by Stefani Barbero
FOR THE PAST few decades, we’ve witnessed the steady march of services leaving hospitals in favor of outpatient care centers. Everything from diagnostic imaging to dialysis and cancer treatment to routine surgical procedures has migrated out of the traditional hospital setting. This movement has been seen as revolutionary, disruptive, transformative, and in recent years, possibly inevitable. The COVID-19 crisis gave us occasion to question that inevitability. The pandemic had a quick, dramatic impact on health care in the US, but it remains to be seen how lasting that impact will be and how it will affect office-based labs and ambulatory surgery centers.
As the outpatient revolution has continued, a wide range of surgical procedures has increasingly moved away from hospitals to outpatient settings, with endovascular procedures representing the bulk of that shift. Reimbursement changes combined with technological advances have enabled the cost-effective treatment of ever-more complex cases on an outpatient basis. With these advances came a rapidly changing landscape for health-care delivery, with more than 60% of elective surgery procedures in the US being performed as outpatient surgeries.2 By the end of 2019, there were more than 750 office-based labs alone in the US, and that number is expected to rise.3 Market analysts signaled continued expansion in the coming years with most predicting annual growth rates for outpatient care facilities of 10% or more.
As we rolled into 2020, the future of the outpatient setting looked bright. Then came COVID-19. When the pandemic arrived in the US, it hit the health-care system with a force the country had not experienced in generations. In much of the country, routine care ground to a halt. Wellness checks were canceled, elective procedures were put on indefinite hold, and in many cases, even more, serious but non-emergent procedures were deferred.
Office-Based Labs (OBLs) and Ambulatory Surgery Centers (ASCs) providing vascular care had been at the forefront of the trend toward outpatient services, but in the context of COVID-19, their future looked less certain. In the first weeks of the crisis, many facilities witnessed a dramatic drop in scheduled procedures and other appointments, including diagnostic imaging. Nationwide, the volume of imaging exams declined by at least 50%. Some facilities found themselves with nearly empty calendars.
But hidden in this early data were the seeds of a positive trend—outpatient migration of surgical procedures was actually speeding up, and COVID-19 was pressing the accelerator. In the wake of the crisis and its associated concerns about exposure and the potential for further stressing hospitals in pandemic hotspots, outpatient options like OBLs and ASCs seemed like an even more attractive option for both patients and referring physicians. In the short term, case volume had dropped sharply as a necessary early response to the pandemic. But long term, as deferred procedures get rescheduled, these outpatient facilities will likely receive a growing share of cases.
Payers have already been on board with the migration of procedures from the hospital for some time now. Across clinical specialties, CMS continues to move in the direction of reimbursement changes favorable to OBLs, ASCs, and their hybrids, with the range of supported procedures continuing to grow. Insurance companies, of course, are also on board, given the cost savings associated with the move to outpatient care.
Plus, patient satisfaction with OBLs, ASCs, and other outpatient care options was already high before the pandemic. From the patient’s perspective, these facilities offer clear and obvious benefits over the hospital experience, from the ease and speed of scheduling to the perception that OBLs and ASCs offer more patient-centric care provided by specialized clinicians.
Despite early concerns about safety and questions about appropriate care, especially in cases of self-referral, multiple studies in recent years have resoundingly demonstrated that OBLs and ASCs can and do maintain both patient safety and quality of care, with clinical outcomes at least on par with outcomes in the hospital.
The results of those studies are not lost on patients. In recent years, we have all become more educated and empowered consumers of medical services, and the broadly held perception that care is more personalized at an OBL or ASC is a strong incentive to choose an outpatient facility for a non-emergent procedure. Add the cost differential and broad-based concerns about COVID-19 exposure in the hospital, and the patients’ choice of an outpatient setting as the preferred alternative is to be expected.
Referring physicians’ attitudes also seemed to shift as we adjusted to the COVID-19 world. In a survey from McKinsey & Company published in July 2020, more than 40% of physicians reported that post-COVID-19, they will be more likely to refer patients to non-hospital facilities for procedures, office visits, and diagnostic testing.1 “A possible rationale is physicians may be wary of the safety of hospital-based care in the return from COVID-19, although the survey did not include questions to that effect,” the analysis stated.
It’s also possible these physicians were already concerned that as their local area slowly emerged from the worst of the COVID-19 crisis and rescheduled procedures, sufficient support for non-emergent procedures from hospital administrators might lag. The backlog is difficult to meet, and some hospital administrators have been understandably wary of over-scheduling less critical cases in the short term, which leads to additional delays in care for patients with less urgent needs.
Regardless of what was driving the physicians’ survey response, it sent a clear message—concern for their patients dictates that it makes no sense to delay a case when it could be treated with a quick outpatient intervention at an OBL or ASC.
For OBLs and ASCs, What’s the Next Move?
By mid-summer 2020, procedure volume in many geographic regions started to rebound, although slowly. The future of the pandemic remains uncertain, but it seems prudent to anticipate additional localized outbreaks as we head into 2021. Regardless of what happens with the pandemic, long term, the volume of procedures referred to outpatient facilities will continue to rise. Those facilities that are most flexible and prepared to meet the changing demands that accompany this growth are most likely to succeed. Right now, OBLs and ASCs can take specific steps to help ensure that they not only survive the COVID-19 crisis but are prepared to weather the elastic demands of possible localized outbreaks and other pandemics in the future. Meanwhile, these strategic changes will help outpatient facilities continue to thrive in what will likely be a realigned health-care delivery system with a higher demand for outpatient services.
Foster Referring Relationships
Relationships with referring physicians already play a significant role in growing a practice. With physicians’ attitudes and concerns shifting as we adjust to new realities, these relationships are even more important. OBLs and ASCs that take a proactive approach to addressing concerns about patient exposure and safety, offer efficient, responsive scheduling, and demonstrate a commitment to both patient outcomes and satisfaction will be most effective in fostering referring relationships. Communication is key to this effort.
Reduce Exposure for Patients and Caregivers
Some measures, like strict protocols to avoid contact among patients in waiting rooms, are obvious. But reducing exposure throughout the continuum of care can require more planning. Technology solutions can be a great help in this effort, especially with regard to diagnostic imaging. For example, solutions that enable remote interpretation of exams, virtual consults, and digital transfer of patient records, including images and study data, can eliminate touchpoints without compromising care. In addition, some solutions can help technologists shorten the patient’s time on the table for diagnostic imaging exams by taking measurements post-exam. The benefits of these solutions stretch beyond exposure concerns by increasing efficiency.
Many insurance companies and CMSs relaxed restrictions on payment for virtual services during the pandemic. Obviously, the services that can be delivered virtually are limited, but taking a detailed medical history, checking in with a patient for a medication refill, or providing critical patient education for ongoing management of a chronic condition can often be done via video conference or even phone. Long term, incorporating telehealth options can do more than enable continued care during a pandemic. It can also generate additional efficiencies and broaden the facility’s reach for patients who have ambulatory issues or live in rural areas.
Ease Accreditation Burdens
Accreditation offers significant benefits, but preparing for it can be an onerous task. For practices still relying on paper-based policy binders and physical logs to ensure compliance, integrating technology solutions can streamline the process and ease the burden. Some solutions also help with vascular case selection for case reviews and provide correlation data automatically. Facilities that reassess their efforts in this area and incorporate technology solutions will benefit from long-term efficiencies.
Improve Peer Review
A robust quality control/quality assurance program rooted in peer review is vital, particularly in the vascular space, where overtreatment was a persistent concern in years past. Internal peer review can help the practice demonstrate a commitment to consistent, appropriate care. Some information systems and reporting solutions help automate the identification, assignment, and tracking of reviews, making the process a seamless part of the clinical workflow.
What’s the Long-Term Impact?
It’s too early to predict exactly where the US health-care delivery system is headed, particularly in the wake of COVID-19, but clearly, the disruption of the pandemic has helped expose the need for a realigned model of care that offers new efficiencies. The continued migration of care away from the hospital seems like a sure bet, with a range of surgical procedures being performed in outpatient facilities. With sufficient planning now, OBLs and ASCs can continue to lead the way in the outpatient revolution, moving us toward a more broadly distributed model of care with an overall outcome that’s very good for patients and physicians alike.
Stefani Barbero holds the title of Marketing Content Man-ager at Core Sound Imaging, Inc.—makers of the Studycast System, a comprehensive imaging workflow system. Studycast transforms manual data entry into automatic data population; printing, scanning, and filing into secure cloud storage; and dictation and transcription into an intuitive, streamlined workflow available from any Internet-connected device.
1. McKinsey & Co., (2020) “Physician employment: The path forward in the COVID-19 era”
2. Jeffrey Carr, MD, FACC, FSCAI (2016) “The Office-Based Interventional Suite: The Dread of Hospitals… or the Future of Cardiovascular Contemporary Care,” Cardio-vascular Disease Management annual symposium
3. Jeffrey Carr, MD, FACC, FSCAI (2019) “Peripheral Vision: As Office-Based Practices Proliferate,
Who Is Watching Out for Patients?” tctMD.com