CEO Report: Culture and Cost of Outpatient Care - Ambulatory Surgery and the Transformation of our Health System

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August 1, 2013 Volume 77, Number 8
CEO Report: Culture and Cost of Outpatient Care - Ambulatory Surgery and the Transformation of our Health System Paul Pomerantz

This issue of the NEWSLETTER has given me pause to reflect on experiences early in my career and the impact of the trend toward ambulatory care on the health system. I would argue that this trend is possibly one of the most significant over the last three or more decades in terms of its impact on health policy and the delivery of care.

In 1980, soon after earning my M.B.A., I started a position at Thomas Jefferson University Hospital in Philadelphia as manager of several departments, including what was then termed the “Short Procedure Unit.” At the time, this was considered a major innovation, a place in the hospital where surgery patients would be admitted and discharged on the same day. The SPU (or “spew,” as we called it) was placed in an old section of the hospital. Patients were prepared and recovered in semi-private rooms. There were two staff members dedicated to admission and administrative processing. The nursing staff rotated from among the surgery staff. There were no dedicated O.R.s or anesthesia staff.

The SPU was an early pilot launched at the behest of Blue Cross of Greater Philadelphia, under the assumption that shorter hospital stays meant lower cost. Fast forward more than 30 years, and the ambulatory setting predominates for surgery. Hospitals across the country have restructured to provide this surgery in dedicated units with dedicated staff. An industry of day surgery centers has emerged with its own trade organization and accreditation programs. Today, ambulatory surgery is being further disrupted by “office-based” surgery; this, too, with its own accreditation program.

We have learned over these years that shorter stays and ambulatory surgery do not necessarily lead to lower costs. Short stays are often more resource-intensive and require new, often expensive, enabling technologies. Nonetheless, there have been critical benefits that have changed our health system forever.

The first is a focus on the experience, convenience and comfort of the patient. When I first started in hospital administration, our focus was on the convenience of physicians – often at the inconvenience of patients – because physicians drove admissions and business to the hospital. Ambulatory surgery was one aspect of a trend geared to a more patient-centered, customer-friendly health system, which also included the advent of urgent care centers (to replace crowded emergency rooms and long waits). These innovations raised expectations of consumers. Patients greatly value convenience and prefer preparing and recovering from surgery in the comfort of their own homes. Longer hours, shorter waits and services available close to home are important criteria for patient decision-making. The influence of the patient on the process of care is all around us, as evidenced by the growing importance of patient-reported measures of quality and outcome.

Second, and related, is that we have, over the last three decades, consistently re-engineered surgical, anesthesia and information technology, as well as the process of care, to provide for the shortest possible stays. Ambulatory surgery is much more than a short stay. It is a system of care that focuses science on both efficiency and safety. It requires cross disciplinary collaboration and teamwork.

The foundation of ambulatory surgery is safe anesthesiology, something (such as safe flying) often taken for granted. In a system of high turnover, unplanned errors and complications are very costly. As this issue of ASA NEWSLETTER attests, anesthesiologists are leaders in the science, process and policy behind ambulatory surgery. I recently had the pleasure to attend the spring Board meeting of the Accreditation Association for Ambulatory Health Care. Especially noteworthy was the strong presence and participation of our specialty representing ASA, the Society for Ambulatory Anesthesia and other organizations.

Today, more than 20 million ambulatory procedures are performed each year in the U.S. The period from 1996 to 2006 saw a 300-percent increase in ambulatory surgery center visits. Procedures that wouldn’t even be considered 20 years ago are now performed routinely and safely. But we still have much work to do to realize the full potential of outpatient care.

The demand for ambulatory care will only increase as a result of patient demand as well as the pressures from health care restructuring and reform. As much as anesthesiology has done to support this trend, even more will be required in the future. This is, of course, only one of many constant changes and challenges that our members must address and where ASA, through your leadership, volunteer network and staff, seeks to support you.

Our best wishes for a pleasant end of summer. I look forward to meeting many of you in San Francisco in October at the annual meeting.

Paul Pomerantz is ASA’s Chief Executive Officer.