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ASC Specialty to Watch: Gynecology in 2012

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This is part of a series on the five ambulatory surgery center specialties to watch in 2012. The five specialties are gynecology, ophthalmology, orthopedic and spine, pain management and urology. These specialties have a favorable outlook in terms of case volume, revenue and new procedures moving into the ASC setting.

Amy E. Rosenman, MD, urogynecologist, who is a clinical assistant professor at the UCLA School of Medicine and is in private practice at Saint Johns Health Center in Santa Monica, Calif., discusses five points on gynecology in ASCs for 2012 and beyond.

1. Gynecology is going through an evolution, not a revolution. Dr. Rosenman says gynecologists were actually the first physicians to use laparoscopic techniques back in the 1960s. At that time, it was used mostly for diagnostic procedures. In the 1980s, German gynecologist Kurt Semm began teaching laparoscopic techniques, which he developed. Although he was originally criticized for "unethical surgery," the technique has now become common. Today, new procedures are increasingly done laparoscopically, which negates the need for large incisions and speeds recovery time.

"We have increased capability to do minimally invasive surgery which lends itself to ASCs," she says. "I think with gynecology, it's evolution, not revolution," she says. "The revolution occurred in the '80s. The evolution is that everyday you realize you can do something less invasively."

2. Increase in minimally invasive hysterectomies.
The Department of Health and Human Services estimates 600,000 hysterectomies are performed each year, and one-third of U.S. women have had a hysterectomy by age 60. With the baby boomer generation aging, the demand for this procedure will continue to increase, as will the demand for minimally invasive techniques such as laparoscopic and vaginal hysterectomies.

Dr. Rosenman thinks there will be an increase in laparoscopic and vaginal hysterectomies performed on an outpatient basis. She sees the change depending on a good post-operative care program, including removing the foley catheter as soon as possible.

"We've gotten there with midurethral slings," she says. "We can get there with hysterectomies."

The Advisory Board, a research, consulting and technology firm, predicted laparoscopic hysterectomy procedures would increase starting in 2010 and that by the end of 2010, 44 percent of all hysterectomies undertaken in the United States will be performed laparoscopically. By 2017, this figure is expected to jump to 55 percent. However, the National Digestive Diseases Information Clearinghouse estimates that only 15 percent of hysterectomies are performed laparoscopically. This represents a tremendous opportunity for gynecological surgeons working in ASCs.

3. An aging population will boost demand for prolapse procedures. Incidence of prolapse, a condition where the uterus falls into the vagina, increases with age. As with hysterectomies, the demand for this procedure will increase as the population ages.

One minimally invasive treatment for prolapse is vaginal prolapse surgery, where the surgeon enters through the vagina and makes no visible incisions. This procedure is done in the upper two-thirds of the vagina and causes little pain. Another treatment for prolapse gaining popularity involves removing a strip of skin from the anterior and posterior wall of the vagina and sewing the vaginal walls together, Dr. Rosenman says. This is done mostly in elderly woman who no longer want vaginal function and have no desire to be sexually active. Dr. Rosenman says all of these procedures can be done in an ASC setting but have yet to see much popularity.

"Since the demographics are going to be more incontinence and prolapse, it would behoove us all to figure out how to package that in an ASC setting," she says.

4. Robotic-assisted surgery will allow more procedures to be done in an ASC. Gynecological robotic surgery is growing. In 2010, more hysterectomies were performed with the da Vinci surgical system than any other procedure, according to Intuitive Surgical, the company that manufactures the system. Worldwide, 110,000 robotic-assisted hysterectomies were performed in 2010 — up from 69,000 in 2009. About 70 percent of those procedures were for benign conditions, such as heavy menstrual bleeding, while the other 30 percent were for cancer.

"I think a big trend in gynecology is going to be robotics," Dr. Rosenman says. "ASCs with robotic programs can make a profit."

Another procedure that can be done with robotic assistance is a sacral colpopexy with mesh for the treatment of prolapse. Patients are awake and alert soon after the surgery, though the procedure takes four hours. Robotic surgery can also be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors and female cancers.

5. Medicare is improving when it comes to reimbursement. Dr. Rosenman says Medicare has begun to reimburse more gynecological procedures done as an outpatient.

"Over the years, Medicare has gotten smarter," she says. "They sometimes miss the forest for the trees, but when they get it, they get it."

Dr. Rosenman says certain private payors are now telling her that a hysterectomy procedure is going to be done as an outpatient. They better understand the cost-benefit to doing appropriate procedures in an ASC setting.

"Outpatient reimbursement for private insurance companies is usually ahead of Medicare," she says. "They have pretty good reimbursement for outpatient surgery. Clearly it's cheaper in an outpatient setting. Good surgery centers have very clear criteria as to who is safely done there and who isn't. This helps to avoid disasters and keep your cost predictable."

She sees Medicare and other insurers moving toward criteria-related instead of procedure-related recommendations for whether procedures are done as an outpatient or inpatient. For instance, if a patient can't urinate, walk or be on oral pain medication, the patient will need to remain in the surgery center. However, Dr. Rosenman says this only works for centers that have the ability to keep a patient for up to 23 hours. Not all surgery centers have this ability.

Related Articles on Gynecology:
Doctors Question the Value of Robot-Assisted Surgery
Robotic Gynecologic Surgery Delivers Better Outcomes, Decreases Post-op Pain

Women's Health in 2011: Shift Toward Minimally Invasive Hysterectomy

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