The business of outpatient surgery will change dramatically in the coming years. Healthcare reform is looming, surgical techniques are advancing and regulatory agencies are clamping down hard on such hot-button topics as physician ownership and out-of-network billing. To give OR Excellence attendees an overview of the shifting clinical, regulatory and reimbursement landscape, we assembled an opening-day panel to discuss the keys to succeeding in the new healthcare economy.

Brace for more scrutiny
First, the good news. Two undeniable trends — more outpatient care and fewer uninsured — will drive more outpatient surgery business your way in the coming months and years, says Robert I. Field, JD, MPH, PhD, professor of health management and policy at Drexel University School of Public Health in Philadelphia, Pa. But you'll also be dealing with undeniably negative pressures, says Dr. Field, including more focus on value by purchasers, more focus on fraud and abuse, less capital for expansion, more outside scrutiny and more aggressive push-back from hospitals.

ASC business arrangements in particular are facing increased scrutiny. Dr. Field cited the latest unflattering studies linking physician ownership and increased surgical volume: "Physician-Ownership of Ambulatory Surgery Centers Linked to Higher Volume of Surgeries" in the April 2010 issue of Health Affairs and "Effect of Physician Ownership of Specialty Hospitals and Ambulatory Surgery Centers on Frequency of Use of Outpatient Orthopedic Surgery" in the August 2010 issue of Archives of Surgery.

Dr. Field detailed the increased scrutiny that surgical centers might soon be under. For example, there's talk that Certificate of Need laws could be extended. CON laws are drags on new surgical growth and construction. They prohibit healthcare providers from acquiring, replacing or adding to their facilities and equipment, except in specified circumstances. There's also talk that the Stark Law's "whole hospital exception" could be eliminated. The whole hospital exception lets a physician refer his Medicare or Medicaid patient to a hospital in which he has an ownership interest.

Dr. Field presented some scary what-if scenarios. What if new surgical centers were permitted only if a hospital or medical school jointly owned them? What if specialty hospital reimbursement went away?

He wasn't done. There's more to be on the lookout for: new financial disclosure requirements that would force you to disclose a physician's ownership interest to patients in writing at least 24 hours before their procedure, uncompensated care requirements, reduced facility payments and global/capitated payments.

Surgery through a single hole
Minimally invasive surgery is getting bigger and bigger as the number of ports gets smaller and smaller, a movement known by many catchwords, including "reduced port surgery," a term and a technique pioneered by Paul Curcillo, MD, FACS, vice chairman of the department of surgery at Drexel University College of Medicine in Philadelphia, Pa. In 2007, Dr. Curcillo and his wife, Stephanie King, MD, performed the world's first single-port cholecystectomy through an incision in the patient's bellybutton.

For all of the wow factor, Dr. Curcillo says the only proven benefit of reduced port surgery, thus far at least, is better cosmesis. It's not what you might have hoped and expected: decreased pain, faster recovery or faster hospital discharge. He's on a crusade to maintain the safety and economy of reduced port surgery for cholecystectomy, gynecology and bariatrics. To that end, he issued a couple of warnings.

• Safety. One of the most common ways surgeons have learned about reduced port techniques is from what Dr. Curcillo considers an unlikely source: instrument manufacturing companies. He suggests surgeons undertake a "stepwise progression" with reduced port surgery, beginning with familiar cases and slowly reducing the number of ports. "Don't rush into it," he says. "Start with the easier cases first. If you're using 4 ports, try it with 3 before you go to 2 or to 1."
• Economy. Reduced port surgery increases surgeon expertise and increases device costs. "How do you bill so that you cover costs? Shouldn't we receive more?" asks Dr. Curcillo. "A lap chole is a lap chole is a lap chole. Be careful of creative billing."

Healthcare reform
Marian Lowe, executive director of the ASC Advocacy Committee in Washington, D.C., discussed the many ways that the health reform bill will impact surgical facilities.

• Medicare reimbursement will be flat. Beginning next year, a new payment formula will keep Medicare reimbursement roughly flat for ASCs each year into the future. A so-called "productivity adjustment" will reduce future annual updates by an estimate of labor productivity improvement in the general economy, generally 1% to 2%. For 2011, ASCs will receive a 1.5% update, based on the consumer price index, but the "productivity adjustment" is -1.3%, resulting in a 0.2% update.
• Colonoscopy co-insurance waived. Medicare patients will no longer pay co-insurance for screening colonoscopies. The waiver applies to ASCs and hospital outpatient departments. This move was meant to encourage more preventative care, but some fear that colonoscopies will migrate back to higher-costing HOPDs.
• Payment to be tied to quality measures. Look for a system of "value-based purchasing" by the end of next year, in which ASC payments will be tied to quality measures. The ASC Advocacy Committee and the ASC Quality Collaboration (ASCQC) will work with Medicare in formulating these measures. The industry has already begun voluntarily reporting 6 quality measures through the ASCQC: patient burns, prophylactic IV antibiotic timing, patient falls, wrong-site surgery, hospital transfer/admission and appropriate surgical site hair removal. Around 1,200 ASCs are reporting on these measures, and the results are published quarterly at www.ascquality.org.