Over the past few years, there has been a push to perform more surgeries outside of the traditional inpatient setting, whether that’s in a hospital’s outpatient area or as part of an ambulatory surgery center. As hospitals and health systems consider offering more outpatient surgical options, it’s important to fully appreciate the advantages and risks associated with relocating procedures and develop solid processes for enabling an effective and safe outpatient surgery program.
What’s Driving Change
Several factors are pushing organizations to shift certain surgeries to the outpatient setting. First, there are advancements in surgical techniques, which allow surgeons to complete operations in less time and more safely, reducing the risk of infection and complications. There have also been significant advancements in anesthesia, with the field moving away from general anesthesia and embracing other forms from which patients can recover faster. This in turn reduces postoperative recovery periods, getting patients home and on the road to recovery more quickly.
Patients are also encouraging the move due to their increasing engagement. As individuals become more consumers of healthcare rather than just recipients of it, they are starting to ask more questions about their health and have definitive opinions about where they should receive care. They are looking for a relatively convenient surgical experience which allows them to return home sooner and get back to their activities of daily living.
The most substantial pressure is coming from the Centers for Medicare & Medicaid Services (CMS). The agency tends to drive care in general because of its size and influence, and it has recently urged providers to offer more procedures in the outpatient setting because of the abovementioned reasons. More specifically, CMS has taken certain procedures, such as total knee replacement, off their “inpatient-only” list, and opened them up to be performed as “outpatient” for appropriate candidates.
Before shifting procedures into the outpatient arena, organizations should think through some logistics. One consideration is where the relocated procedures should take place. Will units be geographically separate from the hospital or will outpatients and inpatients co-mingle within the same location? There are positives and negatives to both options. If the facility is geographically separate, it is easier to differentiate outpatients from inpatients but there are additional facility costs.
By hosting outpatients and inpatients within the same setting, outpatient surgery is part of the larger campus, which can be more convenient. However, the organization must be sure to have defined processes and teams that efficiently and safely move outpatients from preoperative care through to discharge.
Shifting to more outpatient offerings also requires providers to revisit how they deliver care and develop pathways for patient screening, surgery, and post-op care. These pathways should account for the unexpected, including complications like bleeding, anesthesia side-effects, and so on.
In addition to the care ramifications, there are also financial considerations, including how the physician and the facility will be reimbursed for inpatient versus outpatient experiences. This impacts payers as well, as they will need to strategize how to pay for an outpatient procedure as compared to an inpatient one to encourage the best choice depending on the patient’s condition and prognosis.
Patient Selection is Critical
Although offering surgery in the outpatient setting can be a good strategy for hospitals and health systems, it is not appropriate for every patient. As such, organizations should have objective, evidence-based criteria to help determine which patients qualify. These will allow care managers and providers to be confident in their decisions to pursue outpatient options and ensure the organization does not put the patient at undue risk. Factors that should influence criteria include:
- Existing comorbidities—If a patient has COPD or congestive failure, for example, it may be preferable to offer the surgery in the inpatient setting due to potential complications
- Procedure type—If the patient is having knee replacement due to osteoarthritis, then the outpatient setting could be a viable choice provided there are no significant comorbidities. However, if the patient has a bone tumor that is prompting the knee replacement, the inpatient setting would be preferred
- The patient’s motivation and support system for recovery—If an individual is committed to following a post-op plan at home and has the resources to support that plan, then the outpatient setting is possible. However, if the patient has a limited support system or has some other barriers to post-op care, then it may be preferable to remain in the inpatient location
Establishing and regularly applying criteria is a complex task, and it can be beneficial to leverage clinical decision support technology, such as InterQual® Criteria, which has already gone through a thorough evidence-based development process. The technology considers all the relevant factors and makes an informed and research-driven recommendation as to whether the outpatient or inpatient setting is the clinically appropriate choice. This takes some of the pressure off care managers and providers, supporting them in making the best possible decision given the patient’s specific characteristics.
What the Future Holds
The move to outpatient surgery is only going to continue because technology is advancing, and outpatient facilities are increasing their capabilities. Patients are also going to push for outpatient opportunities because they would rather heal at home, go to work sooner, and get better quicker in their natural surroundings. Plus, they hope to reap some of the cost benefits associated with outpatient surgery.
Enabling value-based care is yet another motivator. When people are healthy and it is safe to perform surgery in an outpatient setting, that helps an organization meet the tenets of new payment models—high quality, patient-centric care options at lower costs.
Given all these factors, it’s clear that providers and payers will need to adapt to the changing surgical environment and create processes and systems to successfully make the transition from solely inpatient offerings to safe and effective procedures in the outpatient space.
Value-based care seeks to improve care quality while reducing cost, and does so, in large part, through the use of innovative alternative payment ...