Surgery Center Deaths: Who Is To Blame, If Anyone?

Posted on  March 9, 2018


A recent USA Today front page article (click here), essentially did a hatchet job on surgery centers.  In the opinion of this writer, the article is misleading, misplaced and inappropriate.

There has been a recent surge in the number of surgery centers – approximately 1,000 in 1988 to approximately 5,500 surgery centers in 2015. In all likelihood, the number will continue to grow.

The isolated cases that are reported to be the product of pouring over thousands upon thousands of Medicare records and postmortem records, which would seem to add legitimacy to the article, are anything but – as they represent a very small percentage of the number of patients that have been treated at Surgery Centers.

Furthermore, other than citing lawsuits brought against surgery centers, and the opinions of expert attorneys that were hired by the plaintiffs in those malpractice cases, there seem to be very few REAL stories or statistics that would answer the underlying question of how patients would have fared had they been in a hospital, as opposed to a surgery center.

The article ignores the fact that doctors are being squeezed in terms of reimbursement for the services they provide. The government is seeking ways in which to cut the cost of the provision of medical care, and like many other countries, has come to the realization that lowering the cost with the use of surgery centers makes a real impact on the cost of providing those very services.

It is inappropriate to take issue with the fact that doctors can own part of the surgery center and derive financial benefit from treating patients at those centers, when it is the very same cost saving initiatives that have driven doctors from the practice of medicine, to the business of medicine.

Let’s be honest; would we rather that the profits to medical centers go to independent real estate investors, or would we rather that they go to doctors so that for the same procedure doctors can enhance their earnings based on rates carefully set by the government and the varied insurers.  If we want to have enough doctors, it is pretty clear that we must allow doctors to earn amounts commensurate with the number of years they went to school and incurred significant debt and/or cleaned out their parent’s savings accounts.

Without the benefit of any real independent comparison between how patients would fare at hospitals under the same circumstances, it is hard to really know the potential issues regarding surgery centers. It is true that they do not have the facility for comorbidities and very complicated or high-risk patients going through what would otherwise be more simple procedures. Surgery centers regularly assess medical history and general health regarding that very issue.

There may always be a judgment call, however, that turns out not to be accurate, just as there will occasionally be a patient that is less than candid about their medical history.

It is surprising that Bill Prentice, chief executive of the Ambulatory Surgery Center Association, dignified this article with any comment except that a failure to respond might sound like an admission of a problem.

It is logical that he declined to speak about individual cases as he may not be aware of the details, and even if he has any knowledge, his comments would have been inappropriate.

However, he did say that “he has seen no data proving surgery centers are less safe than hospitals.”

“There is nothing distinct or different about the surgery center model that makes the provision of health care any more dangerous than anywhere else,” Prentice said. “The human body is a mysterious thing, and a patient that has met every possible protocol can walk in that day and still have something unimaginable happen to them that has nothing to do with the care that’s being provided.”

Prentice said physician ownership of surgery centers is a good thing.

What I find possibly the most troubling of all is that ultimately, if we want to curtail the cost of medical care, we have to assign actual dollars to actual health risks. Let me be clear that at a very personal level, I believe in life at all cost. The question is, though, can society afford life at all cost?

In a simple example, how much would it cost for an airline ticket if there had to be an ironclad 100% guarantee that no flight was ever late. This may not be the perfect example and there are other industries of which that the same question can be asked.

In assessing cost, there is a trade-off between cost and perfection.

Many such considerations are readily made with respect to hospitals. Do we have enough hospital and/or trauma units to accommodate mass casualties in every locale?

Does every hospital have a trauma center, or do hospitals regularly divert or transfer patients?

With healthcare costs approaching 20% of GDP, it is abundantly clear that something must be done and it is apparent that surgery centers operate at lower costs than hospitals. It is also obvious that people die in hospitals.

Interestingly, this rather lengthy article did not compare surgery centers with the mortality rates at hospitals and/or the percentage of medical malpractice claims that were brought at hospitals.

The almost bizarre part of the article was the apparent skepticism that 911 had to be called in the cases where the facility could not provide the necessary level of emergent care.  What did the writers of the article expect when an emergency transfer was needed – Uber?

In totality, I think it is unfair to cobble together a number of albeit tragic stories assign blame to the surgery care centers and somehow try to both impugn the integrity of all of the doctors in almost 5,500 centers, as well the efficacy and efficiency of those centers.

It is clear that we need major reform in lowering the cost of the provision of healthcare and it will not be accomplished by one-sided stories that give a recitation of a few stories primarily based on malpractice lawsuits, a few opinions of hired medical experts.  It is not a real comparison, and makes it sound as though there are no issues or problems within the hospital system.

If we want to address the of the cost of provision of medical care and patient safety, let’s do it in a real, accurate, even handed and comprehensive manner that gives the pros and cons of alternative methods, as well as the benefits and burdens thereof.

To the best of the writer’s knowledge AXO BILL [] does not provide any billing or revenue cycle management services to any of the surgery centers referred to in the USA Today article.

What do you think?

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Comments 151

  1. I think credentialing of physician and appropriate screening of high risk patients are key to reducing the comorbidities. A + business model for the doctor / investor.

  2. Ambulatory Surgery Centers vary widely in terms of medical resources, doctors and equipment both. It is entirely possible that some patients visited a modestly resources and lightly staffed smaller Surgery Center when the treatment required that a large hospital would have been the better choice. This, in and of itself, is not a reason to brand all Surgery Centers as less safe than all hospitals.

    And as for the profit motive, why would we eschew or deny doctors the capitalistic right to make a profit? Doctors are being squeezed from both ends, from HMO organizations all the way to high judgment award lawsuit settlements that make their liability insurance extremely expensive.

    If we continue to press the doctors, trying to coral them into low pay and undesirable environments, we may lower costs, but commensurately lower quality of care much further.

    1. Agree, doctors are often corralled. I am near Holy Cross Hospital ED, Fort Lauderdale, Fl and experienced near death event this past Wednesday myself. For over fifty years, I have been a first responder and saw myself being aided. In the neuro ICU, a neurointensivist told me was told about 24 hours after a life guard witnessed me collapse, called for paramedics. I vaguely remember an IV jammed into my left jugular and someone held my left hand and said, “my name is Noah, we are going to help you”. It seemed as if my throat was being choked. Someone had intubated me and I seized 4 times successively en route to the ED, in the CT scan, and in the ICU. Keppra IV stopped the seizures, which to date appear to be a result of rare side effect to off label RX . Monday, neurology will readmit me for 3 days of EEG and video monitoring to change the Keppra to Depakote, twice daily and to perform additional tests. Needless to say, I am blessed many times over. As I or my daughter, who flew from Massachusetts to assist me, called for additional appointments, the first questions asked were; “what is your date of birth and what is your insurance? I have quipped my true date of birth, but said, “would you accept payment in bitcoin or gold bullion?” Not one receptionist understood, until I asked “do you take cash for payment?” Sad, that my treatment was being routed according to my ability to make payment and/or have insurance. By the way, I have lived just long enough to have Medicare, Presently, have flights booked on Jet Blue to return to Yale-New Haven Hospital, CT to do a turn of academic and clinical teaching to residents and medical students. My speech, short term memory, balance, strength et al are affected. It seems surreal to have had this experience. The new young internist and neurologist impressed me with taking notes with a pencil on scrap paper as they engaged me with direct eye contact. I’LL just finish my missive to post in years. How blessed am I to have collapsed on the beach, and to have received such extraordinary care?

  3. In order to make tgerse surgeries ssfe and competative I think they need accreditation so the patients are assured of their safe practices. No one can predict a death however safety nets are there to minimize these. These settings must as an example assure that a proper pre-anesthesia check-up is done. Cost saving should not be at the forefront of this. Cost containment can be worked into after care in areas such as take home medication and wound supplies etc. comparing appkes with apples would have given the findings more credibility.
    Transferring of patients in distress can be done by MOU with nearby hospitals and ambulance services.
    Compromising on care in order to give the dr more take home money should not even come into the equation.

  4. Thanks for sharing. This reply is critical. To lump all surgery centers together and create a global impression is not only unfair, it is incorrect. And physician investment in these centers should not be an element of discussion as it really makes no difference at all in terms of safety. Why would a physician, such as myself, want to be financially vested in a center that is not safe. That simply makes no sense.

  5. It it is rather sad at attempts to limit doctors from earning commensurate with the value they provide to society and the solution they provide in resolving problems and enhancing the nwell being of their patients. Savings in health care delivery would only be realised when famines and communities are empowered to prevent problems from developing and rehabilitate after interventions. From an economic perspective the real issue is cost if care in “a hospital” versus cost of care in a :””community” settings

  6. There are no absolutes in any business, and this is no different. Surgery Centers offer a great alternative to the hospital setting which can also be fraught with many complications for a relatively healthy patient. To try to bundle them all together is unfair and irresponsible. Calling out the surgeons financial relationship is also irrelevant…would it be better to have a no named investment firm running it?

    Healthcare is still an art as much as a science…

  7. Nice article. I learned in marketing that you need to counteract something with proof positive – how many patients were seen in surgery centers? How many in hospitals? How many deaths in hospitals? Then show a chart of #of and percentages to show a real argument. In NJ, for example, 1 million procedures are performed on patients in surgery centers, with 350,000 of them on Medicare patients. NJ has 209 surgery centers, more than NY, CT or PA. I moratorium was imposed in 2010 that surgery centers must be in a hospital.

  8. We are seeing a similar reaction to high costs in mental health with the start up of respite centers as alternatives to expensive and ineffective emergency rooms for people experiencing mental health crisis. We can ground emotional states more rapidly than any pill and teaching such tools empowers the patient toward self care. Surgical centers are a natural evolution that need to be supported but all of us benefit when we look in the mirror, not to see our faults but see see how we can improve.

  9. HI Michelle,

    I read this USA Today article as well and found it to be extremely one sided. As you point out there was no comparison between ASC morbidity rates and hospital morbidity rates which is very shocking.

    Shame on Christina Jewett and Mark Alesia for publishing such an article without providing all the facts from both sides of a story. We hear about fake news in politics today, and this seems to follow the same lines within the healthcare industry.

    To state that they examined thousands of records……………..”Reporters examined autopsy records, legal filings and more than 12,000 state and Medicare inspection records, and interviewed dozens of doctors, health policy experts and patients throughout the industry, in the most extensive examination of these records to date.” why did they not also examine those of hospitals?

    Hospitals struggle today to keep beds occupied and that costs revenue. ACS’s are as efficient as hospitals and that is why the federal government has approved such services to be performed there. If the infectious, readmission and morbitidy rates are so much higher than those of hospitals, why would the government allow these practices continue?

    I believe this is a fear factor being reported in an attempt to funnel more surgeries back to hospitals which drastically inflate prices charged for services performed through a “Charge Master”.

    Great blog Michelle, thank you for sharing and bringing this to light.

  10. Your critique of the article is comprehensive and appropriate. You raised good questions.
    The sad part of this circumstance is that an article can suggest anything and skew perceptions easily based on one fact. As we all know research is much different.
    I believe most professionals are aware, it’s the general public that may tend to over generalize.

  11. Excellent job with this article. One of the outcomes of a for-profit, incentive driven healthcare system we live in. No matter how organization wants to describe it, the bottom line is the bottom line.

  12. The number of malpractice cases that occur due to outpatient Surgery center procedures is very small, even minuscule, compared to the total number of cases that occur.
    I have written over 5000 opinions in Malpractice cases as the Medical Malpractice Physician Consultant for the State of Pa since 2001. I have reviewed and discussed many thousands more.
    The public needs to understand that any procedure, whether surgical or radiologic, that is done outside the Hospital , costs less and is done more efficiently with respect to time spent in the facility. This is due mainly to the fact that the Hospitals are required to provide care to everyone, regardless of their Insurance coverage, and that cost must be reflected back onto the general public. The inefficiency in “time spent’ for the patients, is also due to the geographic separation of services that occurs in Hospitals ( lab, radiology, OR’s and registration are all different departments on different floors).
    Surgery Centers are essential to the continued health of our medical care system, which currently is in serious trouble. These centers allow Physicians to set the rules, regulations and policies for the care they deliver. This care is of a HIGHER overall quality, compared to hospitals. I personally have the experience and data to support this statement.
    There will always be complications in medical care. All bad outcomes are NOT due to care that was below Standard of Care. WE, the Medical community, must continue to fight back against the large hospital conglomerates that are buying up Hospitals and practices and then controlling referral lines from the primary care providers to the specialists, and pushing the privately owned Physician practices out of business.
    Independently owned outpatient surgery centers are the last stronghold for Physicians who want to control the decisions about their patient’s care, based solely on what’s best for their patients.

  13. Thank you for this nicely written article. I agree with many points made but my response won’t be popular with most of your readers. There is no doubt surgery centers vary in the quality and safety of care they provide, and yes, doctors should be paid fairly for the work they do and the years of training required to become knowledgeable and skilled at what they do. The issue with surgery centers in general is they are generally acquired, built, run by the physicians, usually surgeons, who are already paid 2-3 times more than primary care and other specialties, so the argument that they need to do this to be properly compensated falls a flat in my opinion. That said, they have the right and it is hard to blame them for being capitalistic and taking advantage of a system that allows them to choose the healthiest and best insured patients and doubling or tripling their already high incomes, usually to the detriment of the local not for profit community hospital. While it is their right I can’t help but wish we could go back to the days when patient needs and community interest trumped personal income and yes, greed.

    1. Dr. Klocke,

      Thank you for taking the time to share your thoughts. The amount that surgical centers are reimbursed is not set by the doctors but rather by Medicare and the insurance carriers that normally reimburse as a multiplier of the Medicare rate. There was also the Medicaid reimbursement rate. Accordingly, how much revenue a surgical center receives is not dictated by the doctors. The only question is who should receive the payment. The argument that doctors should be precluded from receiving payment or otherwise not be allowed to have an ownership interest in the surgical centers does not seem to make sense.

      With respect to surgeons earning more money than general practice doctors, the rate of reimbursement and the argument set forth above applies as well. In addition, the malpractice premiums, additional training, and various other factors are probably part of why surgeons are paid more.

      Accordingly, we believe that efficiencies must be sought in the delivery of healthcare to try and keep costs under control, but do not think that doctors should be penalized and somehow precluded from having an ownership interest in a surgical center.

      With respect to the competition to not-for-profit or for-profit hospitals, ultimately we will have to tame the expense of healthcare. With healthcare costs approaching 20% of GDP, the costs are unsustainable.


  14. I trained in surgery/neurosurgery in prestigious academic settings and worked with pioneers like Charles Byron Wilson founding chair of the UCSF Neurosurgery Department in the early 80’s. I continued my surgical training at Stanford University in Aeromedical transport and emergency services. While impressed with the efficiency of surgery performed in high paced academic centers, when it came time for me to choose where I would undergo an anterior cervical discectomy, I opted for a community hospital setting. My most rewarding patient experience occurred in a surgery center operated by Fred Naraghi, MD – doubled boarded in spine and orthopedics. I underwent spinal therapeutic injections there and was impressed with the excellence of service and the belief I was the center of attention and care.

  15. Michelle, your blog is right on, however, surgical centers are just an example of rampant story telling in the guise of journalism. Putting half baked stories into mainstream media outlets that drive a half truth (therefore false) narrative akin to tabloids has replaced true investigative journalism. This lazy, sensationalistic approach is driven by greed in the media and desire for the 5 min of fame by the reporters. Shame on them and their editors for using one of the most important communication tools in society in this shabby way. While your blog is an important way to communicate among your peers, I would encourage you and others in the surgery center business to write factual letters to the editor to voice your concern and hold them accountable. After all who else will or can? Consumers continue to lap up these stories with shock thinking that they are reading unbiased research and reporting.

  16. Universal sharing of patient’s medical records with permission of patient when possible will go a long way to ensuring latest most accurate patient medical history is available when taking medical decisions. Surgery Centers should be accredited on a regular basis by appropriate agencies to perform set procedures for which they are properly equipped to handle. Violations of doing procedures they are not certified to do should be very stiff to prevent establishments from breaking the law. I agree with the author that the prognosis of a patient’s outcome is not in the hands of a surgeon but ensuring all precautions are taken to provide the best possible patient care is what we should strive for.

  17. thanks for sharing Michelle
    intelligently appropriate response
    i agree also with all comments

    in my opinion, there is a trail of other malevolence
    preceding death

    hopefully with this kind of diligence in facing facts we can discover a new way to establish goodwill and protect appropriate compensation for each other

    i.e. transform healthcare

    keep it up Michelle!

  18. I did not read the initial article that spurred this response. However, articles that generalize or misrepresent statistics flourish in this society because they “sell fear”. In most cases, patients (or their doctors) opt for surgery in a hospital setting due to their commodities, surgical equipment needs or needed postoperative care, not because the surgeons and anesthesia teams are “better”. In fact, most surgeons with whom I’ve worked in the past 25 years have privileges at their surgery center and a nearby hospital. That means “properly screened patients” can expect excellent surgical care in an ambulatory surgical setting. As far as for-profit surgical centers with the $$ going to the surgeon–why not? No one thinks twice about a lawyer keeping the profits of his law firm, correct? And how about the CEO of a hospital making a million dollar bonus? Why is it different for a man or woman who spent over ten years of their life training to give you quality healthcare?

  19. The article is interesting and I also read the article in USA Today. The topic is more one-sided and needs more data to support and also the post effects – what changes were implemented in those centers after the never events happened… That is important to see there is a plan moving forward. Maybe there is a need for more data. Many cases are couple years old and regulatory compliance with ASC have been updated. Strategically the best option (in theory) for ASC (stand alone) would be to located close to a good hospital with Trauma services for those once in a while emergencies. Staff should be educated and go through emergency management so they are ready to assist and stabilize patients as they are being transported. There are pretty strict regulations around competencies for staff and providers for health care. Staff should know the process, know the resources and be able to demonstrate and speak to it. The center’s leadership is also responsible for patient safety and risk assessment.

  20. I would like to comment as a physician owner and medical director of a former Surgery center in NY. It is extremely difficult to provide profitable care to surgery center patients given the payment structure tightly controlled by insurance companies and government. The centers provide care with fees that are 45% less than the hospital rates for the same procedures. What is untenable with these rates is the regulations and compliance laws which need to be adhered to to provide this care. If we want to provide quality , safe care we need to loosen the noose and let these centers not have to adhere to hospital level regs and get better rates thru group negotiations with insurers. I have a lot more to say on the subject. Ty

      1. I don’t know much about the subject but I could restate the obvious. The primary focus of healthcare should not be cost reduction, convenience or bedside manners but offering the best outcomes especially in critical situations. however, for some people secondary factors may determine whether they will receive healthcare services so it has its place in the healthcare field as long as doesn’t become mainstream or dominant.

  21. Excellent article with really good information. My thoughts are this: My mother was in and out of hospitals for years with COPD and seizers. And, I strongly believe that her many hospital stays contributed to her early death. I do not believe that surgery centers pose a health threat to the patient. As long as the physician is putting the patients needs over their own compensation.

  22. I have worked in both a medical center and a hospital. This was a very interesting take on comparisons and critique of hospitals verses surgery centers. Our society has become so quick to “sue” and cast blame, which is very unfortunate. The United States needs a total revamp of its medical system. The poor individuals of this world are neglected because they don’t have the resources for quality services or accommodations, while the rich have resources and are willing to sue should things not go their way. As far as the question of surgery center deaths verses hospital deaths and whether surgery centers are equipped with staffing or competent doctors, I believe was the question at hand. In my opinion and observation, a surgery center is equipped to handle the patients surgical needs. Surgery centers are able to focus on the specific needs of the patient that comes in for their services.

    These facilities are not going to set themselves up for litigation or negative propaganda from the public. These facilities realize the ramifications of incompetency. Of course, you will always have that small minority that try to cut costs at all expense and where the human life is just a small acception to the rule to the almighty dollar or revenue.

    This article ignores the fact that doctors are being squeezed in terms of reimbursement for the services, or the fact that our government is seeking ways in which to cut the cost of the provisions of medical care to the people. The government has realized that lowering the cost with the use of surgery centers makes a real impact on the cost of providing those cutbacks and it stirs up more revenue which is taxable, again the government focused on fattening it’s own wallet. Hospitals are huge money consuming elephants. In my opinion, surgery centers are more practical and effectively, efficient. Again, thank you for inviting me to read the article, and I appreciate you valuing my opinion on the matter at hand. To me, a view of statistics on the populous regarding the variances of opinion would be beneficial; however, I suppose time will generate the concensus as individuals will seek out ways to save their monies. Thanks again for allowing my opinions.

    Warmest regards, Tammy Spencer, MSW

  23. Thanks for sharing. You have considered so many different angles to understand and analyze the issue. Good data, and independent comparison, as you pointed out, are crucial to any improvement effort.

  24. Your article was a nice attempt to question the objectivity of the USA today article. I agree, the USA today article was indeed a hatchet job against the Surgical centers.I believe the surgical centers are here to stay as they serve to help reduce acute care cost, nevertheless most can use some more improvement. I also don’t see anything wrong with physicians being part owner of some centers. As a matter of fact, this will further motivate the surgeon/owner to improve his practices. Regards. -Ahmed

  25. This is a good article, that questions the veracity of the stories published by USA Today and The Bergen Record. These publications have strong commercial ties with hospital organizations, and are thus not impartial reporters. Ultimately though, as with all the best arguments, it comes down to the evidence, of which these stories were completely devoid. The conclusions they drew were based on anecdotal reports, and rather bizarrely, they admitted that there is no central data base, which collects outcomes, thus making meaningless their proclamations of surgical center risk. Reporting on the specifics of a limited number of adverse patient outcomes is not scientific, and is designed simply to inflame the public against surgical centers. One step that the surgical center community can make in response to these articles, is to establish a central data base, that will leave no question in the public’s mind that they are the safer, more economical and infection free healthcare option.

  26. Thank you for the blog article. As an experienced anesthesiologist, intensivist, and expert witness , I can only offer opinions with regard to standard of care for those cases I have personally reviewed. I can, however, attest to the inherent risks of anesthesia: death, profound hypoxic brain damage and other forms of serious bodily injury. The assumption made by some administrators (whether they have MD after their name or not) is that anesthesia is inherently totally safe and that cost-cutting has no impact whatsoever. The working hypothesis that cost cutting has risk is far more likely to be explored by “60 Minutes” than any government agency, as CMS ardently maintains the psychotic view that cost cutting is not only risk-free, but also produces miraculous re-engineering. There is not one shred of evidence for this view. Your clients need to know that anesthesia risks are real and a single large verdict or settlement can be devastating to a small business.

  27. Thanks for sharing this interesting article. I have not seen the USA Today article you mention. However, I can imagine the contents. The media always sensationalize stories to sell them. As you eluded in your article, healthcare costs are too complex to be penned for one reason. I truly believe the costs are due to the unreasonable expectations the American society places on medicine. It is not acceptable to leave a very premature baby to die. We have to resuscitate it and spend millions of dollars in a lifetime for a disabled child. It is not accepted for an alcoholic dying of liver failure to die without giving him a liver transplant. I can cite you thousands of examples of hopeless cases that we insist on providing care for few months or few weeks at huge expenses knowing fully that it will be useless intervention. Who is at fault? Families, lawyers, government laws, doctors, hospitals?! It is a broken system that needs total change not from the financial point of view, but from the societal, legal and ethical points. Once we correct our expectations, the costs will continue to go down.

  28. As I see it Hospitals in my area are closing and Surgical Centers are opening. With this in mind Hospital stats will be diminishing and Surgical Centers stats will be rising. If I were to have surgery, I would choose a Surgical Center due to the fact that they do not have all of the infectious germs. If doctors have an interest in the center, they would have the interest of the patients as well. Thanks for the article, Jim

  29. This was a very well-written, well- spoken, response. These days many healthcare related articles are written in haste, with little regard to facts. Authors prefer buzzwords to generate hits. Buzzwords that are used correctly (in a bad way) will cause the article to be read as “news” not fluff; this is the unfortunate result in the average person not understanding the complicated health behemoth. Great job! Keep it up!

  30. Thank you for sharing this blog. This needs to be addressed and discussed more! Kudos to you for reaching out and speaking truth.

  31. I take a patient to a surgical center for those procedures that do not require a full hospital team to cater for any and all eventualities. i.e. Class ASA 1/2 or maybe 3 if well controlled. The patient will first undergo a medical evaluation for fitness to proceed. When is the last time your dentists performed a root canal in a hospital setting? In 30+ years I have not witnessed a fatality, under such circumstances. As for ‘profit’ motivation: stop, just stop. The author clearly does not know, or care, to know the economic reality. The primary motivation is the opportunity to help a patient get a better quality of life. There is no financial ‘incentive’ when there can be more dollars earned attending to the office patient. Believe it or not folks, some doctors just want their patients to have the help they need and ask for.

  32. Firstly I sincerely believe that doctors are not businessmen, they are professionals who have been earmarked by society to perform a life saving duty to the best of their ability and judgement. Questioning their judgement often tantamounts to questioning the ability and judgement of well wisher, parent or best friend.

    Of course there are bad apples everywhere and this profession is no different. However it’s regressive generalizing the entire profession due to few back sheep. Also it’s become fashionable to question a doctor’s earnings. The mindset of lay people requires overhauling pronto.

    There are generally predefined medical / surgical interventions for specific cancers depending on the stage and grade and that should be standardized without prejudice by all healthcare providers. Few relevant deviations should be permitted.

    Doctors shouldn’t be made to scavenge for their earnings and then automatically the black sheep shall be eliminated. Let us understand that only the elite few with high intellect manage to become a doctor, so let’s trust him !

  33. I read your article with interest. You make a number of good points. Deaths in Surgery Centers are every bit as concerning as deaths in hospitals. The reality is that any one set of statistics can be utilized to perform a disservice by creating the appearance of whatever the user wishes to stress. First off, all surgery centers are NOT the same. To assume that this is a blue vs gray (pardon the Civil War analogy) issue (i.e. hospitals vs surgery centers) is to begin with a flawed comparison. Surgery Centers that perform complex orthopedic (for example total hip replacements) or lengthy medical plastic procedures requiring five or more hours of general anesthesia (for example a double mastectomy with reconstruction) are different than surgery centers that perform only lumps and bumps removal, wisdom tooth extractions, planters wart removals, and endoscopies and knee scopes. Often, the human protoplasm that an inner city hospital performs surgery on is different than the wealthy suburban located surgery center. The back up resources in a teaching hospital may be far superior to those of a surgery center that would instead send a patient to that teaching hospital should a problem develop. At the heart of the reimbursement issue is the simple fact that in general hospitals have more Medicaid patients in their surgical mix than surgical centers. Yet plenty of surgical centers are LLC’s with hospital financial interest because the hospital chose to partner with surgeons creating a surgery center rather than lose them entirely from their market. There are hundreds of hospitals with Operating Rooms constructed so long ago that the number of hourly air changes (an infection control consideration) are half that of a newly constructed surgical center. Simply stated these examples all point to the fact that you cannot lump the focus on quality in one surgical center to another anymore than you can in hospital surgical departments. Looked at in the big picture the cost advantages of a wood frame built surgical center (yes you can build a surgical center out of wood and NO you cannot build a hospital surgical suite out of wood) reflect just one difference in the cost equation. A hospital with a 20 percent Medicaid and 50 percent Medicare grouping of surgical patients and a 50 percent private insurance patient load will be reimbursed accordingly. The hospital pays for a more expensive building due to building codes and is paid less after insurance reimbursement from Medicaid and Medicare and Private Pay insurance patients are cared for than the surgical center in a wealthy suburb that is perhaps 85 percent private insurance patients and 15 percent Medicare. The hospital must then try and subsidize that income difference. Had the surgical center never existed the hospital would have had the superior income of the surgical center. This reality is why surgical centers do not save money in the big picture – there is no free lunch and someone pays for the lost income in the hospital. Early in my career I actually watched a physician who was disciplined and lost privileges to perform certain complex surgeries in a hospital who then opened a surgical center where he continued to perform those procedures. I would never suggest that this is how surgery centers operate today. They don’t. My point rather is that there can be key differences sometimes between the standards in a hospital and a surgery center. Today, I have chosen to be a patient in a surgery center over a hospital. I chose because of cost. I also chose because I believed there were superior personnel in the surgery center I chose over the hospital option. Both were quality operations – I would have been safe in either setting in my opinion. Many is the time I have witnessed a physician who simply could not adjust to the standards and “rules” of a hospital surgical center (show up on time for your surgery as an example) become a model of timeliness when they had an ownership interest in the surgery center they chose to work in. I believe there is room for both hospitals and surgery centers to compete in the market and simple non governmental accreditation agencies such as Joint Commission can be charged with external oversight. Ultimately the entire argument of hospital surgery vs surgical centers is a fools errand. Neither grouping can be accepted as representative of all their constituents. Legislation favoring one over the other is simply protectionist in my eyes. I will choose based on my estimation of the surgical team and their facility. I will not choose based upon a three story atrium lobby and building beauty. I have an advantage the general population does not due to my experience. That advantage is perhaps misleading, it emphasizes my own biases. In general we have excellent medical care in this country. Unfortunately the cost issue does not really belong in the argument. The middlemen, the needless regulation and the endless complexities of geography and cost as well as enormous government reimbursement and public expectations are factors that impact both hospitals and surgery centers. You touch on the perfection issue and at what cost in your article. Truly that is the greatest cost issue. We as a public expect much more from our medical system than is actually affordable in my opinion. My first step solution were I king would be to offer ALL social security pensioners a two or three tiered medical care system based upon how much social security pension is paid. Just as most Americans choose social security at 62 at a reduced amount than if they waited till age 66 (currently or 67 in the future) I believe most Americans would forgo the right to kidney transplants at age 68 if they received higher social security income. Medicare is promising a form of immortality in the comprehensiveness of its coverage today – not everyone wants that. Many Americans would prefer more income to utilize in the golden years they have left…. I could explain many more surgery center vs hospital surgery differences but ultimately considering all the differences, both deliver quality care and both cannot be categorized without degrading the comparison to a level of pointlessness.

    Regards, Stephen Dailey FACHE

  34. I am advocate for accredited ASC’s. When an ASC is accredited by the Joint Commission, American Association for Accreditation of Ambulatory Surgery Facilities and the Accreditation Association for Ambulatory Health Care, I am confident that such units and their clinical and administrative personnel are competent in guiding quality outcomes for their patients. The PRO’s versus CON’s of using an ASC is apparently why ASC’s have tripled across the country since the 1980’s. Convenient location, same day surgery availability, lower overall costs for outpatient procedures have proven success based on the millions of procedures done annually. The CON of an overnight stay when needed can be addressed by having a transfer agreement with a quality acute care hospital. Of course I would expect that the patient’s diagnosis and condition will be properly evaluated before being scheduled in an ASC versus a hospital OR. Based on our current reimbursement system, competition is a very good thing in addressing the nation’s escalating healthcare costs. Again, it’s important that ASC’s and their clinical personnel are overseen by an accreditation body to help insure that safety is a priority.

  35. Excellent blog. As an experienced medical assistant who worked out of an minor ambulatory center and who has been a patient of a surgery center, this article stands correctly. Judging all surgery centers due to the lack there of of just a few is totally unbalanced. The services being provided by surgery centers have been a great help not only with healthcare costs but a convenient option for patients. Once strict protocol is being adhered to risk factors tend to be on the low side but there may still be instances where things can go wrong. (It’s just the nature of things).

  36. We must be careful to not use one brush stroke to paint all establishments. Despite the inefficiencies of some establishments, as a retail clinic Nurse practitioner, the emergence of this structure of healthcare management has left an indelible print in the overall improvement of the healthcare system in recent times. Thanks for sharing this article which provides enlightenment.

  37. I’m unfamiliar with the original USA Today article, but this was a nice, articulate rebuttal. Sometimes there is no one to blame but nature and physiology, and not uncommonly patients may omit history that indicates they are not candidates for treatment in an ASU.

  38. Interesting article Michelle. I was recently in Maryland visiting a hospital and they happen to love ambulatory surgery centers in that state. In Maryland, the hospital is paid a lump sum of money to care for the community. If they spend less, they get to keep it. If they spend more, they can go bankrupt. So they like to do as many surgeries as possible in an ASC at a significantly lower cost than the hospital. Saves the patient money, saves the hospital money, and the doctor might make a little. The incentives are all aligned and when that happens we should see good care. I don’t think doctors make a ton of money on these centers. Some might, but the startup costs are high and it takes a long time to get back your money. – Mark

  39. “If the only tool you have is a hammer, to treat everything as if it were a nail.” An analogous thought to Abraham Maslow, The Psychology of Science, is to consider any surgical intervention as a life-threatening physiologic altercation. All surgeries are serious business and mandate a strict business plan because the focused mission of a surgery center is to provide surgical intervention. PRO Surgery Center List: Practice, repetition, case exclusivity and volume in surgery procedures will strive for six sigma outcomes i.e., 3.4 defects for every one million opportunities. This is called methodology and should be address in the business plan. CON Surgery Center List: Greater than 3.4 defects for every one million opportunities. No case exclusivity with low volume threatens a consistent and predictable result. My personal opinion for many surgeries performed in the United States for both acute care hospitals and surgery centers should be the last resort medical intervention usually required of catastrophic illness. I admire Six Sigma physicians who practice surgery. The only prejudice I may harbor in general, “caveat emptor.” Nota bene: I am retired from pathology, therefore my opinion is solely as an advised civilian and may not be consistent with current evidence based medicine.

  40. Thanks for sharing your article on a topic that is very complex and which doesn’t have any easy answers. I agree that the mainline press often goes for the sensational without having a lot of hard evidence to back up its conclusions. However, I continue to believe that the most crucial issue we have relating to the US healthcare system is costs vs benefits to our citizens. Its just in not acceptable that we spend 3 times more on health care than any other industrialized country for only middling morbidity and mortality rankings compared to other nations. Whether for-profit surgery centers contribute to this problem can be argued on either side of the issue. But what cannot be contested is that regardless how much the US continues to spend on healthcare, until we can successfully turn around certain lifestyle/socioeconomic realities (i.e., bad diet, high opioid use, health disparities based on racial & income differences, etc.) I don’t see how the issue of escalating costs (projected now to be near 20% of GDP by 2024) can be resolved. Thanks again for sharing your article and good luck in the future. – Dennis

  41. This is a very politically charged topic. I will share my opinion from the point of view of an Anesthesia Technician. I assisted Anesthesiologists in Surgery Centers and also served as a consultant maintaining anesthesia equipment and supplies for some private ASC’s. I have found ASC’s to be more dangerous to patients than hospitals for the following reasons:
    1. Extreme cost savings measures: Poor quality/cheapest devices and supplies on the market. These are also usually unfamiliar to providers that float from the hospital to the ASC
    2. Adherence to maintenance protocols are usually very relaxed compared to hospitals
    These conditions are more magnified the more “removed” the surg ctr is from the parent hospital.

  42. Nice article. I agree. Surgical centers can not all be painted with the same brush. They can perform many procedures exceptionally well; and offer safe alternatives to out-patient/in-patient hospital stays.

  43. Having not read the article, did the author use data? I can only imagine how many surgery center cases occurred in 1988 vs. currently. We know working in health care there has been a large shift of patients from hospitals to ASCs. If we changed the number of deaths to a percentage, how would they compare? I agree with a physician above, better screening of high risk patients would almost certainly decrease this number, assuming the issue is not resources at the ASC.

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