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.
The day starts before 6 a.m., and once inside the gray one-story building, patients find a comfortable waiting room decorated in soft pinks and greens. It doesn't smell like a hospital, or take as long.
"Some places you wait and wait till hell freezes over," said Alma Horan after cataract surgery.
On that day, two of the five operating rooms were in use. Nurses greeted patients, telling them what to expect, administered drugs, taking them into and out of operating rooms, and issuing post-surgery instructions.
Trade offs
Everybody has more than one job. Nurses also order supplies, check on patients by phone, or clean and resupply operating areas. They earn less than a hospital nurse because they have to establish seniority all over again, but they don't work nights or weekends.
"It's kinda like being off-Broadway," said Ms. Hoerl.
The pace is brisk, as Robin Babylon found when she joined the staff from a hospital surgery suite. There she passed instruments for up to three hours at a time and took coffee breaks while another crew prepared the room for the next patient.
Here, we move very quickly, but we do not lose the personal touch, so the patient doesn't know," she said, emerging from the operating room after nine procedures. In a hospital, she said, they'd still be on No. 5.
Independent centers don't have a large caseload of uninsured patients -- an area of contention with hospitals that argue they represent unfair competition -- but they do treat poor patients brought in by doctors who use the centers.
The nurses acknowledge they don't have emergencies to push back elective surgery and, by specializing, they can be more efficient.
Unlike competitors, they don't spend money on advertising or marketing. One of Ms. Hoerl's jobs is to visit doctors' offices several times a month to tell them about the center.
Their goal is to offer the same care at lower cost.
Since October, the center has shaved expenses by 5 percent by switching vendors, sometimes on very simple things. For example, Mark Schmidt, a recovery room nurse who doubles as a purchasing agent, recently found a company selling cardiac monitoring paper for $1.65 a roll. He had been paying $5.75 a roll. "A lot of it is hunting," said Mr. Schmidt.
He obtains surgical equipment at prices 40 percent to 50 percent below the market leader by listening to companies shut out by hospitals that buy large volumes from established vendors. Mr. Schmidt tries out the competitors in conversations with doctors in the hallways -- never for the first time in the operating room.
Sometimes the most expensive product can't be beat, as in the case of the "Steri-Strip" suture. Mr. Schmidt has been searching for a cheaper alternative for 18 months with no success. When it comes to holding a patient's incision, he said, "you never want to forgo quality."
The center also saves money by keeping inventories low and carefully choosing drugs. Nurse anesthetists are in constant contact with suppliers.
"I know the prices of all my drugs and we shoot for the lowest cost," said Lois Kretsch-Gemmill, one of four nurses in the operating room. "It takes time away from the job but it's more fun," she said.
Sometimes lowest cost means using a more expensive drug that lasts only as long as the operation so the patient can go home sooner.
Maryland was one of the last states to have specialized surgery centers for low-risk cases -- the parent company of the South Baltimore center entered Maryland with a Rockville facility in 1986, more than a decade after they began springing up elsewhere. They haven't taken off the way they have in other states partly because the medical establishment is conservative and because hospitals fought those who set them up.
"It was a battle all the way down," said Dr. Pinkner of the SurgiCenter of Baltimore. Outpatient surgery still is less common in Maryland -- 46 percent of all procedures in 1992 compared with more than 50 percent in other states.
The SurgiCenter on Reisterstown Road in Owings Mills was the first multispecialty center in Maryland. It was started by 26 doctor-investors who tired of six-week delays for operating time at Sinai Hospital, Dr. Pinkner said.
A few years ago, Sinai took an "if you can't beat 'em, join 'em" approach and signed on as a minority owner of the SurgiCenter -- less for the revenue as for potential inpatient referrals from doctors who use it. More than 200 doctors have privileges there, prices are up to 33 percent cheaper, and doctors' income is up because they can see more patients.
Surgical Care's two Maryland centers, however, were started largely for insurance companies.
"We found in other areas of the country, outpatient care could be provided on a high quality basis and we wanted to look at that for our patients as well," said David D. Wolf, president of CFS Inc., whose subsidiary, CareFirst, became a one-third owner of the center when it opened and initially provided all its patients.
In the early days of the South Baltimore center, acceptance "was more a matter of changing the physicians' behavior than the patients' -- it is very convenient for the patient, with parking and access," Mr. Wolf said. "The doctors were the ones who needed to be reoriented," he said.
To win over doctors, the surgery center had to convince them it was worth their time to get in the car and travel. They schedule operations in blocks around the doctor's time at the hospital. If there's a delay, the center calls the doctor. Once at work, the center provides a free lunch.
"You'd be amazed what a marketing tool that is," Ms. Hoerl said.
In the end, the emphasis on controlling cost is pushing doctors at the surgery center to the forefront of medical practice and patient care.
Using a local anesthetic for cataracts, for instance, is rare in Maryland, and requires doctors who are quick with a knife. Dr. Ivan H. Garcia, who operated on Mrs. Bonadio and 10 other patients during a recent Monday, can finish within 30 minutes compared with the usual 45 minutes to an hour.
It is easier on the patient. Mrs. Bonadio started when she felt the drug, "Oh, that one stings," she said. But the pain lasted a second, a minor inconvenience compared with the bruises and swelling that can occur after the usual method -- injection of the drug around the eye by needle.
And to his surprise, Dr. Garcia found that patients recover their sight a bit sooner -- the day after surgery.
In the past four years, his income has risen and his quality of life has improved as the result of the efficiencies afforded by the center, Dr. Garcia said.
He can take credit for some of the changes: besides the new anesthetic, he recently learned of a way to position equipment to avoid rearranging between right-eye and left-eye operations.