What does a complex multi-billion cell organism, like a human, and a simple, single-cell organism, like an amoeba, have in common? Both have a primal desire to avoid noxious stimuli. How is this related to having an Office Based Lab (OBL)? Hospital administrators are a noxious stimuli. In the United States, over the last 50 years, there has been a 150% increase in the number of physicians; however, over the last 30 years, there has been a greater than 3000% increase in the number of hospital administrators (Figure 1).
Office-based laboratories (OBL), also known as outpatient interventional suites (OIS), have grown in prevalence since the revision to the Centers for Medicare and Medicaid Services (CMS) reimbursement fee schedule in 2008. Endovascular procedures have shifted from the inpatient arena to the outpatient setting, and this migration to outpatient intervention has been supported by patient safety data.1,2,3,4 It is currently estimated that there are approximately 750 OIS in the United States. This number is likely to continue to climb as CMS revised the fee schedule in 2020 to provide coverage for percutaneous coronary intervention (PCI) in an Ambulatory Surgery Center (ASC) environment.
An OIS offers many advantages over a hospital, including: they are incredibly more time efficient, more patient friendly, and more cost-effective. In an OIS, patients are treated like people; they are not de-humanized and herded around impersonally through a mega-building maze. They are not asked to waste hours of their day wading through the check-in process, and then hurry up and wait hours for their procedure to begin. It has been well documented that patient satisfaction scores are tremendously higher in an OIS compared to a hospital.2,5 In addition, an OIS offers a marked cost savings to the healthcare system. Currently, on average, a hospital is paid 40% more by CMS for the exact same procedure compared to an OIS yet hospitals incur so much waste they are barely able to remain financially solvent. In more hard numbers, if all of the approximately 750 OIS in the United States performed about 100 procedures a year, this would result in approximately $1 billion savings to CMS each year.
But the question is, why did I choose to have an OIS? Quite simply, hospital administrators have destroyed the healthcare system in our country. The exponential growth of hospital administrators over the past few decades have paralleled a hostile decline in an amicable working relationship between physicians and the hospital system. The levels of bureaucracy in a hospital have become insane. Rules and decisions are made by C-level graduates that have no idea about patient care. Hospital CEO’s, presidents, vice presidents, and other executives command 6, 7, and even 8-figure salaries while providing no direct benefit to the healthcare system. They are more worried about their bonus or “Golden Parachute”, rather than actually what is good for a patient. They are not accountable to a state medical board to maintain their license, or have to worry about being reported to the National Practitioners Data Bank. These people tell us how to do our job, but have never held the hand of a dying patient and tried to comfort their family. Middle-level management is redundant and comprised of people who have risen to their level of incompetence. Nursing staff has lost the ability to care for patients, while mindlessly perfecting their ability to click buttons on a computer in the guise of compliance. It is mind numbing to sit through endless hours of VAT committee meetings trying to convince the administration why the cath lab needs the latest and greatest stent. The physicians are arguably the most educated people in the entire healthcare system, but have gradually been removed from all hospital-based decision-making processes. Most states have mandatory abuse reporting laws; yet, it is ironic that hospitals routinely abuse their relationship with physicians, but are never reported for abuse.
The OIS brings the patient back to the center of attention. The physician and nursing staff are intimately involved in patient care from the minute the patient arrives to the minute they leave. Decisions about capital equipment, disposable equipment, patient flow, patient safety, patient education, and literally every aspect of the patient encounter has been returned to the people that are educated the most about treating the patient. Plain and simple, not only is patient satisfaction orders of magnitude higher in the OIS than in the hospital, but so is physician and staff satisfaction. Staff and physician burn out has been completely eliminated. Happy staff make happy patients.
Of course, there are OIS naysayers that sit in their ivory towers and claim outpatient labs are unregulated and uncontrolled. To specifically address these issues, the Outpatient Endovascular and Interventional Society (OEIS) was founded in 2013.6 OEIS is the only society in the United States completely devoted to the OIS. The mission of OEIS is to serve the public and medical profession by improving the quality of healthcare through setting and adhering to professional quality standards. OEIS is a patient-centric society focused on ensuring quality healthcare in all settings, including the outpatient hospital and office-based interventional suites. OEIS is a multispecialty/multidisciplinary society that was formed to establish standards of safety, successful outcomes, education, fiscal responsibility, appropriateness criteria, and quality of procedures performed in office-based interventional centers. OEIS’s commitment is to the highest ethical standards placing the patient first in the decision making process. OEIS has created five pillars of quality. These five pillars aim to help foster innovation in our field of medicine, protect the patient-physician relationship, and promote improved care coordination and communication with office-based interventional centers. The OEIS Five Pillars of Quality are: 1) The highest commitment to patient safety and quality, 2) A commitment to excellence in outcomes, 3) A commitment to selecting and performing clinically appropriate procedures in all cases, 4) A commitment to continuing education, 5) A commitment to fiscal responsibility and transparency.
In summary, the OIS has given the patient back to the physician, given the ill back to the healthcare provider. This has been accomplished by eliminating the middle man; eliminating the hospital administrator; eliminating what provides no benefit to the equation. This is why I choose to have an Office Based Lab; my only regret is not doing this 10 years ago.
1. Jain KM, Munn J, Rummel M, Vaddineni S, Longton C. Future of vascular surgery is in the office. J Vasc Surg. 2010;51(2):509-514.
2. Jain K, Munn J, Rummel MC, Johnston D, Longton C. Office-based endovascular suite is safe for most procedures. J Vasc Surg. 2014;59(1):186-191.
3. D’Souza SM, Stout CL, Krol E, Dexter DJ, Ahanchi SS, Panneton JM. Outpatient endovascular tibial artery intervention in an office-based setting is as safe and effective as in a hosptial setting. J Endovasc Ther. 2018;25(6):666-672.
4. Oskui PM, Kloner RA, Burstein S, et al. The safety and efficacy of peripheral vascular procedures performed in the outpatient setting. J Invasive Cardiol. 2015;27(5):243-249.
5. Lin PH, Yang KH, Kollmeyer KR, et al. Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice. Vascular. 2017;25(2):115-122.
7. Ahn SS, Tahara RW, Jones LE, Carr JG, Blebea J. Preliminary results of the outpatient endovascular and interventional society national registry. J Endovasc Ther. 2020;27(6):956-963.