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CCMS President's MessageOffice Surgery RulesMark A. Zapp,
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On March 30, 1842, Dr. Crawford Long administered the first ether anesthetic for surgery. This event along with a continual effort by doctors for noteworthy patient care is the basis for the celebration of Doctors Day. Doctors Day gives the medical profession an opportunity to raise public awareness about physicians' active roles in their communities. We however have this opportunity every month through Clay County Medical Society. Gone are the days when physicians were regularly consulted by the legislature. Now is a time requiring great effort and financial support to have our concerns heard. This is a time, however, that most physicians are extremely busy and believe that they have little time to invest in their future. How can we approach those individuals who are too busy in their practice with little time for their families to get them involved in their medical societies? One way is through newsletters like this. We have been fortunate to live in the same area as two legislators from our state. This is, however, a big election year. In fact, over 60% of the House of Representatives and 25% of the Senate will have open seats next year. We can either unite financially and with our common political goals or we stand a great chance of losing valuable ground to third party payors and trial lawyers. The Florida legislature meets from March 7 to May 5. The 2000 FMA/FMAA Days at the Capitol are March 15-16. This program allows members to discuss current legislative issues, attend educational sessions, and meet the legislators during the 2000 session. I hope some of you will attend. Registration forms are available at www.fmaonline.org. There is a lack of communication between physicians, hospital administrators, third party payors, and politicians. We can either work toward alliances or we will certainly encounter more separations. There has been a push to move surgical cases out of hospitals to ambulatory surgery centers and office practices. In 1981, 80% of surgical procedure were performed on an inpatient basis, compared with only 35% in 1994. It is projected that by 2001, 26% of surgery will be inpatient, 43% ambulatory, 17% at a freestanding surgery center, and 14% office based. With an increased office surgery practice comes increased regulation. New office surgery rules began on February 17. There are many patient care issues to be finalized which need your support. Letters of support should be addressed to Georges A. El-Bahri, M.D., Chair of the Florida Board of Medicine; 2020 Capital Circle SE, BIN #C03; Tallassee, Florida 32399-3253. The big push for changes in office surgery deal with liposuction. More than 172,000 Americans have liposuction every year by board certified plastic surgeons. However any doctor has been able to perform this surgery so the number may be higher. In fact, there are doctors in other fields who have injured or killed patients by performing procedures outside of their area of expertise, like a woman who died while getting a breast implant from an otolaryngologist. The shocking fact is that the death rate from office surgery for liposuction is about 1:5000 compared to the death rate in hospital patients (undergoing all types of surgery, including risky procedures on very sick patients) of about 1:100,000. Adopted rules include requirements and restrictions relating to the level of anesthetic, training, equipment and supplies, assistance of other personnel, and hospital staff privileges. Specific rules currently restrict the amount of liposuction and injection of local anesthetic, require OSHA regulated levels of sterilization, expand requirements for office records and surgical logs, require information about surgical risks and precautions, and require timely reporting of adverse incidents. Other topics which were voted in by the board include stronger patient protection standards which will face a public hearing on April 8. These include training requirements for surgeons and requirements for an anesthesiologist to be present for level III (clarified below) office surgery. These also restrict office surgeries to eight hours in duration and require a doctor to be on premises or within 15 minutes travel while patients recover in the office. These changes may be influenced one way or another at this time. I would like all society members to actively support these changes which can result in improved patient care. Improved care is what organized medicine needs to focus on now and in the future. There is no downside with any of these proposals. Training requirements are very important with the current statistics and examples which exist. The involvement of an anesthesiologist in the office setting can directly help the surgeons geographical restrictions, as highly qualified medical physicians will still be able to care for these patients. It might also decrease surgeons malpractice premiums as several of the Board of Medicine's recent office surgery disciplinary cases have centered upon deficient anesthesia-related patient care. Anesthesiologist involvement is also the standard of care throughout the State of Florida in metropolitan hospitals and ambulatory surgery centers, and it should be in the office setting. Restricting the length of surgeries and improving post-operative care make inherent sense. We do not perform surgeries for 8 hours and send the patient home from hospitals and surgery centers. Office surgeries with the least regulation should not be our trendsetters. New morbidity and mortality rates will be tracked and the rates must be comparable between office surgeries and hospitals to be considered responsible appropriate care. There are three levels of office surgery. Level I office surgery includes minor procedures such as removing skin lesions. Surgery must be limited to the skin and subcutaneous tissue performed under topical or local anesthesia not involving drug-induced alteration of consciousness other than minimal preoperative tranquilization of the patient. Joint aspirations, limited endoscopies, thoracentesis, paracentesis, cystoscopic procedures and closed reduction of simple fractures are acceptable. Level II is that in which peri-operative medication and sedation used are required intravenously, intramuscularly, or rectally, making intra and post-operative monitoring necessary. Surgeries may include hemorrhoidectomies, hernia repairs, reduction of simple fractures, large joint dislocations, breast biopsies, and colonoscopies. Level III office surgery is that which requires, or reasonably should require, the use of general anesthesia or major conduction anesthesia and pre-operative sedation. In level III office surgery, the surgeon must document in the patient's record the justification and precautions that make the office an appropriate forum for the particular procedure to be performed for ASA class III patients. The complete text for the "Standard of Care for office surgery" can be obtained here. Other hot topics in the political environment include a 41.4 million (7.6%) Florida budget increase in reimbursement rates for physicians; a repeal of 1.5% tax on net operating revenues for physician office practices providing diagnostic imaging and clinical laboratory services; a prohibition of managed care organizations from mandating the use of hospitalists by their subscribers; a requirement of physicians, not HMO bureaucrats, to make adverse determinations regarding treatment denial in the practice of medicine; HMO accountability for the failure to exercise ordinary care when making health care treatment decisions; increasing the time a physician has to file a claim from 30 to 60 days (designed to assist those who have not been given correct insurance information and as a result miss the filing deadline); prevention of expansion of the prescriptive authority of ARNPs to include controlled substances; prevention of inappropriate extension of the scope of practice by physicians. I would encourage all to express gratitude to those legislators who work towards improving medical care. This also helps to build relationships. Lobbying for the issues which have not passed is the work which remains before us. Jacksonville Medicine / March, 2000What's New
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