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Sunday, June 30, 2013

Ambulatory Surgery Centers, Regulations, and Access to Abortions

It has been an interesting news week, with all sorts of intriguing stories from the Supreme Court, stock market frothiness as a consequence of Fed whispering, the expanding civil war in Syria which threatens to to broader into a broader Sunni/ Shiite regional war, as well as the Paula Deen pile-on.

However, the story I found most intriguing was the story out of Texas where Senator Wendy Davis successfully filibustered proposed legislation. I have not blogged on anything related to abortion because I am basically hopelessly confused and conflicted. The issue can best be characterized as an impossible moral issue which will only become more difficult to address as technology pushes the bounds of what is medically possible. Who knows how we will handle the inevitable issues which will arise when we can really make test tube babies without the need for a human carrier. Anything that pulls the public away from the polar regions in this debate will be useful. The abortion issue is not going to be settled by anything as cut and dry as Roe vs. Wade this time. The science and medical advances have made this increasingly difficult.

This blog is not about such issues but instead I wish to look at on part of the Texas bill which applies regulatory standards on the centers which offer abortions in Texas. I need to ask what are the criteria we apply to require specific procedures to be done in an ambulatory surgery center and what are the benefits which accrue to patients by invoking such a requirement?

Not so long ago there was a piece written in the New York Times which highlighted the cost differential for procedures done is the US vs. elsewhere in the world (NYT). One such procedure was colonoscopy where much of this work is now done in ACS's. While ACS's are touted as lower cost environments when compared to hospitals, US ACS's are much more expensive than similar environments in Europe where colonoscopies are done. The US ACS's may offer higher level of service but the outcomes are virtually identical to what is seen in Europe where such procedures are done at substantially lower cost.

One of the issues raised by the Texas bill is the cost of moving the abortions done after 16 weeks to ASC certified facilities is that this is projected by some to essentially decimate the pool of available facilities which provide abortion services. Proponents of the bill say this is essential for patient safety, an argument made by multiple parties when arguing for this same requirement when applied to other procedures. In those cases the argument is potentially riddled with conflicts of interest because more expensive approaches to interventions may also be associated with higher fees and better margins. In the case of abortions that does not appear to be the case.

The key point here is whether the call for movement of this procedure to higher cost environment is likely to be associated with better patient outcomes. Data from a survey looking at abortions identified that there were 12 maternal deaths associated with the almost 800K abortions reported in the most recent year surveyed (2008 -CDC). Depending on how one looks at this it can either be viewed as the horrific death of 12 women in facilities that did not meet the standards set for ACS's which is UNACCEPTABLE or it could be spun as the services are offered in an environment which is marked by a remarkable safety record.

Taking all the moral baggage aside, one should ask why should procedures performed in abortion clinics be viewed any differently than procedures performed in other medical facilities.  This is really no different from how we look at statistics relating to certification of other medical facilities and their outcomes. We get alarmed by specific egregious examples where medical or dental offices are found to fall far outside acceptable practices and in response to these outliers, we push for onerous standards which are unlikely to affect the very outliers who prompted action in the first place.  We end up with procedures, which could be deployed safety at reasonable cost, which then are deployed at markedly higher cost with little of no additional benefit to those they are applied to.

Yes, we can rally for a safer environment for patients to have their procedures done in but we need to ask the question as to who this actually delivers value to? Does certification translate into anything useful? The anti-abortion forces can use the patient safety dodge and it puts the pro-abortion camp in a difficult t argue position unless they come to realize that this issue must be addressed as part of a much larger question; do more expensive and complex care environments lead to better outcomes and is any amount of money spent to save one life always justified?

It is probably a bad idea to attache this specific debate to the abortion issue. What can be guaranteed is that the likelihood for rational discourse approaches zero when abortion enters into the debate. Still, the question remains; why compel care move into higher cost environments when there is likely no benefit to those receiving the care? Just claiming one's intent is to create a better care environment should not be enough.


  1. Thank you for the great information and insight on such a difficult subject. I agree that there should be safe centers to go to for an ambulatory surgery. You shouldn't feel like you can't go because you'll be judged or like you're risking your health.