Home that Afternoon: New Techniques and Technology, Cost Pressures Drive Transition to More Outpatient Procedures

Heath Journal ArticleThe Health Journal / Published 2010 / By Karen Haywood Queen

Almost 25 years ago, Kathy Santini had to have open abdomen surgery to remove her gallbladder. Laparoscopic gallbladder surgery, where the surgeon makes a few puncture marks and removes the organ through the belly button, was a new technique that many surgeons weren’t yet using.

“I was in the hospital four or five days,” says Santini, now vice president of surgical services at Bon Secours Richmond Health System. “I had to be off work for six weeks so the lining under my skin could close and heal. And I could work only half days at first. I had a bunch of restrictions. Once you open someone’s abdomen, you’re affecting a lot of systems. It was a big deal.”

Today, 54 percent of gallbladder removal patients have outpatient surgery, meaning they are able to go home within 23 hours, according to a 2010 report for the Agency for Healthcare Research and Quality (AHRQ). Looking beyond gallbladders, 63 percent of all surgery patients in hospitals did not have to stay overnight in 2005, compared to 51 percent in 1990 and just 16 percent in 1980, the AHRQ says.

Any surgery is still a big deal. But new surgical techniques and technologies that minimize incision size, blood loss and tissue trauma have made faster recoveries possible, says John S. Hudson, director of surgical services at Sentara CarePlex Hospital in Hampton. For example, a laparoscope—a long metal tube with a camera lens at the end— allows a surgeon to see what he or she is doing without having to make a long incision. In some cases, a surgeon is able to remove the tissue or affected organ through one of the body’s natural openings.

Often, the benefits of the new techniques go beyond just avoiding a stay in the hospital.  Patients who have laparoscopic procedures generally return to normal function and work several weeks earlier, Hudson says.

The cost factor

The other factor driving the shift to outpatient surgery is pressure on insurance companies and other third-party payers such as Medicare and Medicaid to reduce rising health care costs, according to the AHRQ and physicians.

“A lot of this got driven by the insurance business,” says Dr. Wilhelm Zuelzer, Chief of Perisurgical Services at VCU Health Systems in Richmond. “It’s ultimately cheaper to do an outpatient surgery rather than inpatient.”

Across the board, the mean charge for all ambulatory surgeries was $6,100 compared to $39,900 for inpatient surgeries, the AHRQ says. But it’s difficult to make an exact comparison between the same surgery done as an outpatient and inpatient basis because surgeries and patient conditions that do require a hospital stay are, by their very nature, more complicated and likely to be more expensive.

Patients can get outpatient surgery in hospital outpatient centers and in a growing number of stand-alone outpatient surgery centers. Since the stand-alone ambulatory surgery centers don’t have the added expenses of hospital emergency rooms and critical care units, they can offer even more savings compared to a hospital outpatient department, notes Jay Schukman, regional vice president
and medical director with Anthem Blue Cross and Blue Shield in Virginia.

Top outpatient procedures

The top six outpatient surgeries and procedures performed in ambulatory surgery centers billed to Medicare in 2009 were all related to cataracts and digestive tracts.  Procedures done on the eye, ear, nose and mouth were predominantly outpatient.

Colonoscopy and biopsy was the most commonly performed outpatient procedure, an AHRQ study found. About two-thirds of procedures on the skin, digestive tract and urinary tract were outpatient, AHRQ says.

The most significant shifts in the last decade have been in the areas of gynecology and general surgery, due to the use of laparoscopic techniques, Hudson says. Gynecologists now perform hysterectomies using a total laparoscopic approach, allowing women to go home the same day and often return to work within a few weeks. The once common tubal ligation for prevention of pregnancy is now rare, replaced by a simple procedure performed in the doctor’s office, he says. Weight loss lap band surgery is also being done on an outpatient basis, he says.

Dr. Gregory FitzHarris, a colon and rectal surgeon at Sentara Surgery Specialists in Hampton, is enthusiastic about a less invasive technique for removing large polyps in a patient’s mid to upper rectum, lesions that are too far up to reach with a retractor. With the old technique, the surgeon opens up the patient, remove a portion of the rectum and resections the rectum. The patient stays in the hospital three days to a week and is off work four to six weeks. Using the newer technique (official name: transanal endoscopic microsurgery), the surgeon blows up the rectum with carbon dioxide and removes the polyp. The patient is usually back to work within two days, he says.

“I just did one lady and I finished the surgery around 10:30 a.m. and she went home around 3 p.m.,” FitzHarris says. “Most leave the same day. There’s very little pain involved and very little disability.”

Patient selection is important

Outpatient surgery isn’t for every procedure or every patient. People who are older or obese and have what doctors call core morbidities—high blood pressure, diabetes and heart problems. “We have to fine tune the outpatient surgery,” Zuelzer says. “You have to individualize it. You have to look at the home situation.”

A younger, healthier patient with good social/family support may be able to have procedures done on an outpatient basis that an older patient with chronic conditions and poor social support may not, Hudson says. Important considerations are pain management, post-procedure monitoring and therapies, and insurance coverage.

“There’s no reason for a patient to be in the hospital if he doesn’t need to be,” says Shirley Gibson, interim vice president of nursing for VCU Health System. “The hospital is a very expensive place to be. [However, with] inpatient you have nurses there always, you have the labs there always. You can look in on the patient, pay attention to nuances.”

If a patient doesn’t have family or friends who can step in and help, the patient may be transferred from the hospital to a skilled nursing care facility instead of going home, at about one-eighth to one-tenth the cost of a hospital, Schukman says.

Doctors, their patients and hospitals don’t always have much choice—at least if they want the extra time in the hospital to be reimbursed by the patient’s insurance company. “It’s not where somebody can say ‘I want to stay in the hospital three days,” Zuelzer says. “A herniated disc used to be three days in the hospital. Now it’s considered a 23-hour outpatient procedure. If the patient or doctor says ‘I don’t feel comfortable going home today’ it’s still a battle with insurance.”

Some in the medical field worry that too much pressure is coming from health insurance companies to save money by discharging patients quickly. For example, Santini says the hospital has just been informed by an insurance company that laparoscopic gastric bypass surgery is now an outpatient procedure. That means the hospital now has to negotiate with the insurance company for every patient they feel needs to be hospitalized.

“If a procedure is designated outpatient by a third party payer and you’re there for 48 hours, you’re still an outpatient,” Santini says. “They call that ‘an outpatient in a bed.’”

Physicians can advocate for insurance companies to cover a longer stay, but often, “They’re not going to reimburse for more than they pay for an outpatient procedure,” Santini says. “Outpatient rates are obviously a lot lower than inpatient rates. For a procedure that has been polled as outpatient, we sometimes don’t come anywhere near making the cost, let alone breaking even or making a profit.”

On the flip side, some patients have requested to remain in the hospital solely for convenience, says Schukman says.  “Someone might say, ‘My husband doesn’t want to take off work today to pick me up, so I’m going to stay overnight and he can pick my up tomorrow. When they’re paying several thousand dollars a day for a hospital room, it’s not appropriate to stay for convenience. You’re paying that bill and we’re all paying that bill in our insurance rates.”

Tree of Life: Giving People with Brain Injuries Hope and a Future

The Health Journal /Published 2010 / By Karen Haywood Queen

Health Journal: Brain Injury TreatmentWhen “Lisa” came to Tree of Life in 2002, she drank too much, needed psychiatric care for depression, could not walk up steps or on uneven ground, had gained 50 pounds and needed 24-7 care because of her brain injury, suffered in a car accident. Now Lisa, who wishes to remain anonymous, has lost the weight, gained a boyfriend, conquered the drinking problem and run a 5K. She works part time in retail and lives in a supervised apartment.

Lisa and others who’ve suffered traumatic brain injury say they have been transformed by a comprehensive rehabilitation program at Tree of Life, a private facility for brain injury patients located in Richmond.

Lisa originally went to a residential facility and outpatient rehab in Michigan, where she lived at the time of her accident, say her parents, who live in Williamsburg. But instead of getting the help she desperately needed, Lisa was raped by one of the center’s drivers.

“She was so without hope [after that] that she said she no longer wanted to live,” says Lisa’s mother. “She was extremely depressed. She was extremely damaged mentally.”

So Lisa’s parents, who, because of the nature of their daughter’s injuries, have also requested anonymity, began looking for another place where their daughter could at least be safe and possibly rehabilitated.

“We went to see a lot of places in Michigan,” says Lisa’s father. “Every one we saw was like a dog kennel. People were just shoved into rooms. They didn’t even have their sheets changed sometimes. Basically, it was a storehouse for damaged people.”

Then they found Tree of Life. “We were welcomed with open arms,” says Lisa’s father. “The house was very warm, very family-oriented. The people who spoke to us were so kind, so welcoming. I knew this was the place where she could recuperate.” An added bonus: Tree of Life is less than an hour’s drive from their home in Williamsburg.

Internationally known neuro-rehabilitation physician Dr. Nathan D. Zasler started Tree of Life in 1997 with a five-bedroom house and one patient. The goal: to help people with brain injuries achieve as much independence as possible. Zasler teaches in the departments of physical medicine rehabilitation at both Virginia Commonwealth University and the University of Virginia schools of medicine and has lectured and written extensively on the unique challenges of rehabilitating brain injury patients.

Zasler saw the need for a long-term program, one that worked with such patients beyond the acute rehab and therapy patients receive immediately following an accident or other event that caused the brain injury.

Tree of Life has grown to a full staff including physical therapists, cognitive behavioral therapists, neurorehabilitation psychologists and others. During the day, staff-to-patient ratios are at least one-to-one, Zasler says.

Tree of Life is not a hospital, nursing home or adult day care center. Therapy works toward getting patients back into the community as fully as possible. Patients come from all over the East Coast and as far west as Illinois and Michigan, he says.

A typical day might include formal one-on-one therapy, a group therapy session, recreation time, music, art, and a meal out at a restaurant. Average transitional length of stay is six to 12 months.

The cost is high—about $650 a day. But that cost includes room and board and more important, 24-7 access to Zasler, Tree of Life’s medical director, and Dr. Michael F. Martelli, director of neuropsychology. A patient who needed 24-7 supervision from a certified nurse assistant might pay almost $400 a day, not including room and board, Zasler says.

The recovery time for people with brain injuries is longer than usually funded by commercial or government insurance, Zasler says, so almost all of the patients rely on workers’ compensation to help pay for care. “Unfortunately for people with these type of injuries, insurance won’t pay for long-term care or transitional care,” he explains.

Among Zasler’s goals: to educate private and federal insurance programs across the country about the many benefits of neuro-rehabilitation services. Even though a rehabilitated patient may still be considered 100-percent disabled and not necessarily able to get a job on his or her own, even a part-time job and the social life enabled by the program offers a huge benefit.

“It’s more than just the financial benefits of working,” Zasler says. “There are the psychological benefits, the social benefits. Many of these people with brain injuries are socially isolated. We’re getting these people out of their homes and into the community.”

Lisa is still in the program, living mostly independently in one of Tree of Life’s apartments. She still needs the supervision, her parents say. “But if you would talk to her now, you might not even know she had a brain injury,” her mother says. “Her recovery is absolutely a miracle. Yes, it’s due to her efforts. It’s also due to Tree of Life. They gave her hope. It’s an incredible transformation.”

Tree of Life employs the “bio-psycho-social” model in treating patients—another way to say the program approaches treatment from the physical, emotional and social aspects (i.e., treating the “whole person”).<b> “We want to understand who the person was before their injury,”</b> Zasler says. “One of the mistakes other programs make is they don’t take enough time to figure [that out].”

She delivers without fail …

Karen is among the finest reporters with whom I have worked. I save the most complex assignments for her: No subject is too complex for Karen. She keeps in close contact when necessary, and she consistently demonstrates the flexibility needed for any daily news publication focused intently on enterprise news. She delivers without fail the delicate mix of clarity, brevity and precision I seek from my top guns.

–Brett Brune, former editor of Smart Grid Today