Tuesday, February 20, 2007

Office-based Plastic Surgery: Is this going to be legislated away?


Some times you can survey events in our field and get an idea about the way things are likely to change in the future. Office-based plastic surgery is one of those things which I think is destined to become an endangered species.

A story like this in the Arizona Daily Star is one of those things that gets my wheels spinning. Last year a healthy well-known Tuscon, AZ lawyer died during an office based surgery from respiratory arrest. There was no salacious back story about either the Doctor or his clinic, it just happened. The office O.R. was accredited and a nurse anesthetist was present which both meet standards of care.

It only takes a few publicized instances of these case to really cause dramatic changes in the law. This already happened in Florida a few years ago and is likely to spread.

Why are so many cases done in the office? It's more convenient for patients and doctors and dramatically cheaper. Using a hospital or surgery center will nearly double the cost of many procedures. A less admirable reason for many providers who do office-based procedures is that they cannot get hospital privileges to do surgery. This is where Dermatologists, OBGYN's, and ENT/Facial Plastic Surgeons do liposuction, breast surgery, & other things they are arguably under trained to perform.

Again surveying the news I have no doubt that IV conscious sedation & general anesthesia will eventually become so heavily regulated that it makes it impractical to be done in the office and the pendulum swings back to doing all these procedures in the hospital again. I do a great deal of minor office surgery under local (biopsies, skin cancers, some skin grafts), but do major procedures in the hospital. It has less to do with feeling uncomfortable about office-surgery, but reflects my hesitancy to make a large capital investment for an accredited office OR when with the stoke of a pen I can no longer use it.

5 comments:

Anonymous said...

interesting how plastic surgeons use this story as a platform to slam other surgeons who do cosmetic procedures when it was a plastic surgeon who ran into the problem.
rumor has it that this patient ate during the hours before surgery, aspirated and was transferred to a nearby hospital for ventilator support and died several days later.
if this is true, the surgery should not have been performed.
in addition, CRNA's are mostly not as good as MD anesthesiologists, particularly if you are operating on a malpractice lawyer.

Dr. Rob Oliver said...

This story is more of cautionary one, namely that dramatic complications can happen even when things are done by the book (accredidation, sedation managment). If true, it would be a horrifying thing that the patient ate close to surgery & died from respiratory arrest after aspirating.

Plastic Surgeons have surely had their share of misadventures in office surgery. However, it is fairly intuitive to say that doctors not formaly trained or able to handle expected complications should not be doing these procedures. That doesn't seem to be the case here.

If CRNA's can do organ transplant surgery or coronary bypass largely unsupervised (as is common), then they're eminently qualified to do anesthesia on most cosmetic surgery patients (who tend to be healthier) in an office setting.

Scott said...

Rob,

Enjoy your blog very much. As a plastic surgeon in training, its easy to see the cost-benefit and incredible convinience of an office-based OR for routine elective cosmetic procedures, and even hand surgery. The added cash-flow from the facility fee doesn't hurt either.

I disagree with your assesment that office based surgery is heading the way of the Dodo. In my community, Portland OR, there is massive private expenditure to build office-based ORs. As soon as its financially feasible for me, I'd like to build one.

The problem, which you have eluded to in your previous posts, is the crowd of non-board certified 'cosmetic surgeons' practicing surgery which is out of their scope of training. It is these spectacular and horrifying office-based patient deaths that has casted a pale light on office-based surgery.

When done with competent MD or CRNA anesthesia, office-based surgery is safe, cost-effective, and might have lower wound infection rates than hospital based surgery. In this era of third-party payer cost-containement, one could argue that it is cheaper for insurance companies to fund surgery done in office-based OR, compared to hospital based procedures. Certainly the facility fee could be made more flexible in an office-based practice, making these facilities more attractive to insurers.

Hopefully this modality will become the standard of care for elective surgery.

Scott said...

Rob,

Enjoy your blog very much. As a plastic surgeon in training, its easy to see the cost-benefit and incredible convinience of an office-based OR for routine elective cosmetic procedures, and even hand surgery. The added cash-flow from the facility fee doesn't hurt either.

I disagree with your assesment that office based surgery is heading the way of the Dodo. In my community, Portland OR, there is massive private expenditure to build office-based ORs. As soon as its financially feasible for me, I'd like to build one.

The problem, which you have eluded to in your previous posts, is the crowd of non-board certified 'cosmetic surgeons' practicing surgery which is out of their scope of training. It is these spectacular and horrifying office-based patient deaths that has casted a pale light on office-based surgery.

When done with competent MD or CRNA anesthesia, office-based surgery is safe, cost-effective, and might have lower wound infection rates than hospital based surgery. Hopefully this modality will become the standard of care for elective surgery.

Dr. Rob Oliver said...

Scott,

No one can argue the convenience of office based OR's.

The economics is a different story. Experts on this will tell you that is rare that these OR's will break even and some can lose signifigant amounts of money when you factor in maintainence, liability, and opportunity costs (ie. how much a similar amount of capital would be earning in some investment).

Also consider that in many states, insurance companies will not pay facility fees even in states without certificates of need (CON).

The context of this post was observing some of the reaction to well-publicized complications. There is clearly going to be some blow-back on this and I expect some states to radically alter the scope of practice you can do in an office OR. Do not be surprised if the ability to offer general anesthesia in that setting is one day prohibited