Once ridiculed as 'doc-in-the-box' medicine, surgery centers have moved to the forefront of reform efforts CUTTING COSTS

June 19, 1994|By Patricia Meisol | Patricia Meisol,Sun Staff Writer

At the Central Maryland Surgery Center in South Baltimore recently, a nurse prepared Mildred Bonadio for cataract surgery by dropping a local anesthetic into her eye.

Normally, the patient would be asleep and a physician would have injected the drug with a needle. But the drops, introduced this spring at the center, saved 10 minutes on Mrs. Bonadio's procedure and the others that followed. By 2 p.m., the operating room was running ahead 1 1/2 hours -- enough time to schedule four more patients.

In a hospital operating room, an extra 10 minutes hardly makes a dent. But in same-day surgery centers such as Central Maryland, success is measured in pennies and minutes.

Once ridiculed as "doc-in-the-box" medicine, surgery centers are the front lines of the war against rising health care costs. The price for a cataract operation at Central Maryland is $900, compared with $1,800 to $2,600 in most hospitals.

As a result, more and more patients are being forced to use surgery centers by cost-conscious insurance firms and managed care companies.

"We are cheaper because we only do one thing," said Lawrence D. Pinkner, a plastic surgeon and president of SurgiCenter of Baltimore, the largest same-day surgery center in the state, which handles more outpatient cases annually than most Maryland hospitals.

The transition away from hospitals to the centers hasn't been easy. Doctors accustomed to walking across campus from office to hospital often balk when managed care companies order them to get privileges to work in the centers, which may be on the other side of town. And some patients can become numb with terror, worrying about the quality of care they will receive.

Patients "say they want a real operating room," said Thelma Hoerl, the director of Central Maryland Surgery Center. "Or, 'The HMO made me come here and I don't want to be here.' "

In the end, patients are easily won over.

When hospital nurse Verna Barranco went to the center to have cancerous tissue removed, she said, "I was skeptical." But she found the staff warmer and more efficient than at a larger hospital. "Here they treat you like a person," she said.

It's the doctors who are hardest to convince. The main obstacle is change -- nobody likes it.

Ms. Hoerl can attest to that. Part of her job is convincing doctors to try a suture priced at $1.95 instead of the $12 one they trained with. Some items, such as gauze pads, she can substitute and get away with it. Others, such as gloves, are almost impossible to replace without incurring the doctors' wrath.

"I get threatened like that three times a week. 'If you don't get such-and-such I'm taking all my patients back to the hospital,' " said Ms. Hoerl, a surgical nurse.

"Doctors love to operate. That's all they really care about -- they don't want to be bothered with the business of surgery," Ms. Hoerl says. "But you are starting to see a change."

"In the beginning, I didn't like it. I had an office at Sinai and I thought it was crazy," said Moshe Salomy, a gynecologist in practice 30 years who was forced to the center when managed care companies signed up his patients in 1989. But now, he said, he sees little difference between the surgery center and Sinai Hospital.

"Everything is state-of-the-art," he said of the center. "Otherwise, I would not keep coming here. If anything happens, it's me, not them [the center]."

CareFirst was first

The 4-year-old Central Maryland facility, in a business park on Joh Avenue, opened with a single customer, the HMO CareFirst, which also was a minority investor. Now it has contracts with 19 companies including Cigna, Kaiser Permanente and U.S. Healthcare. CareFirst accounts for 38 percent of its patients.

Last year doctors throughout Baltimore used the center for 5,200 cases, including about 1,000 cataracts, 400 gynecological procedures, 950 general surgery procedures, and 710 ear, nose, and throat operations. Other specialties include orthopedics, urology and plastic surgery.

The facility is one of two in Maryland owned by Surgical Care Affiliates Inc. The Nashville-based company has opened 62 centers nationwide in the past five years, some in joint ventures with local doctors, hospitals or insurance companies.

Hospitals account for most same-day surgery procedures, but the number of free-standing surgery centers in the country rose 24 percent in the two-year period ending in 1992 to 1,690, according to Chicago-based SMG Marketing Group Inc., and more than 3 million procedures are performed in them annually.

Their increasing popularity is pushing down prices at hospital-based outpatient centers and leading some hospitals in Maryland to open off-campus centers of their own.

Efficiency is partly the result of a screening process in which Central Maryland Surgery and others like it reject all but the most healthy patients.

Central Maryland doesn't have a team of cardiologists waiting in the wings, so it has to be more selective about nurses. Usually they are operating room nurses.

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