Office-based surgery: Many opportunities, some challenges

How significant? In the state of New York, OBS reimbursement for transurethral microwave thermotherapy (TUMT) to treat BPH is about $4,500. Urologists who perform the same procedure in an ambulatory surgery center can expect to earn less than half of that, said John Fracchia, MD, of New York Urological Associates in New York City.

"There is an economic push to get as many surgeries as possible out of the hospital and out of the ambulatory center and into the office," Dr. Fracchia said. "We have people doing things in the office today that you would not have dreamed of just a few years ago."

Urinary incontinence surgery is a growing area in OBS, noted Scott Blickensderfer, DO, of Urology Associates, South Bend, IN. Minimally invasive slings are the latest procedure to move from hospital to ASC to OBS.

"You can do anything in an ambulatory surgery center that you can do in a hospital outpatient center, and you can do anything in OBS that can be done in an ASC, depending on how the OBS facility is equipped," Dr. Gee said.

Some OBS facilities are large and resemble an ASC; others are just a room in a physician's office suite.

Lowering the bar

But that does not mean that OBS is not routinely used for patients at greater risk. Most plastic surgeons, Dr. Blickensderfer noted, do almost all of their surgeries in the office setting, including surgeries requiring deep sedation or general anesthesia.

"Their office is their only surgery center," he explained. "At least in theory, there is not much difference for urologists. In practice, it is a question of equipment and cost. Not every practice can afford fluoroscopy, but as equipment costs come down, we can expect to see more procedures performed in more offices on a routine basis."

There is no reliable count of how many surgical procedures are performed in the office setting each year. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) estimates that 40,000 office-based surgery facilities are in operation throughout the United States, up from a handful of centers in the early 1990s. Then, plastic surgeons, dentists, and other specialties were doing OBS, but most clinicians were still using hospitals or hospital-based ambulatory care facilities.