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August 1, 2013 Volume 77, Number 8
What’s New In ... Office-Based Anesthesia - Preparing for Tomorrow Girish P. Joshi, M.D., M.B.B.S., FFARCSI, Committee on Ambulatory Surgical Care
Meena S. Desai, M.D., Committee on Ambulatory Surgical Care



Over the past decade there has been a significant growth in office-based procedures.1 Concurrently, office-based anesthesia (OBA) practice has grown rapidly. Economic forces are the primary factors driving office-based surgery (OBS) and OBA practices. The benefits of OBS/OBA practices are well described and include patient convenience, comfort and cost efficiency. The procedures performed in offices burden the healthcare system less because offices do not receive facility fees, although the physician fees are slightly enhanced. Thus, it is not surprising that the Centers for Medicare & Medicaid Services (CMS) has gradually increased the number of office-based procedures that would be covered for its beneficiaries, as well as liberalized the procedure and recovery period time constraints. Third-party payers have accepted the definitions and regulations of CMS. Thus, there has been a significant enhancement of procedures that are covered in the office setting. However, a current sampling of administrative and clinical listserves show no new additions by CMS, to the site of service differentials, to encourage the movement of procedures that may be performed in the office setting.


Recent changes in health care have created significant uncertainty regarding the projected growth in OBA practice. There is an emphasis on the integrated care approach, which has resulted in development of accountable care organizations (ACOs) or coordinated care organizations (CCOs). Also, it is expected that there will be a move from a fee-for-service payment system to a fixed payment concept. It is not surprising, therefore, that several major hospital systems are acquiring independent ambulatory surgery centers (ASCs). However, there is a concern that these changes might influence OBA practice, as it is without an apparent “niche.” In fact, at no time in recent memory have forces on the health care marketplace been as fluid as today. This volatility adds a tremendous uncertainty, particularly to the less traditional venues such as OBA practice.


Furthermore, reports of high complication rates in the office setting have led to increased demands that the office-based setting should be required to fulfill the same standards currently imposed on ASCs.2,3 This has resulted in an increase in regulations and requirements for accreditation of office practices.4 Such changes would increase the “cost of doing business” and impose a significant economic burden on office-based practices. The loss of revenue due to increasing costs has led to use of “creative” approaches. In several states, accreditation is required if intravenous sedation is used in the office setting. To avoid the need for accreditation procedures that were previously performed using intravenous sedation, procedures are now being performed with local anesthesia and oral sedatives and analgesics. If the patient does not tolerate the procedure, it is cancelled, but the surgeon still receives some payment. For example, in the Commonwealth of Pennsylvania the surgeon is paid approximately $3,500 for a hysteroscopy/ablation procedure. The payment for a cancelled procedure is $800, which is still greater than what is paid if the procedure were to be performed in the ASC or the hospital settings (i.e., $500). Also, physician extenders such as acute care nurses and paramedics are being used to facilitate pre- and post-procedure care in the office setting.


In this era of the evolving health care environment and uncertainty, it is necessary to understand how these changes will influence the OBA practice. What should one do to preserve and expand the OBA practice?


It is well recognized that patients are looking for convenience and thus would always prefer a facility closer to home while staying away from big hospitals that are intimidating and inconvenient. In addition, ambulatory facilities are more efficient than hospitals. A study using the propensity-matched national sample revealed that the top-10 ambulatory surgery procedures performed in ASCs are more efficient than hospital outpatient departments in terms of use of operative and non-operative times.5 Analysis of the same database showed that the incidence of delayed discharge and unanticipated hospital admission is lower in the ASCs.6 Also, one could assume that the peripheral networks of ASC should increase the flow of patients to hospitals. For the same reasons, one could speculate that the trend which has resulted in migration of procedures from hospitals to ASCs will result in movement of procedures from the ASC to the office venue. The fact that several health and hospital systems are acquiring ASC practices suggests that the value of these venues has been appreciated. Thus, it is possible that office practices will also be included in ACOs.


Because the site service differential allows surgeons greater reward for shifting services to the office, certain procedures will continue to be performed in the office setting. For example, prostate brachytherapy, which was a hospital procedure, is now performed in the office setting, as radioactive materials can be safely stored in offices. Similarly, newer treatments for benign prostate hyperplasia with bladder outlet obstruction (e.g., artificial urinary sphincter placements, Green light and Holmium lasers), which have replaced traditional extracorporeal shockwave lithotripsy (EWSL), can now be performed in the office setting. Also, gynecological (e.g., hysteroscopy, uterine ablation and mini laparoscopic tubal ligation) procedures should continue to be performed in the office setting.


In addition, procedures not typically covered by insurance are gaining a foothold in this environment of uncertainty. As the economy recovers, there might be an increase in cosmetic and reconstructive procedures, and thus the need for anesthesia services. Also, there may be an increase in anesthesia (sedation/analgesia) services for pain management procedures, particularly for those performed by our specialist colleagues (e.g., physician medicine and rehabilitation and neurology). Furthermore, the types of procedures that could be performed in offices keep increasing. For example, general surgeons are now providing care in offices for minimally invasive care and vascular procedures, such as shunt de-clotting for dialysis patients. The current themes of the growth of the OBA sector are also looking toward anesthesia services in allied health specialties such as dental anesthesia, including pediatric dental anesthesia.


There is a concern that once the procedure is established for the ASC/office location, the payers will reduce the payments for these services, which may further compromise the profitability and thus the feasibility of performing procedures in the office setting. With reduced remuneration and increased costs associated with office practices, there may be attempts to increase the volume, similar to the ASC practice. Thus, there may be an increase in sicker and older patients undergoing advanced and more complex procedures in the office setting. In addition, in an effort to improve efficiency and maximize the volume of cases, there may be attempts to achieve a rapid throughput and discharge the patients from the facility. This may actually jeopardize patient safety.


We “anesthesiologists” have always been in the forefront of improving patient safety. We can play a major role in improving safety and efficiency in the office practice. Best practices can be developed to guide appropriate patient selection and optimization, intraoperative care and postoperative management, including post-discharge care. However, these recommendations should be developed only in collaboration with our surgical colleagues7 as unilateral approaches are doomed to fail. Furthermore, it is critical that these are pragmatic and specific for the procedure and the venue – not all office practices are alike. Some offices are part of multispecialty medical groups that have diagnostic and support capabilities, while others are smaller, uni-specialty offices that are poorly staffed with no additional support capabilities. Just as not all hospitals or ASCs are alike, there should not be a one-size-fits-all approach. Anesthesiologists practicing OBA on a daily basis should be involved so as to avoid unrealistic recommendations that can actually be detrimental to day-to-day practice. Combined efforts of specialties and subspecialties are warranted as we innovate to take the best and most efficacious care of our patients in this environment. Recently, the Malignant Hyperthermia Association of the United States, or MHAUS, and SAMBA jointly worked to outline a transfer protocol for the OBA venue as it differs from the ASC venue in scope and services.8 Of note, a simple survey of OBA practitioners is not adequate, as phrasing of the survey questions can be biased and limited in scope, and thereby may influence the results in a deleterious and non-representative manner. Importantly, these recommendations will have to be dynamic and be modified when new information is made available.


In summary, although economic uncertainty coupled with changing oversight and the quality landscape pose many challenges for the office-based arena, there is a potential for further increase in OBA practice. However, we will have to embrace the move toward safety in the office setting. The ASA Committee on Ambulatory Surgical Care and the Society For Ambulatory Anesthesia (SAMBA) Committee on Office-Based Anesthesia have published a comprehensive document that can serve as an excellent guide to safe OBA.9



Girish P. Joshi, M.D., M.B.B.S., FFARCSI is Professor of Anesthesiology and Pain Management, and Director, Perioperative Medicine and Ambulatory Anesthesia, University of Texas Southwestern Medical Center, Dallas.

Meena S. Desai, M.D. is President and CEO, Nova Anesthesia Professionals, Villanova, Pennsylvania.


References:

  1. Avalere Health. Chart 3.14: percentage share of inpatient vs. outpatient surgeries, 1991 – 2011. In: Trendwatch Chartbook 2012: Trends Affecting Hospitals and Health Systems. Chicago: American Hospital Association; 2012:36. http://www.aha.org/research/reports/tw/chartbook/2012/chart3-14.ppt
  2. Desai MS. Office based anesthesia: new frontiers, better outcomes, and emphasis on safety. Curr Opin Anaesthesiol. 2008: 21(6):699-703.
  3. Starling J 3rd, Thosani MK, Coldiron BM. Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal. Dermatol Surg. 2012; 38(2):171-177.
  4. Desai MS. Why is everyone trying to accredit my office-based practice? ASA Newsl. 2010;74(6):14,56.
  5. Rosero EB, Adesanya A, Timaran CH, Joshi GP. Perioperative outcomes of ambulatory surgery in hospital settings and free-standing surgery centers in the United States [abstract S-03]. Anesth Analg. 2011;112(5)(suppl):S-03. http://www.iars.org/abstracts/11_Abstract_Supplement_FINAL.pdf. Accessed June 6, 2013.
  6. Rosero E, Joshi GP. Efficiency of free-standing ambulatory surgery centers and hospital-based ambulatory surgery departments in the USA: a propensity analysis [abstract S-13]. Anesth Analg. 2012;114(5)(suppl):S-13.
  7. Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC 3rd. Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. Obstet Gynecol. 2010;115(1):147-151.
  8. Larach MG, Dirksen SJ, Belani KG, et al. Creation of a guide for the transfer of care of the malignant hyperthermia patient from ambulatory surgery centers to receiving hospital facilities. Anesth Analg. 2012;114(1): 94-100.
  9. ASA Committee on Ambulatory Surgical Care; SAMBA Committee on Office-Based Anesthesia. Office-Based Anesthesia: Considerations for Anesthesiologists in Setting up and Maintaining a Safe Office Anesthesia Environment. Park Ridge, IL: American Society of Anesthesiologists; 2008. https://ecommerce.asahq.org/p-319-office-based-anesthesia-considerations-in-setting-up-and-maintaining-a-safe-office-anesthesia-environment.aspx. Accessed June 6, 2013.

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