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

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.”