Health care delivery after COVID-19: Move more procedures to the outpatient setting

The United States has some of the most advanced medical technology in the world, yet COVID-19 has exposed significant deficiencies in our health care system. As nothing will be the same after coronavirus, our health care system must also change as we move forward.  Now is the time to work towards improving the current system and begin to develop an infrastructure that delivers medical care at an optimum level, not only in crisis situations but also in daily care.

The decision to close down non-essential businesses in most states and implement social distancing protocols was necessary to attempt to control the spread of the virus. However, these policies have resulted in foreseeable but unintended consequences that have had a direct impact on the ability to deliver health care for physicians who provide non-emergent procedures and care. Physician practices are small businesses, and many clinics have had to close and furlough or fire much of their staff. Hospitals have been dealt with large financial blows, and the economic consequence of these decisions will inevitably result in hospital closures and the failure of physician practices. In order to preserve resources for patients with COVID-19, state health departments also issued mandates requiring the cancellation of all elective cases, and hospitals canceled the majority of elective operative procedures.

While currently on hold, these canceled elective procedures will eventually need to be rescheduled, and many systems across the country have plans to resume cases in a step-wise manner. However, prior to this pandemic, many hospitals were already working near to or over capacity, and COVID-19 has overwhelmed an already overburdened health system. When elective procedures do resume, a reallocation of already limited resources will be necessary to provide care.  As clinics and hospitals begin to adjust to a new normal where preoperative COVID-19 testing and use of PPE may become the standard of care, in a system already pushed to its limit, safely performing emergent and elective procedures will be a challenge.

One component of addressing these shortcomings and finding solutions will be a need to develop a strategy that would avoid a total shutdown of elective surgical procedures in times of public health crises.

Currently, patients are able to receive surgical care in the hospital, a hospital’s outpatient surgery department, an ambulatory surgery center (ASC), or in a physician’s office. However, many procedures currently performed in the hospital can be transitioned to the outpatient setting. Implementing a strategy to intentionally move more procedures to ASCs has many benefits, such as:

  • Moving these cases out of hospitals as a standard of care would result in an increased capacity for hospitals to take care of patients with acute illnesses.
  • Orthopedic Reviews and the Ambulatory Surgery Center Association estimated significant cost savings for patients.
  • The Centers for Disease Control and Prevention have shown that the ASC setting is potentially a cleaner and safer environment for performing procedures.
  • Delays in procedures can result in complications when procedures initially identified as elective progress and become more emergent. In ASCs, scheduling can be undertaken more seamlessly and personalized to the patient’s needs.
  • By decreasing the burden of the numbers of patients receiving elective or less emergent procedures in the hospitals, hospitals would be able to better provide care for those requiring emergent care, patients with acute illnesses, and those who require complicated labor-intensive procedures.

All procedures cannot be performed in ASCs, and more complex procedures requiring hospitalizations would continue to be performed in the hospital setting. However, there is a need for more of these centers to supplement the care provided by hospitals. Unfortunately, barriers remain for opening ASCs. ASCs receive less reimbursement for procedures compared to hospital outpatient surgery centers. More than 30 states have a certificate of need requirement that prevents the opening of these centers. Payments for procedures done in ASCs are also often delayed while awaiting certification. In order for these centers to function optimally, efficiently, and succeed, it is essential payments occur when the procedure is performed, and a swifter certification process is necessary. A certification process should also be required for carrying out complex surgical procedures in the office setting.

These outpatient centers must also have safeguards in place in order to deliver safe care and protect both health care workers and patients, especially during times of national crisis such as a global pandemic. Precautionary measures such as a presurgical COVID-19 test are easier to implement in smaller health centers and decrease the potential exposures to communicable illnesses, including COVID-19, when compared to hospitals where patients interact with far more health care workers. The ability to control exposure while still performing these non-emergent procedures is more easily achieved in the smaller, more intimate outpatient setting. Thus, physicians have a more cost-effective and potentially safer environment in which to deliver care.

The U.S. health care system is broken, as has been made even more apparent during this crisis. In order to continue to provide the best care to patients across the country, the health care system must evolve to meet new challenges. It is time to analyze the current health care delivery system and make changes for the future. One necessary component is an increase in ASCs.

Shikha Jain is a hematology-oncology physician who blogs at her self-titled site, Dr. Shikha Jain.  She can be reached on Twitter @ShikhaJainMD. Krishna Jain is a vascular surgeon.

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