Some of my colleagues in OB-GYN are scheduled to begin performing gynecological procedures at a new venue this month, a surgery center that's just added the specialty to its lineup of services. Adding GYN is an idea the center's partners had been considering for some time, but which had taken a back seat to the possibility of adding GI services. Given the impact that Medicare's changes to its ASC payment system wreaked on GI, those plans were shelved, but Medicare's favoring some GYN procedures in the outpatient arena, and it's likely that commercial payors aren't far behind. Here are some insights on how your facility, too, might profit from the situation.

Possible procedures
All of the following quick and reimbursed options can be done with paracervical blocks and oral painkillers prior to the procedures:

• Diagnostic hysteroscopy. For patients with abnormal, intramenstrual or heavy bleeding, diagnostic hysteroscopy uses an endoscopic camera to closely examine the uterus and seek out the pathology behind the abnormality. A reproductive specialist or endocrinologist might also employ the procedure to seek out structural or fertility issues.
• Endometrial biopsy. A biopsy sampling endometrial tissue for testing is well-suited for the outpatient setting, either as a standalone procedure or in conjunction with diagnostic hysteroscopy. If a polyp is unexpectedly detected during a diagnostic hysteroscopy, a site-directed biopsy may be ordered intraoperatively.
• Global endometrial ablation. This procedure also frequently accompanies diagnostic hysteroscopy. A remedy for menorrhagia, it cauterizes the uterine wall. Multiple methods exist, but two systems are commonly used. Ethicon's Gynecare division offers ThermaChoice balloon ablation, in which a balloon inserted into the uterus is inflated with dextrose and water at 87 ?C to destroy the endometrial tissue with heat and pressure. Hologic's NovaSure technique uses radiofrequency ablation to achieve similar results. In our specialty, global endometrial ablation has significantly reduced the number of hysterectomies that need to be done.
• Essure. In this permanent hysteroscopic sterilization procedure, developed by Conceptus, microinserts creating tissue scarring and blockage are placed in a patient's fallopian tubes with a catheter under direct visualization. The procedure can be done without systemic anesthesia in about 20 or 30 minutes.
• LEEP. The loop electrocautery excision procedure uses a Bovie-like electrosurgery generator and a handle fitted with a wire loop electrode to remove precancerous lesions from the cervix if you discover abnormal cells during a Pap smear test. The procedure requires anesthetic numbing and, as with any electrosurgery, an accommodation for smoke evacuation.

Non-office options
Other procedures, such as standard dilation and curretage (a diagnostic and therapeutic treatment for abnormal bleeding), require the support of a surgery center's OR and perioperative process.

One area that's shown impressive advances is the treatment of stress urinary incontinence by way of mesh slings. Sling procedures were once major open surgeries, arduous procedures involving massive vaginal reconstructions, bladder lifts and grafts. In the past 10 or 15 years, however, medical device manufacturers have developed lift kits that have simplified the operation down to a 20- or 30-minute minimally invasive procedure. Ethicon's Gynecare division, for example, offers its TVT (transvaginal tape) tension-free system, in which a sling is passed by trocars through an incision in the vaginal wall at the mid-urethral point to serve as a sort of hammock for the urethra.

Mesh lift kits are also available for the treatment of anterior, posterior or global pelvic floor dysfunction. While TVT is designed to support the bladder's neck, these procedures lift the entire bladder, treating pelvic laxity without open surgery and the wholesale reconstruction of the area.

While there has been much discussion about outpatient laparoscopic supracervical hysterectomy, and I've done a fair number of LSH procedures, I'm not certain that it's best suited for surgery centers.

It surely revolutionizes the way we do the procedure by amputating the uterus above the cervix and removing it from a 12mm port, as opposed to subjecting the patient to the large abdominal incision of a conventional hysterectomy. However, the potential risk of vessel or bowel injury and major bleeding, the possibility that the surgery will have to be converted to an open procedure intraoperatively and the inability to predict whether the patient will need to stay overnight for observation leaves me cautious. If you're operating in a hospital's outpatient department, the procedure could be a candidate for same-day surgery, but the possibility of admission makes it slightly more risky to be handled at a freestanding center.

While freestanding surgery centers can host many of gynecology's surgeries, they may find it difficult to attract the specialty's surgeons, who are for the most part drawn to hospital ORs and their own office-based procedure rooms. Many GYN surgery cases are done in hospitals or on hospital campuses while the surgeons are on call for obstetric work, their primary, time-sensitive and attention-demanding clinical pursuit at the hospital. Since the GYN surgery cases can be temporarily put on hold if a delivery situation arises — something that would be more difficult to manage, logistically, if they're working at a freestanding center — the hospital is a convenient venue.

On the other hand, if the surgeon is free to devote a morning to GYN procedures, a surgery center can prove more efficient in terms of scheduling and OR time than a hospital. But the surgery center may have a hard time competing with the surgeon's office. Many of the procedures described above can be performed in both places, and the surgeon may be better reimbursed for performing them in the office than the ASC. While a physician-owner, who will profit from the facility fee as well as the professional fee, will bring his cases to the ASC, a non-owning physician may simply gravitate toward his own practice. (Additionally, OB-GYNs often don't become ASC partners on account of their hospital affiliations.)

Attracting GYN surgery to your center — and making the process appealing to non-partner surgeons — isn't impossible, though. Outpatient surgery continues to involve patient-driven choices. A patient may not want to travel to the hospital downtown for a 15-minute procedure that could be done closer to home. The shorter turnaround time, the sense of patient anonymity and the more personal service of the ASC appeal to many patients. And some patients, apprehensive about a procedure, request more than just the local anesthesia available in the office setting.

Once patients have driven surgeons to the ASCs, the doctors are soon aware of how much more work they can get done in the fast-paced environments as compared to in hospitals. The appeal of doing double or triple the amount of cases in fewer hours cannot be understated. The availability of your capital equipment for use in their procedures is another draw. Accommodating GYN surgeons with your schedule will make performing procedures at your center a convenient choice for them while also pleasing the center's partners, for whom visiting surgeons are money in the bank.

Also, keep in mind the GYN surgeon's patient population. Women are the primary caregivers in most families and make most of the healthcare decisions. They want treatment that's accessible and hospitable. Your surgery center can make that happen. You might not receive a high volume of a GYN surgeon's cases, but with a good experience, his or her patients will provide word-of-mouth marketing, seek out the doctors who can do their children's myringotomies and their husbands' colonoscopies there, and perhaps even return in the event they pursue cosmetic or other elective surgeries.

Do the math
Adding GYN procedures to your facility depends, of course, on doing your due fiscal diligence. You're not adding GYN because a single patient opted against a hospital procedure, but because there's a case volume that can be sustained. And if you're footing the capital equipment costs, it's fair to ask the surgeon how he can ensure he'll bring the cases.

At the previously mentioned surgery center that's adding GYN procedures, the administrator chalked up the direct costs (such as hands-on patient care and supplies) and the indirect costs (operational overhead, staff salaries and OR time) involved as well as reimbursements for each procedure to ascertain which it would make sense to host. Having armed herself with data on how many procedures were expected, what each cost to do and how much more efficiently they could be done at the surgery center than at a hospital, the administrator then renegotiated contracts with insurers.

In terms of capital equipment, you may already have some of the components. Diagnostic hysteroscopy, endometrial biopsy and the Essure procedure require an endoscopic camera and video tower. The scope is specialized to the field — given the narrow diameter of the anatomy, it's more like an ENT scope than a GI scope — but a surgery center can use the camera heads and video carts or towers that it uses for GI procedures to get the most bang for its equipment buck. If you've got GI, ENT and GYN procedures going on at the same time, however, you may need multiple sets to dedicate to each OR, or skillful diplomacy, to coordinate the logistics of the equipment's use.

I'm told that the surgery center that's adding GYN spent $15,000 to equip itself for the specialty, a sum that included an operative diagnostic hysteroscope and sheaths for $9,000; instrument trays for $2,500; a smoke evacuation device for $1,500; a colposcope for $750 and LEEP-specific speculums in multiple sizes for $500.

Purchasing refurbished equipment when possible, as the center did, is one way to cut costs, as is finding flexibility in the vendors you're dealing with. If you've got multiple purchases underway, see if they're willing to work with you. For example, I've heard of practices buying a tower and camera and scoring a set of biopsy forceps on the deal. Or, in the case of thermal ablation equipment, most manufacturers will rent or loan you the main generator as long as you continue to purchase the balloon probe or the deploying radiofrequency modulator.