Rather than go to a big hospital to have a cataract operation, Ian Gordon chooses the small St. Agnes Surgery Center.
It's more convenient -- tucked away in a quiet neighborhood in Ellicott City 10 minutes from his home.
And the center is less daunting than a hospital. A compact, three-story brick building, its automatic sliding glass doors open into what looks like a large doctor's office with upholstered chairs, magazines, a TV, piped-in music and coffee for patients' families.
Arriving about 6:30 a.m. on a freezing February morning, Mr. Gordon, a sandy-haired native of Scotland, is soon stretched out in one of four operating rooms. By 9:30 a.m., he is dressed and ready to go home, with a new lens on his right eye.
"You don't grow old around here," says Mr. Gordon, 78, a retired teacher who hopes to resume flying lessons now that his vision is improved.
Outpatient surgery centers such as St. Agnes' are a rapidly growing industry, probably the future site of most elective surgery.
Sixty percent of the 723,000 operations performed in Maryland in 1993, the latest year for which data are available, were done on an outpatient, "ambulatory" basis. Hernia repairs, varicose vein strippings, breast biopsies, knee arthroscopies -- even some gall-bladder removals -- are among the many procedures done this way, allowing patients to go home the same day.
Hospitals still perform the bulk of outpatient procedures, about 85 percent in 1993. But surgery centers, the vast majority owned by doctors, are grabbing a bigger share of the business -- about $61 million two years ago.
The main reason is cost. Lacking the overhead and other expenses of 24-hour hospitals, surgery centers generally operate more cheaply. The Maryland Health Resources Planning Commission found in 1993 that a breast biopsy done at a multispecialty center cost an average of $792, $369 less than hospital outpatient departments charged.
For that reason, health maintenance organizations and other managed-care insurers are steering an increasing number of patients to the centers, encouraging doctors and other entrepreneurs to open new ones.
The growth has been spectacular.
There were just seven surgery centers in the state in 1984; today there are 99 single-specialty centers that perform just one kind of operation, and 12 multispecialty centers such as St. Agnes.
Maryland has twice as many surgery centers per capita as the nation, one for every 57,000 residents, according to the most recent information. But that is a mixed blessing in the view of the planning commission, which regulates expansion of the health-care industry, including the larger surgery centers. Smaller single-specialty centers, those with fewer than five operating rooms, don't require the commission's approval to open. .
"This growth in capacity has resulted, in the short run, in improvements for patient care, improved access [for patients] and lower costs," the commission states in a recent report. "Some of these centers have led the health care industry in the innovative use of medical technology and the use of state-of-the-art anesthesia for a growing number of patients."
But the centers have opened mainly in suburban areas, providing little benefit to the urban and rural poor. And their proliferation has created an operating-room glut.
The result is costly inefficiency and "fragmentation and duplication" of services, the commission says.
The growing volume of services performed by surgery centers also threatens Maryland's unique system of paying for charity care.
Each year, hospitals provide more than $400 million in care to those who can't afford it. They are reimbursed through the state hospital rate-setting system, run by the Health Services Cost Review Commission, which adds the cost of charity care to the rates paid by insured patients.
This system rests on a foundation of hospital-based care, which is being eroded by competition from surgical centers, whose rates are not regulated.
The rate-setting commission supported legislation, introduced in January, to require surgery centers to contribute to the cost of charity care at hospitals. But the surgery centers, doctors and insurers are strongly opposed.
"We don't want to be subject to the same bureaucratic nightmare that hospitals are subject to," says Gerard E. Evans, lobbyist for outpatient cancer treatment centers and HMOs.
Cautious legislators have decided to study the charity-care issue this summer. But last week, the legislature moved toward approval of a bill that would permit the planning commission to regulate the growth of the smaller surgical centers.
The commission's goal is not to strangle future expansion, but to guide it, says Executive Director James R. Stanton.
"As we look into the future, we see more and more ambulatory surgery being done outside the hospital," he says.
St. Agnes is playing a role in this transformation.
A pioneer when it opened in 1985, the St. Agnes center has gone through a couple of ownership changes before becoming the property of the hospital. It's an unusual arrangement, binding a hospital with a competitor, but it makes sense, says Robert E. Pezzoli, president and chief executive of St. Agnes Hospital.
Recognizing the shift toward outpatient care and seeing a need to move closer to patients from Howard County, the Baltimore hospital bought the surgery center, which is 11 miles away, in 1993.
Business has been robust: 3,258 operations last year.
"It's been a good move for us," Mr. Pezzoli says. "We have contracts with every HMO around."
Winning the competition for contracts depends not only on prices, but also on the ability to satisfy patients. When Mr. Gordon arrived at St. Agnes, he was handed a heated blanket to help him warm up and relax, a gesture he remembered weeks later when describing his experience at the center.
St. Agnes' small scale also appeals to patients. The staff members who greet patients guide them through the short circuit from the waiting room to the operating room to the recovery room, which is colored a soothing pale rose.
"Surgery is stressful enough," says Tina Beerman, a nurse and supervisor who pads around the center in a blue surgical cap and slippers, making sure there is no unnecessary stress.
Mr. Gordon, who had hernia surgery two years ago at St. Agnes Hospital and felt well treated, likes the center's ambience more.
"This is so much more peaceful than the operation downtown," he says.