Office-based procedures (OBP) are not a new construct in healthcare. Physicians have been performing a host of procedures in a range of settings – now known as sites of service – pre-dating the modern idea of the hospital. When it became apparent that standardization around preparation, sanitation, and organization were needed to ensure care was delivered in the most effective, efficient manner possible, most procedures rightly migrated into hospitals. But, as our understanding of medicine and healthcare delivery evolve, it is apparent that not all procedures need to be, or even benefit from being performed in hospitals.
Yet, the idea of OBPs – ubiquitous and growing as they are – remains shrouded in misunderstanding and trepidation. People are guarded with how, where, and when they access healthcare services, and understandably so. Time and again, though, OBPs have proven safe, convenient, and affordable when compared to the same procedure performed in a hospital or even an ASC.
Further clouding the understanding and acceptance of OBPs is the business of healthcare. For better or worse, hospitals – and healthcare at-large – is an industry, and as such it is centered on generating a net revenue. Procedures drive a large portion of that revenue for hospitals and health systems. Thus, OBPs, rather than being viewed as a necessary evolution of care delivery, are seen as competition.
Expansion – not disruption – of care
Healthcare is an ecosystem made up of many parts and players, the great majority of which play a vital role in safeguarding the health of the population. Hospitals and health systems; nurses and physicians; medical technicians and healthcare administrators; insurance companies and agents; ambulatory surgery centers and specialized clinics; all of these play crucial roles that ensure patients receive the best care possible.
OBPs, too, are part of this ecosystem, one that is reflective of the broader move towards value-based care and the quadruple aim. They have been proven to increase access to care, deliver equal quality, lower overall costs, and improve the care experience for patients and providers.
What is important to understand is what OBPs do not represent, which is a profit-motivated move aimed at stripping revenue from hospitals. Physicians who undertake procedures in their offices and clinics do so not wantonly, but with the understanding that for every combination of patient, diagnosis, and treatment plan, there is a proper procedural setting. Sites of service are chosen such that it allows the highest level of care required. Then, and only then, are considerations made for the patient’s convenience and comfort, the provider’s satisfaction, and general affordability.
OBPs are not indicative of healthcare disruption in the way that Uber was to the taxi industry. What they are is an important step in the evolution of healthcare that stands to improve access and experience and thus promote a healthier population in the most equitable way possible.
Why is it, then, that OBPs are not fully embraced across the healthcare continuum? What is holding the various stakeholders back from recognizing the role they have to play in the care delivery?
How should health systems – the primary owners of most hospitals – view OBPs given their focus on revenue generation? Instead of seeing them as a drain on the volume of procedures that are being performed in their outpatient department or in ambulatory surgery centers in which they are invested, they should see this as a way to improve utilization and the bottom line across all sites of service. Shifting lower acuity and lower revenue-generating procedures to offices increases the utilization of more complex, high margin cases in facility settings. Additionally, given how strained the current healthcare worker labor pool is, this can also allow for better utilization of those scarce resources.
Worry may also arise from the perspective of anesthesia resources or safety as procedures migrate out of hospitals. This presupposes that a hospital’s primary anesthesia group is the only viable option to service OBPs that require sedation or general anesthesia. But there are many third-party anesthesia providers that specialize in ambulatory and/or office-based anesthesia care.
OBPs are a unique niche that requires anesthesia providers who are comfortable with shorter cases, turnarounds, and recovery times. Using an approach tailored to the specifics of the case at hand eliminates the need to recruit additional anesthesia providers or stretch the resources of a hospital- or facility-based group. As far as safety, experienced office-based anesthesia groups will provide everything that is needed, often at their own expense, to ensure that the same quality, safety, and emergency protocols are in place at the office as they are in the hospital.
As OBPs definitively lower the cost of care, insurance providers – both governmental and private – stand to gain much from expanding sites of service. While these companies are usually resistant to change in care and pricing models, the rising cost of healthcare has led, slowly, to a growing openness to paradigm shifts. That has included the incentivizing of OBP growth. Physicians and surgeons have benefitted from increased reimbursements, while payers have shed facility fees and administrative costs that go along with hospitals and ASCs.
Payers have, though, been too narrow in their incentivizing, and have not made appropriate adjustments for the role of secondary providers, such as anesthesiologists. Incentives provided to physicians do not take into consideration the costs associated with anesthesia-related medications, supplies, equipment, emergency resources, or post-operative care clinicians. Rather, they cover only the surgeon’s equipment and supply expense. As the list of OBPs expands, anesthesia providers typically provide these resources at their own expense, without seeing any uptick in their professional fee or willingness by the payers to contract for a specific ancillary code that would cover the costs of the additional services they are providing.
Education is the key to OBP acceptance at the patient level. Certainly, with the aging population in the U.S., many have undergone routine procedures in their physician’s office, with the most common being a staple of preventative medicine: colonoscopies. But, as more procedures migrate out of hospitals, their will naturally be worry on the part of some that the shift in site of service means some degradation in safety standards. However, with accreditation for physicians and facilities practicing OBPs legally-mandated in many states and the elevated risk of exposure to pathogens in a hospital, OBPs have a safety track record on par with other sites of service. Anesthesia providers versed in ambulatory and office-based cases further increase the level of safety given the perioperative care and emergency readiness they provide.
Beyond safety, patient education should be inclusive of cost transparency. It is a fact that procedures performed in hospitals are more expensive, but many patients don’t know why. Administrative costs, facility fees, and more can make the bill for a procedure tower over its OBP counterpart. The lower cost setting can not only reduce healthcare expenses for the payer, but can often mean that the out-of-pocket cost for the patient is drastically reduced. Healthcare that takes a broad view of the financial health as well as the physical health of the patient is a boon to all.
If the goal is to move away from fee-for-service models and into the value-based care healthcare model, and if the quadruple aim is what should be guiding healthcare design and policymaking, then OBPs have to be part of the healthcare ecosystem. Stagnant legacy thinking and institutional inertia are roadblocks to reform that will only keep costs high while depressing savings, comfort, convenience, and efficiency.
Portions of this piece on anesthesia and value-based care were originally published by Scope partner practice Mobile Anesthesiologists in Becker’s ASC review. It has been updated to reflect policy changes by CMS and changing landscape of non-hospital surgical care. While the backbone of value-based care is primary care and preventative medicine, inevitably surgical intervention is...
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