Challenges and opportunities in office-based medicine

Many medical procedures are moving from the operating room to the doctor’s office, and a Forum held Oct. 9 at the Simches Research Center at Massachusetts General Hospital provided full and illuminating discussion of the significant trend.

Four speakers presented on a variety of topics, including “Office-based gynecologic procedures,” “Office-based anesthesia,” “Technology implications of office-based anesthesia safety,” and “Regional anesthesia in the office-based setting.”

Keith Isaacson, MD, medical director of the Minimally Invasive Gynecological Surgery Unit at Newton Wellesley Hospital, and CIMIT site miner at that institution, said that many gynecologists are moving toward office procedures because the net rate of reimbursement is greater.

He said that the federal Center for Medicare and Medicaid Services (CMS) is “directing” doctors to office procedures because that venue is less expensive than an OR. But there is less regulation in such facilities, and he warned that office-based medicine could become “the wild West of medicine” if it is continues to develop with a minimum of oversight.

Fred Shapiro, DO, who is with the Department of Anesthesiology, Critical Care and Pain Medicine Unit of Beth Israel Deaconess Medical Center, said that the use of anesthesia in an office setting is increasing rapidly because in the past 10 years, the number of office-based procedures has grown from 5 to 10 million cases. He noted that only 22 states have any regulations regarding office-based anesthesia, and he said that patient care could be compromised if medical professionals are not vigilant.

Beverly Philip, MD, director of the Day Surgery Unit at Brigham and Women’s Hospital, said there are both opportunities and challenges associated with OBA. She said that doctors must choose their patients carefully, and train in emergency procedures should an incident occur. She said that office-based medical personnel must excel in information management so that appropriate patients are chosen, and adequate data is available should doctors need it. Dr. Philip concurred that reimbursement is significant for those who practice outside of an operating room.

Lisa Warren, MD, director of ambulatory anesthesia at MGH’s Department of Anesthesia and Critical Care, said that regional anesthesia could be better utilized by those who use the office setting. Noting that about 25 percent of all elective surgery procedures in the U.S. are done in the office now, she suggested that doctors consider greater use of regional procedures.

Gynecologists are spending more time in the office and less time in the operating room, and today’s residents receive less surgical training than in the past.  More and more surgical procedures are being performed in the doctor’s office instead of in the OR.  The increasing number of office-based procedures necessitates new equipment and new training strategies, both designed specifically for the office setting.               
           
Many factors contribute to the current popularity of office-based gynecologic procedures.  First, performing a procedure in the office as opposed to the OR saves time.    According to Dr. Keith Isaacson, of Newton-Wellesley Hospital, an operative hysteroscopy that would take one hour in OR can be completed in around five minutes in the office.  Tubal ligations and endometrial ablations can also be performed efficiently and lucratively in the office.  A second factor that encourages office-based gynecological procedures is their profitability.  Malpractice insurance for a gynecologist who only operates out of an office can cost over $80,000 less than that of an OB/GYN in a hospital, and despite their higher insurance costs, hospital-based gynecologists are paid less per procedure than are office-based practitioners.  Lastly, anecdotal evidence suggests that patients prefer to undergo procedures in the office, rather than in the hospital 

Office-based procedures can create health risks if not performed with proper attention to safety.  Fatal problems can arise if doctors and staff are not properly trained, if patients are not selected carefully, and if emergency equipment and drugs are not readily available. 

Office-based procedures are not going to go away, so the gynecological community should seek to ensure that they are safe.  Gynecology residents are not currently trained to perform procedures in the office, and these techniques, which are not difficult, should become part of their curriculum.  Guidelines should be established to help gynecologists identify patients who should not be anesthetized in the office, and offices should always be equipped to manage severe emergencies, such as cardiac and respiratory failure.  Finally, surgical equipment designed specifically for the office should be developed.

   

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