Joan Dentler, Avanza: The Shift to Outpatient Services and Ambulatory Surgery Centers

May 13, 2024

Joan-Dentler.pngJoan Dentler, MBA, is founder of Avanza Healthcare Strategies, an advisory firm based in Austin, and an expert on the migration of surgery from hospitals to ambulatory surgery centers (ASCs). Dentler spent her undergraduate years at UT Austin and the University of Houston and received her MBA from UT Brownsville. For two decades, she has helped physician groups, hospitals, and health systems plan and open ASCs, consulting on everything from the physical layout of the facility to its workflow.

"The shift to outpatient services has already begun," she says. "Patients and doctors want to be 'in and out.' They want services closer to home. They don't want to go downtown and deal with traffic."

The Partnership: Dentler has worked with Page on projects where her company was the consultant and Page was the architect, specifically Dell Medical School in Austin (Page is the prime architect on all University of Texas buildings in the Medical District). "In fact, Page was the architect on the very first surgery center project I ever did. It was for Valley Baptist Medical Center in Harlingen, Texas, when I worked for the hospital," she recalls.

Three Things to Know about Outpatient Care Trends:

1. Decentralization is here to stay. More healthcare is being delivered outside of traditional hospital facilities, and inpatient stays continue to decline. "To stay relevant, hospitals and other institutional providers must adopt care delivery systems and build outpatient portfolios to meet the needs and demands of this new healthcare economy," Dentler says.

2. Payer pressure and patient preferences are among the top factors driving outpatient services away from hospitals, she says. The hospital-centric delivery system is being replaced by one that delivers non-acute care in outpatient settings conveniently located and accessible to patients and better matches patient care scope and acuity. "There is a move toward not only 'right-sizing' but also 'right-siting' services,'" Dentler says. "This evolution will take leadership and courage, but it will emerge out of necessity."

3. If you can't beat them, join them. Many healthcare providers have made the migration to outpatient care their top priority in 2024, says Dentler. But the reinvention of healthcare is not a new phenomenon. To provide some context, Avanza created a timeline that includes nearly 100 noteworthy events, facts, and figures related to healthcare's evolution.

A Deeper Dive

JoanDentlerAtHealthForward.jpgJoan Dentler's career path hasn't involved climbing a ladder so much as maneuvering around a jungle gym, she says, paraphrasing Facebook COO Sheryl Sandberg's famous 2014 commencement speech at Harvard. 

"I spent the early years of my career on the tip of Texas in Brownsville, which is just across the border from Mexico," says Dentler. "After college, I taught school there." She was recruited to become education director of the local Planned Parenthood affiliate, focusing on teen pregnancy prevention, and became a member of the organization's management team. "I worked in maternal and child health and women's health for a decade. During that time, I learned how the business-side of healthcare worked," she says. Dentler moved from there to a federally qualified health center designed for indigent populations, setting up school-based health centers. 

Then a fortuitous event occurred: In 1996, she went to work for a hospital that wanted her to develop some school-based health centers and, while waiting for funding, Dentler was put in charge of opening an ASC that was a joint venture between the hospital and some of its surgeons. "I came on board in the middle of construction, and it was baptism by fire," she says. "I came from primary care; I didn't know anything about surgery. But that was the beginning of my 25-plus-year career."

Family Lessons

"Owning a small business wasn't foreign to me," says Dentler, the youngest of five. "My dad was a chemist who worked for Shell Oil. He realized there was a lot of glassware the company needed for its labs that couldn't be purchased, so he started his own business supplying custom scientific glassware. I would take my classmates to 'the plant' for field trips, and the glassblowers would make us flasks blown around pennies." 

Her mom worked for National Opinion Research Corporation, now part of University of Chicago. "She  really enjoyed it," Dentler says. "Then one night, she had a headache, went to bed, and during the night had a massive stroke. She woke up but was never the same. She was an invalid until she died at 62. I was 15."

It was the defining event of Dentler's life. "I realized a lot of things from this experience. Life is short. You have no idea what's going to happen tomorrow. I always wonder what my mom had on her to-do list when she went to bed that night."


So when the opportunity came to push forward with her own consulting firm, Dentler went for it. "In the late 1990s, many hospitals were 'anti' surgery centers, viewing them as competition. But it made sense to me that hospitals and healthcare systems were going to have to go in that direction," she says. "Doctors and private physician groups went there first and proved you could do it. Now, hospitals are the biggest sector opening and acquiring ASCs, as surgery is the biggest revenue generator for most health systems. The older population needs more surgeries, and people with high-deductible plans are getting more concerned with how much procedures cost."

Indeed, hospitals are recognizing the need to open and own ASCs so they can keep more of their surgical revenue and surgery patients.

Dartmouth was one of Avanza's earliest clients, as was New York University. "The larger academic medical centers were branching out into ASCs, and they also wanted their outpatient departments to run like surgery centers," she says. "They wisely recognized the value in bringing in outside experts to help them make sound decisions as they pursued these new projects."

Right Sizing and Right Siting

Medicare reimburses freestanding ASCs about half of what they reimburse hospitals, but hospitals can typically negotiate better ASC rates with private payers than independent centers. In addition to rate negotiation, owners also need to recognize what ASCs are and what they are not. 

"ASCs don't need as large a building or as much staff as hospitals," Dentler says. "The cases in surgery centers are largely elective and performed on healthy patients. ASCs don't need all the amenities of a hospital. Nobody cares if there's a chapel in a surgery center."

Also, hospitals must be accessible 365 days a year, open 24/7, have a space allocated for emergencies, and include multiple inpatient beds. "But there is also a need for facilities that perform only outpatient-focused services," Dentler says, "which is a whole different animal." 

She views healthcare as a continuum, from home-based care and treatments to surgical services like tertiary open-heart surgery: "There are different places and different price points needed. A smart health system has that whole continuum covered." 

Dentler, who has three sons and six grandchildren, credits her devotion to ASCs to her indigent-care roots. "The ASC industry really is a success story about reducing the cost for everyone," she says. "Living in South Texas, seeing true poverty, and witnessing all the ways the healthcare system is not fair to people helps explain why I am so passionate about this work."


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