The already complicated process of deciding the future growth of Butler Memorial Hospital became more complicated with the recent announcement of a planned outpatient surgical center to be built off Benbrook Road in Butler Township.

The announcement, made by a group of 12 surgeons, has been widely anticipated for some time. And while outpatient surgical centers like the ones doctors here intend to build have been developed in many other communities around the United States over the past decade, the impact of this move still deserves attention and examination.

The most difficult questions surrounding the surgical center's impact involve Butler Memorial Hospital - specifically, the hospital's finances.

Without knowing financial specifics, it's generally accepted that surgical procedures represent a hospital's most profitable area of care. Some have suggested that profits from surgery more-or-less subsidize other areas of care provided by the hospital.

Given this fact, there is cause for concern over the impact the new surgical center will have on the hospital's finances, especially in light of the hospital's announced plans to spend approximately $150 million on a new hospital - either on a yet-to-be-determined site or at the existing East Brady Street location.

As a nearly-equal partner with the surgeons, Butler Memorial Hospital is expected to be receiving slightly less than half of the surgical center's profits, with the balance going to its business partner, the surgeons.

One uncertainty involves the assumption that freestanding, outpatient surgical centers operate more efficiently and with lower costs, thus producing a higher profit margin for the same surgical procedures as compared with doing the surgery in a conventional hospital. The larger profit margin at the surgical center might help restore some of the hospital's lost profits, but it seems unlikely that barely 50 percent of even enhanced profits would fully compensate for the revenue lost when the surgical center begins operating outside the hospital's control.

While the overall financial impact on the hospital won't be known for some time. Much of that impact will be determined by the details of the partnership agreement now being worked out between the hospital and the surgeon's group.

While the surgeons and hospital officials each spoke glowingly about the benefits to community health that the outpatient surgical center will provide, there are legitimate questions to be asked.

In an ideal world, the new surgical center would be on the grounds of the hospital, either at the current city location or wherever a totally new hospital might build. By being on the hospital grounds, the time required to reach the hospital in the unlikely event of an emergency would be minimized. Some patients might be leery of undergoing surgery miles away from the hospital's emergency room or fully equipped operating rooms. A location on hospital grounds would also be more convenient for the surgeons, who presumably will perform other, more complicated, surgeries in the hospital's operating rooms.

In the past, the surgeons' group had indicated it preferred a location on hospital property, but given the hospital's uncertainty regarding where it will invest money and build for the future, the doctors felt the need to strike out on their own, away from hospital. This clearly complicates things on several levels - both from a financial and health-care perspective.

Another issue of concern for the hospital, and the public, involves uncompensated care. As a non-profit community hospital, BMH performs a certain amount of uncompensated care. It performs this work as part of its role as a community hospital. But the new outpatient surgical center will not be a non-profit organization, and as such it will have no obligation to perform procedures for which it is unlikely be paid.

It is hoped that the partnership agreement will include a commitment by these 12 surgeons to take a percentage of this work, rather than leaving it all with the hospital, further weakening BMH's financial condition.

The surgeons' planned move also seems to complicate planning for hospital administrators trying to develop plans for a new hospital. What level of outpatient surgical facilities should BMH include in any major renovation or new hospital? Should the hospital try to compete with the off-site surgical center? Should it hire doctors to replace those who are taking their business outside the hospital?

Many other hospitals around the country have had to deal with these issues, as hundreds of similar outpatient surgical centers have been constructed over the past decade or so. But it still seems to make the tasks facing administrators and board members at Butler Memorial Hospital more difficult.

The nurses union at BMH has expressed its opposition to this outpatient surgical center, and others, fearing that breaking apart functions of a traditional hospital represent a "piecemeal" approach to medicine, which threatens traditional community hospitals - and is not good for unionized nurses.

As planned, the new surgical center will probably be a good deal for the doctors. It will probably provide good care for patients. Its overall impact on Butler Memorial Hospital is not likely to be as positive. But the doctors are independent business people who have a right to own and operate their own business.

People who receive their health care from Butler Memorial Hospital can only educate themselves on the issues and hope that the final arrangement agreed to by the surgeons and the hospital minimize any potentially negative impact on Butler Memorial Hospital.

- J.L.W.III