optimism over outpatient care, which industry mavens have come to regard as a holy grail in stanching once-runaway inpatient care costs.
"As hospital inpatient payments continue to dwindle, we’ll see a greater emphasis on shoring up overall reimbursements through the outpatient suites," says David Foster, PhD, MPH, chief statistician with HCIA, a Baltimore research firm.
But the optimism may be overstated, according to some industry watchers. Front-line facility managers, who acknowledge there’s been phenomenal growth in the outpatient sector, tell a different story of counteracting forces:
• Most of the migration of services to the outpatient side has come at a heavy cost in expensive new laser and other technologies and capital investments, they say, and managed care, particularly heavy price discounting, has eaten away many of the financial gains.
Optimism notwithstanding, "administrators would be wise to continue a policy of carefully weighing the cost benefits of these new services," cautions Lynne Oliver, RN, MBA, CNOR, administrator of the freestanding Bellingham (WA) Surgery Center.
The temptation to achieve higher revenue should not be enough to make one leap blindly into this highly uncertain managed care environment, Oliver warns. (See related story, p. 128.) Indeed, it isn’t surprising that most of the projected growth in ambulatory surgery continues to occur in expensive high-tech services, says Foster, who extrapolated the data for Same-Day Surgery. Clearly, outpatient surgery has moved into the realm of more complex and technically intricate procedures and will continue to do so, he says.
Other factors driving the inpatient-to-outpatient migration, he says, include cutting-edge advancements in clinical research, alternative surgeries such as laser and keyhole procedures, new outcomes-oriented practice guidelines, developments such as 23-hour patient stays, increasing patient volume (for some procedures), and patient preference. "From the data, we can see where these new services are emerging," he adds. Here’s where to look and why:
• Cardiac surgery: aortic resections, arterial catheterizations, right and left cardiac caths, and arterial blood gas measures. Many of these are achieving high outpatient numbers and are expected to increase, Foster says, mostly due to pressure from payers. Cardiac surgery, among the most costly of inpatient procedures, faces increasing demand for lower-cost alternatives.
In its survey, HCIA examined Medicare hospital data between 1991 and 1994 and found startling percentage growth rates in these four services as they moved from the inpatient to outpatient sector.
For example, of 126,780 reported aortic resections done between 1991 and 1994, the number completed in outpatient settings more than tripled, growing to 1.22% from .34% of the total. Although small in real numbers, the procedure ranked 15th in HCIA’s top 20 ranked by percentage change, and it placed third in total volume among the top 20 behind intravenous disc excisions.
• Minimally invasive and noninvasive diagnostics. While laparascopic procedures have enjoyed enormous gains and continue to show strong growth potential, intense competition could undercut market share for individual providers, industry watchers say. A battle currently rages between facility-based and physician-office based providers. (For a recent history of surgical volume in the United States, see the graph, p. 127.)
But the HCIA report projects a strong outlook in varied specialties, including urinary cystoscopies, closed-lung biopsies, cerebral arteriograms, and vascular ultrasound. By 1994, for example, more than 26% of vascular ultrasound procedures were being performed in the outpatient setting, compared with 18.2% in 1991. Closed-lung biopsies jumped to more than 45% from less than 35%.
• Laser, imaging, and microsurgical procedures. The growth of many new same-day surgeries almost certainly will parallel new technology, Foster says. Six out of 10 surgeries now can be performed on an outpatient basis.1 (For a list of top surgical procedures, see chart, p. 127.)
New techniques such as laser-driven endometrial ablation are catching on in outpatient suites as suitable alternatives to more invasive inpatient procedures such as abdominal hysterectomies.
"The potential for technology in reducing time and improving outcomes is virtually reversing the inpatient-outpatient mix," observes Craig Stewart, chief financial officer of San Gorgonio Memorial Hospital in Banning, CA. Foster adds, "Technology and better science are clearly leading the charge in determining emerging new procedures."
• Age-related orthopedics and gastrointestinals. The nation’s graying population will intensify the large, lucrative market for endoscopic and arthroscopic surgeries, Foster says. Chicago-based SMG Marketing Group, which follows same-day surgery trends, says knee and shoulder arthroscopies were done at more than 50% of freestanding outpatient surgery centers in 1996. The numbers show a steady increase over time.
Fifty-eight percent of all laparoscopic and endoscopic procedures performed at outpatient centers consisted of colonoscopies and gastroscopies, according to SMG.
Reference
1. SMG Marketing Group. Freestanding Outpatient Surgery Centers Market Report, 1997 Edition. Chicago.
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