Outpatient Surgery is Getting Attention from the Largest Players in Healthcare
Right patient, right place, right time, and right care is a mantra of appropriateness within healthcare. And increasingly when it comes to surgery, healthcare leaders believe “right place” means outpatient, especially in an ambulatory surgery center (ASC).
UnitedHealth Group’s 2020 Sustainability Report included a 10-year goal to deliver 55% of outpatient surgeries and radiology services at high-quality, cost-efficient sites of care, most likely at ambulatory surgery centers.
Elsewhere, Empire BlueCross BlueShield in New York implemented a new policy positioning hospital-based providers to declare “medical necessity” for a surgical procedure to be delivered in the hospital setting. All procedures lacking an argument of hospital necessity will be pushed toward ASC’s.
The strategy shift, as you might guess, is propelled by economics. Surgical procedures delivered in ambulatory centers are:
- 25% less expensive than those delivered at hospital outpatient departments
- >40% less expensive than those delivered in inpatient hospital settings
In its report, UnitedHealth made the point by focusing on joint replacements. The report stated that moving joint replacement operations to ASCs could save $20 billion over the next 10 years and result in 500,000 fewer hospitalizations each year. A 2020 Journal of Arthroplasty article estimated 93% of hip replacements can be done outpatient.
But how can a procedure historically done in the hospital—with a full complement of resources nearby—shift to a same-day procedure at an outpatient center? Some contributing factors:
- Better prepared patients (hello, prehabilitation!)
- Minimally-invasive/advanced technique surgeries, including regional anesthesia
- Less dependence on opioid painkillers (and, thus avoidance of all the recovery-slowing side effects that come with them)
If these sound familiar, perhaps it’s because these same concepts form the foundation for Enhanced Recovery After Surgery (ERAS)-based protocols. Widely-studied and clinically-validated, ERAS has been shown to dramatically reduce length of time in the hospital, risk of complications, opioid use, and recovery time.
Perhaps the most important role for ERAS in this new ambulatory surgery world is as the “insurance policy” that positions the patient not to bounce back to the hospital as a readmission. After all, 30-day readmissions represent an important, economically-incentivized quality measure for both hospitals and health plans, not to mention a terrible outcome for patients and their families.
Vinod Dasa, MD, an orthopedic surgeon and Associate Professor of Clinical Orthopaedics, Director of Research, at LSU Health in New Orleans adds:
“ERAS protocols help de-risk the ASC transition to create a sustainable pathway for surgeries that have traditionally been done in the hospital setting.”
Poorly-controlled pain, post-operative nausea/vomiting, and complications of opioid use often lead patients back to ER’s and hospitals in the days after surgery. But that doesn’t have to be the case. ERAS holds the answer—get ahead of the pain, stay ahead of the pain, set appropriate expectations with patients, and minimize opioids.
And there may be one additional element.
A 2019 study demonstrated that ERAS-based surgery with post-surgery “surveillance” cut ER visits and hospital admissions in half, when compared to the already-optimized ERAS-based pathway.
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