Note: Dr. Louis Levitt is quoted here as the surgical center chairman at Massachusetts Avenue. He is also the secretary of The Centers for Advanced Orthopaedics and practices with the Orthopaedic Medicine and Surgery division in Washington, D.C.

Getting beyond Joan Rivers: Bethesda center pushes for more outpatient surgery

By: Tina Reed 

Comedian Joan Rivers' death last month following a routine procedure in an outpatient surgery center cast a decidedly unflattering spotlight on the industry. Despite the recent bad press, a Bethesda outpatient surgery center says regulators and insurers should allow more surgical procedures outside the typical hospital environment.

Massachusetts Avenue Surgery Center officials say they have recently begun convincing insurers to pay for a growing number of outpatient joint surgeries, such as knee and hip replacements. And following an unsuccessful push earlier this year to change rules in Maryland to allow surgeries requiring overnight stays at outpatient centers, the officials are preparing to lobby the general assembly again next session to change an overriding state law that would allow them to perform surgeries that require overnight stays allowed under Medicare rules. The Centers for Medicare and Medicaid Services allow patients to stay up to 23 hours and 59 minutes.

"Our doctors have the same training, the same certification, the same equipment, the same protocols as any other facility,” said Randall Gross, Massachusetts Avenue Surgery Center's executive director, addressing the questions that have poured in since Rivers' death.

He is quick to point out the surgery center’s infection rate — less than 1 percent have been attributed to the center in 10 years — and the low rate of cases that required transfers to local hospitals. There are maybe two or three patients who need to transfer to a hospital for additional care a year, mostly due to pain control, he said. But perhaps the biggest selling point? The cost, he said, can be up to 40 percent cheaper for procedures outside the hospital, he said.

Ambulatory surgical centers make up a growing piece of the surgical market, particularly as the Affordable Care Act has begun shifting incentives away from volume-based inpatient care. More than 5,000 ambulatory surgery centers treated 3.4 million fee-for-service Medicare beneficiaries in 2012, the Medicare Payment Advisory Commission said.

But they still occupy a controversial space in medicine. Experts said the Rivers' case highlighted concerns about surgeries taking place on patients who may have increased risk factors for complications from surgery or anesthetic drugs, particularly older patients, away from the safety net of emergency departments and intensive care units.

Earlier this year, Barbara Fagan, the program manager of ambulatory care services in Maryland's Office of Health Care Quality, told my colleague Ben Fisher the intent of these centers isn't to do procedures that require an overnight stay. She said she doubted whether most surgery centers could, in fact, routinely handle overnight stays without violating other standards of care. "One of the reasons we don't look at ASCs to even be able to accommodate a 23-hour stay is they're not equipped for providing meals, changing linens, they're not set up with those types of services we'd normally see in hospitals," she said in January.

And surgery centers are certainly a threat to full-service hospitals already struggling to maintain volumes. Studies have found physician-owned surgery centers catering to healthier patients were more likely to receive referrals for well-insured patients while those patients on lower-paying Medicaid were referred to hospital outpatient departments, Marketwatch reported.

Dr. Louis Levitt, surgical center chairman at Massachusetts Avenue, said the center is careful to only work with lower-risk patients. They require patients older than 55 to get clearance from specialists and patients with higher body-mass indexes, who have an increased risk of experiencing breathing troubles during surgery, to meet in person with the anesthesiologist before they are cleared.

With advanced pain medications, Massachusetts Avenue has begun expanding its orthopedic procedures into joint replacements and is currently beta testing outpatient hip, knee and shoulder replacements with a major Maryland insurer, Gross said. In the past 90 days, the center has been able to convince two other major insurers to cover the joint replacements in certain patients. But the surgical center still regularly runs into limits in what they can do, because Medicare has a limited defined list of outpatient procedures it considers safe to do at an outpatient surgery center. Many insurers still base their coverage on those Medicare limits and require surgeons to perform certain procedures at a hospital.

This could be more costly. It also may not benefit patients as much as when they go into surgery with an expectation they'll need to be mobile by the end of the day and working with an outpatient physical therapist the next day, Levitt said. "They expect it, so they work harder," Levitt said.

Read more: http://www.bizjournals.com/washington/blog/2014/10/getting-beyond-joan-rivers-bethesda-center-pushes.html