As I See It

Yogi was right; it’s like deja ...

From ASCs to office-based cataract surgery?

By Paul S. Koch, MD, Editor Emeritus

In 1981, when I was 29 years old, I started a practice from scratch. During my last year of residency I built an office building and set aside space for a surgery facility. In 1984 I hired my late friend Lou Scheffler to design an ASC in that space for me and I opened my operating room there in April 1985 — but as an office facility. I used it only in the evenings after my nurses had finished their shift at the hospital and were able to come to assist me. Simultaneously I filed for a Certificate of Need; after two years and three applications it was approved and I had a licensed ASC.

I tell this story (and believe me, there are a lot of interesting back stories about nefarious plots that went on during that time) because the question of office-based surgery is coming to the forefront. It appears the people who once championed getting out of hospitals and into ASCs are miffed at recent proposals to move patients out of ASCs and into offices. As I have owned both an office facility and some ASCs, I have seen both sides of the issue.

Hall-of-Famer Lawrence Peter "Yogi" Berra has a museum and learning center on the campus of Montclair State University in NJ.
COURTESY WIKIMEDIA COMMONS

There’s a new model in town

The Center for Medicare and Medicaid Services (CMS) is soliciting comments on whether to establish a payment category for office-based cataract surgery. As I understand it, CMS is considering establishing a fee that totals higher than the surgeon’s current stipend. It would have two figures: a new surgeon’s fee, lower than the current one, and an ASC charge to urge providers to build office-based operating rooms. The intention is to lower the government’s costs by shifting surgery out of an ASC and into the office.

When the Outpatient Ophthalmic Surgery Society (OOSS) was founded, its purpose was to argue for excellent quality of care in a less expensive and more appropriate setting than a hospital. Later it worked hard to establish the crosswalk between hospital and ASC fees which, while not exactly what we wanted, were a help. At the time I was an OOSS board member and admired the efforts our leaders put into this project. OOSS has excelled at representing the interests of those who perform outpatient surgery; if you are not a member or attend its meeting, I encourage reconsideration.

The more things change …

But now the ASC community finds itself in a dilemma. Does it argue, as did the hospitals back in the day, that quality of care would be sacrificed if anyone could put an operating room in any office, at presumably relaxed regulation to permit economic advantages? Or does OOSS evolve into a new OOSS, defining “outpatient” as simply not being in a hospital, as opposed to being in an ASC?

At the last ASCRS meeting there was a very cool product exhibited in the first aisle on the left side of the hall. It was a portable lamellar flow room. You would unfold some glass walls, slide the stretcher under a flow screen — and Presto! A clean room for surgery.

Whether it works well enough, I have no idea, but the world is changing and we are a full generation away from the battle in favor of ASCs. I sold my surgery center years ago, so I do not have a dog in this fight. I used to have an office-based operating room, but it was built to ASC standards so I don’t know how relevant that is to this development.

Yogi Berra was right. It’s like deja vu, all over again. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His email is pskoch@clarisvision.com.