asc setting
Creating Efficiencies in the ASC Setting Vitreoretinal surgeons face additional challenges.
BY STEVE CHARLES, M.D.

Though the advantageous use of ambulatory surgery centers (ASCs) for such common anterior segment procedures as cataract removal and YAG capsulotomy is already well-established, anticipated upcoming increases in Medicare reimbursement for vitreoretinal (VR) surgery in a free-standing ASC have increased surgeon interest in transitioning to this setting. As this article will explain, advantages as well as disadvantages of operating in a free-standing ASC can be divided into several categories: logistics, economics, medical, marketing and psychological.

Logistics Issues

It is widely perceived that between-case turnover times are faster in an ASC than in a hospital outpatient setting. Although this is generally the case, this is a process issue and not intrinsic.

While turnover times for both anterior segment and VR surgery can be shortened in a hospital outpatient department through good coordination between surgeon and staff, the ability of the surgeon to control the overall environment should allow for greater efficiencies in the ASC setting.

Turnover times can be significantly shortened by working with the nursing staff in a logical, proactive and non-adversarial manner. Key efficiency elements include:

► consistent staffing with trained scrub technicians and circulating nurses

► rapid access to all needed disposables, pharma products and equipment

► an efficient nursing protocol for transitioning patients from the preoperative area to the operating room and from the OR to recovery area

► rapid room cleanup and instrument sterilization methods.

Physical distances between preop, operating room and recovery areas are often greater in a hospital setting, which drives longer patient transportation times. Physical distances between disposable and pharma supply areas and the OR are usually greater in the hospital setting as well.

Economics Issues

Economics issues are more complex than many surgeons perceive when first evaluating moving to a free-standing ASC. Capital equipment costs are higher for vitreoretinal surgery than for cataract surgery, plastic surgery, arthroscopy orthopedic surgery, ENT, podiatry and most other procedures typically performed in an ASC.

Capital equipment necessary to perform VR surgery in an ASC include a high-end operating microscope with stereo beam splitter, XY, 3-CCD camera and digital recording system, laser filters and inverter for wide-angle visualization.

In addition, an advanced vitreoretinal console, a xenon light source and diode-pumped 532 nm laser are absolutely necessary. Even the most advanced phaco machines have insufficient fluidics and cutting performance, so additional features such as a xenon light source have to be used for posterior vitrectomy applications.

If disposable scissors and forceps are not used, a significant collection of reusable scissors and forceps are required. Disposable scissors and forceps always have perfect performance, in contrast to reusable tools which decline in performance which each use because of wear. Both 25-g and 23-g tools are more delicate than 20-g tools, which is an additional reason to use disposable tools. Duplicate reusable tools are needed so backups are available should instruments break or become contaminated during the case.

Surgeons have worked with medical device companies for three decades to improve the technology for these procedures. Advances in vitreoretinal surgery such as 23- and 25-gauge sutureless surgery, perfluorocarbon liquids, disposable forceps and scissors, illumination tools, advanced laser probes, subretinal fluid drainage cannulas, silicone oil and tissue plasminogen activator (tPa) add materials cost, but they can improve outcomes and may reduce operating times. However, the cost-containment requirements required for VR surgery in an ASC will limit access to the most advanced technologies and can negatively impact outcomes as well as surgeon and patient satisfaction.

Disadvantages to Consider

Labor costs for an ASC are often underestimated by surgeons because they fail to take into account the labor and overtime associated with staffing for check-in, preop, recovery, check-out, patient movers, instrument sterilization, security, clerical, administrative, cleaning people and even parking. These costs are referred to as "fully burdened" and are a major contributor to variable overhead.

Vitreoretinal procedures usually take much longer than cataract cases and other highly efficient procedures performed in ASCs. Thus, there is an opportunity cost associated with VR surgery taking the place of more profitable procedures.

It is simply not economically feasible to perform procedures that take more than 45 to 60 minutes in an ASC. Longer and more unpredictable OR times negatively impact ASC logistics, cause longer post-anesthesia care and affect block time for cataract surgery and other, faster, procedures.

If surgery in an ASC is limited to straightforward cases with less need for advanced equipment and disposables, short operating times and full payment, many procedures will still need to be performed in the hospital. This "cherry picking" approach will negatively impact the relationship with the hospital and potentially limit block time, access for indigent, Medicaid or managed care patients, and reduce the likelihood that the hospital will purchase advanced technology for VR surgeons and their patients. Patients undergoing VR surgery frequently have very poor visual function, which limits their income potential. It is unconscionable for these patients to be denied surgery because the hospital can no longer afford indigent surgery after full-pay cases are moved to the ASC.

Physician participation in facility fee profits is a major factor in considering the ASC option, but the above economic issues suggest caution when analyzing the value proposition.

Facility reimbursement will be $717 in 2007. In 2008, there will be a 50/50 blend of the old and new fees. In 2009, the fee will be at least $1,409 for 67038 (vitrectomy, pars plana approach, with epiretinal membrane stripping), which is the most frequent Medicare retinal code. The 67036 code (vitrectomy, pars plana approach) would move from approximately $630 to a proposed $1,464.

Marketing Issues

A branding and marketing opportunity exists with single-group ownership, which is not the case with multiple groups involved or with a multi-specialty facility. If a VR surgeon or VR surgery group uses an ASC owned by cataract surgeons, it will negatively impact referrals from other cataract surgeons.

Medical Issues

The author performed 643 vitrectomy procedures in a hospital-based outpatient setting in 2005 and 303 of these cases required a medical consultation. Approximately 50% of VR surgery patients have a history of diabetic complications, coronary artery disease, cerebrovascular disease, chronic obstructive pulmonary disorder, hypertension and/or obesity.

The ASC setting does not allow rapid access to cardiology, pulmonary medicine and endocrinology. In addition, there is no rapid access to advanced imaging and interventional procedures such as interventional cardiology and radiology, fiberoptic intubation equipment, hyperthermia management, ICU, EP/pacing, tPa, dialysis and MR, CT, nuclear medicine and PET imaging.

Patients often perceive that safety is greater in an ASC but it is actually much less safe for patients with any significant medical problems. Although certified registered nurse anesthetists are usually very well trained, patients with significant medical problems require immediate access to physician-administered anesthesia, which can be problematic in some ASC settings.

Case Selection for the ASC

Cases suitable for surgery in an ASC include: healthy patients, epimacular membranes, macular holes, vitreomacular traction syndrome, dislocated lens material and dislocated intraocular lenses. Endophthalmitis cases rarely need vitrectomy but may be done in an ASC if proper room and equipment precautions are followed to prevent cross contamination.

Although floater-only vitrectomies are very rarely indicated, these cases would be suitable as well. Branch vein decompression for branch retinal vein occlusion and radial optic neurotomy are still performed by some surgeons; however, there is no evidence of efficacy and these procedures have been largely abandoned by ethical surgeons.

Cases not suitable for surgery ASC include: sick patients, diabetic traction retinal detachments, proliferative vitreal retinopathy, complex trauma and vit buckles. Although a case may begin as a straightforward case, intraoperative complications or unexpected findings may require advanced tools, laser, gas and/or silicone oil. Examples of such complications include: suprachoroidal infusion, retinal breaks, retinal detachment, bleeding (diabetic retinopathy, vein occlusions) and lens touch. These complications will increase OR time and labor costs and disrupt the OR schedule.

Take a Cautious Approach

While there some advantages and economic opportunities associated with transitioning some VR cases from a hospital outpatient setting to a free-standing ASC, a realistic evaluation suggests caution.

Steve Charles, M.D., can be reached at the Charles Retina Institute at 6401 Poplar Avenue, Suite 190, Memphis, Tenn. 38119, by phone at 901-767-4499, or via e-mail at scharles@att.net. Dr Charles is clinical professor of Ophthalmology, University of Tennessee and adjunct professor of Ophthalmology, Columbia College of Physicians and Surgeons.