[E]ven before opening the doors of Vermont’s second independent surgical center, administrators are looking to expand.
In a proposal before state regulators, Green Mountain Surgery Center in Colchester would add ophthalmology and plastic surgery to its mix of outpatient services when it opens later this year. Some say those are needed services that would be available more readily and affordably outside a typical hospital setting.
“Vermont patients deserve options and cost competition,” said Dr. David Weissgold, a South Burlington-based eye surgeon who wants to practice at the surgery center.
But there is concern that the center may be overstepping the bounds of its state permit. And a competitor to the north – Northwestern Medical Center in St. Albans – says the surgery center could negatively impact its bottom line at a time when Vermont hospitals are struggling.
“Now, we face an additional expansion of the (surgery center), which will draw more surgical procedures away from hospitals,” said Jill Berry Bowen, Northwestern’s chief executive officer. “That will be detrimental.”
The debate played out Wednesday before Green Mountain Care Board members, who are no strangers to ambulatory surgical center controversies. The board in 2017 approved a certificate of need for Green Mountain Surgery Center, culminating a debate that stretched over two years and included strong opposition from hospitals.
Now, nearly two years later, the Colchester center is almost ready to open pending federal certification. Amy Cooper, the center’s manager, said Wednesday that she does not yet have a firm opening date.
The Green Mountain Care Board also may have something to say about the center’s opening. The board scheduled Wednesday’s hearing for the purpose of reviewing the surgical center’s compliance with its permit; a proposed modification of that permit; the addition of new physician owners; and the two new services it wants to offer.
Many of those issues are not controversial, but Cooper faced some questions on matters relating to patient services and costs.
That included the oft-stated premise that ambulatory surgical centers offer significantly lower prices than hospitals. Care board member Jessica Holmes took issue with Cooper’s pledge in a March 26 letter to accept insurer reimbursements that are “below the average equivalent reimbursements paid to hospitals for providing the same services.”
Holmes said that’s not the same as guaranteeing that all surgery center procedures will be cheaper.
Cooper said it’s “impossible” for her to know the details of the all commercial insurer agreements with every hospital. As a result, she conceded that there could be some procedures that end up being less expensive at hospitals than at the surgery center.
Cooper also offered another reason she could not guarantee that Green Mountain Surgery Center will always have lower prices: She said some hospitals could “artificially lower” their prices in an attempt to undercut the center.
There’s “no doubt that the hospitals see us as a major threat and have been opposed to our opening this whole time,” Cooper said.
Prices aside, the question of additional services at Green Mountain Surgery Center was the most-debated issue.
In the care board’s 2017 approval of the Green Mountain Surgery project, officials noted that the center was expected to focus mainly on gastrointestinal procedures. There also would be pain management, obstetrics/gynecology, orthopedics and general surgery services offered.
The board also took note of testimony indicating that “once the (surgery center) is fully operational, there will be a strong demand for other specialties.” That’s what appears to be happening now, though it’s happening before the center opens.
In a letter to the care board, Cooper said changes in physician availability are driving the changes. Compared with initial estimates, she’s expecting decreases in gastroenterology, obstetrics/gynecology, pain management and general surgery cases.
Plastic surgery, on the other hand, has been added to the surgery center’s roster “because there are now two independent plastic surgeons in Chittenden County who plan to utilize” the center, Cooper wrote.
Wednesday’s hearing included testimony from Dr. Donald Laub, who is hoping to practice at the new surgery center. Laub said the reduced availability of operating room time at University of Vermont Medical Center has delayed surgeries for his patients.
Laub also said less than 10 percent of his practice is cosmetic.
“It is a great benefit to the people of Vermont that they now have the option for timely and affordable surgical care (at) an ambulatory surgical center like the Green Mountain Surgery Center,” Laub said.
When it comes to ophthalmology – which was not mentioned in the center’s initial permitting process – Cooper says she wants to bring certain procedures “into the lower-cost, more efficient community setting.” She also cited the problem of patient wait times, even for relatively common cataract surgeries.
The two additional specialities are important to the surgery center’s financial outlook. State documents show that, by the fourth year of operations, ophthalmology and plastic surgery are projected to account for 22 percent of the center’s revenues.
But not everyone is supportive of the expansion plans.
Northwestern Medical Center is among the Vermont hospitals that have posted operating deficits in recent years, and Bowen told the care board that her hospital will lose physicians and patients to Green Mountain Surgery Center.
The loss of doctors is “real and impactful,” Bowen said. “And you have seen it in hospitals’ financial performance reports, including ours.”
“If the scope of the Green Mountain Surgery Center’s expansion is allowed to happen, the negative financial impact of additional surgical procedures will show as a clear detriment in future reports to the Green Mountain Care Board of Northwestern Medical Center’s performance,” she added.
The board also heard criticism from Dr. Juli Larson, who founded an eye surgery facility in South Burlington that is the state’s other independent ambulatory surgical center.
Cooper acknowledged that there will be some overlap between the two surgery centers in terms of the types of procedures performed. That doesn’t sit well with Larson, who said she was speaking only for herself and not for the eye center.
Approving Green Mountain Surgery Center’s expansion “would not result in any cost savings to Vermont patients,” Larson said. “It will, however, result in unnecessary duplication of care that’s already available in an established (center) which specializes in eye surgeries only.”
The care board did not make any decisions at Wednesday’s meeting. And it’s unclear how extensive those decisions will be, because there’s disagreement about whether the additional medical services proposed by the surgery center are a matter for care board action.
Cooper argues that the care board didn’t impose any restrictions on the number of surgeons or the type of specialities at Green Mountain Surgery Center.
“In the dynamic local health care landscape, a small, multispeciality surgery center project that takes years to plan and build needs to have the flexibility to absorb the loss of certain physicians or specialities over time and the ability to add on other physicians who believe the (center) would be a good fit for their patients,” Cooper wrote.
