By Larry Fox
Much like Cape Cod marking the Ides of March…poised between stubborn winter and reluctant spring…the state of health care also hovered in limbo when the Advisory Board of To Your Good Health, A Health Care Newsletter, held its most recent meeting at the Dan’l Webster Inn in Sandwich.
The State Legislature was still grappling with its health care bill; the avian flu continued to lurk well over the horizon; foods and drugs were bouncing on and off the good-for-you/bad-for-you lists and town meetings around the Cape had yet to address those health-care-for-all resolutions.
The opportunity was ripe for Stephen L. Abbott, President/CEO of Cape Cod Healthcare, to address a particularly troubling issue, the emergence of alternative site specialty surgery centers around the Cape.
Dr. Arthur Bickford, former Medical Director of the Duffy Health Center, sympathized with Mr. Abbott’s concerns and pithily explained that it’s a particularly vexing situation because Cape Cod Healthcare can’t expand market area to compensate for lost revenue.
“They’re (classified as) a Sole Community Provider and, with water all around us, they can’t send buses out to the suburbs like the Boston hospitals,” Dr. Bickford declared.
All agreed that these specialty surgical centers can be more convenient for basic outpatient procedures.
But these procedures are significant revenue-producers and Mr. Abbott observed that specialty centers use several unfair advantages to siphon funds from already-strapped full-service hospitals.
“I don’t fault those individuals,” he said, “They’re not doing anything that in a free market one wouldn’t do. But is health care a free market? The situation is that we are highly regulated and we have our requirements. We are expected to be a public safety net. And we continue to cross-subsidize those (many) things from which there is no revenue with income from the procedural work.”
Full-service hospitals, he pointed out, must take all comers, regardless of their ability to pay or the severity of their conditions. They are required to maintain and staff such facilities as emergency departments and blood banks around the clock. In contrast, Mr. Abbott continued, surgical centers can select who they treat and when, avoiding complicated cases and the uninsured.
They also can open where they wish, he continued, and make no contributions to the state’s “free care pool,” which partially reimburses hospitals for treating the indigent.
“They say, ‘well, it’s just a better mousetrap,’” Mr. Abbott complained, “but I could build one, too, if I had the freedom to pick and choose.”
The only current specialty center on the Cape is the Ambulatory and Laser Center of Cape Cod in Sandwich, but two others are in the works-a urology center in Hyannis and another with surgeons in Falmouth.
One possible bit of help could come from legislation sponsored by Senator Rob O’Leary (D-Cummaquid) that would require these centers to complete a Determination of Need process with the Department of Public Health before being allowed to open. Another equally unlikely scenario would be for the government to provide higher Medicare/Medicaid reimbursements for those procedures done in a hospital.
Andrew Young, a former trustee of the Cape Cod Hospital Foundation, asked how other hospitals were dealing with this dilemma.
“Some hospitals have just sold out to for-profit groups,” Mr. Abbott responded. “But we are a not-for-profit and we have our charitable mission.”
Susan Miller, Associate Dean at Cape Cod Community College, asked about comparable outcomes, but Mr. Abbott said no such data existed because, unlike the hospital, “they can select only the low-risk, high-margin, quick-procedure cases.”
The Visiting Nurse Association of Cape Cod, a branch of Cape Cod Healthcare, is peripherally involved in this dilemma. “We deal with a lot of Medicare patients suffering from chronic conditions and these are the patients with complex health care needs who often end up having to go to the ER,” explained VNA’s President/CEO Diane Kolb, referring to one of the hospital’s “loss leaders.”
And, added VNA Marketing Director Jeanne Sarnosky, “We also have our competition from private home health care agencies that can pick and choose their patients.”
Dr. Bickford said that only once had he seen an example of where specialty surgical facilities really worked. He was practicing in India at the time. But with a billion people, he explained, there were more than enough patients to go around.
One phrase used to describe the new facilities springing up around the country and sending shudders through the accounting offices of established hospitals is “emerging alternate-site surgical centers.”
The Ambulatory Surgery and Laser Center of Cape Cod already is in operation in Sandwich. The Bayside Surgery Center plans to open in the Bayside Medical Complex on Route 28A in North Falmouth in early July.
The Bayside group currently consists of a partnership of six surgeons, all affiliated with Falmouth Hospital, and they will offer “multi-specialty surgery.”
Dr. Garry L. Brake, a general surgeon practicing in Falmouth, has been acting as the group’s spokesperson.
“We feel as physicians that this has been proven the most efficient-and cost-efficient-way to provide out-patient care…and also best for the community,” Dr. Brake said. “The hospital setting has too many variables.”
Besides the added expense, Dr. Brake said emergency cases often force rescheduling of less pressing procedures.
Dr. Brake disclosed that his group had first approached Cape Cod Healthcare about creating a joint venture surgical center but he said they were turned down because “they said it would create a duplication of services and there were some (regulatory) restrictions at the state level.”
Dr. Brake said his colleagues were as dismayed as local hospitals that state mandate prohibits them from serving MassHealth patients. “We’d be more than happy to treat them and we know that would help the hospitals. We recognize the importance of Cape Cod Healthcare and that’s why we went to them first,” he said.
“Restricting the centers is not the cure,” he continued. “We should change the legislation concerning reimbursements and let the hospitals operate under our rules. That’s where the focus should be.”
Dr. Brake said he and his partners continue to have close affiliation with Cape Cod Healthcare. “Falmouth Hospital is great, we’re not leaving them,” he declared. “We’ll still do inpatient surgery there and cover in the emergency room.”
And also, he added, they’ll use the hospital when performing outpatient surgery that involves high-risk patients or procedures; or radiology or other support services.
The center limits its practice to “healthy patients and procedures less than 90 minutes long,” according to Dr. Brake…and that, of course, is the bone of contention.
Dr. Robert P. Yoo, a plastic and reconstructive surgeon practicing in Hyannis, is the new medical director of the Ambulatory Surgery and Laser Center of Cape Cod in Sandwich.
He cites efficiency, which benefits both patients and physicians, as leading to the growing popularity of surgery centers.
From the patient’s point of view, “they find the centers very nice,” he says, and they also appreciate the extra attention created by “a higher staff to patient ratio.”
This increased staffing also leads greater efficiency since surgeons can do up to twice as many procedures in a single day, even to the extent of having patients prepped in one room while the doctor is operating in another.
Costs are lower in these centers, which really benefits the participating physicians. Insurance company reimbursement contracts usually are based on a set schedule of fees, Dr. Yoo explained. The insurance company pays X dollars per patient; the doctor’s cost is Y; X-minus-Y is profit; the bigger the gap, the better it is for the doctor.
As for safety, Dr. Yoo says that certifying organizations are “very aggressive” in assessing outcomes “and we’re every bit as good, or superior to the hospitals.”
But, he adds, echoing Dr. Brake, if the patient is high risk or sick, “We don’t do them.”