Cataract surgery in your office?

A new study says the environment is as safe as an ASC; financial viability is another story.

By René Luthe, Senior Editor

Proponents of bringing cataract surgery into the office environment have gotten a boost for their side, thanks to the results of the largest, retrospective study ever.¹ To gauge the safety and efficacy of procedures conducted in minor-procedures rooms (MPRs), surgeons at Kaiser Permanente Colorado reviewed a three-year, consecutive-series study of 21,501 eyes that had undergone extracapsular cataract extraction in these MPRs. The study appears in the January issue of Ophthalmology.

What the authors found: The results rivaled those achieved in ambulatory service centers and hospital outpatient departments, where the majority of cataract surgeries currently take place.

Some observations first.

• The Centers for Medicare and Medicaid reimburses an ophthalmic practice the facility fee that the practice pays per surgery performed;

• Given an aging population, cataracts will be removed at a faster pace in the years to come.

The question: With CMS already displaying interest in in-office procedures with its 2015 Request-for-Feedback memorandum, could this study help pave the way for the subspecialty’s Next Big Thing?

First, a look at the study

Safety and visual outcomes were “comparable to anything achieved” in another surgical environment, including ASCs, says study coauthor Mark Packer, MD, president, Mark Packer MD Consulting. No cases of endophthalmitis were reported within 30 days of surgery, nor were any life- or vision-threatening events.

Postoperative mean BCVA was 20/28 Snellen. Common patient comorbidities included AMD, glaucoma, high blood pressure, diabetes and chronic obstructive pulmonary disease. Adverse intraoperative events included 119 cases of capsular tear, of which 73 involved vitreous loss. Postoperative iritis/uveitis occurred in 330 eyes, typically when postoperative medication was discontinued. There were 30 retinal detachments and six cases of cystoid macular edema.

According to the study, Kaiser Permanente’s ophthalmology offices in Denver stopped performing ASC-based cataract surgeries in 2006, meaning that it gave up, per 2013 CMS figures, about $960 per ASC fee and $1,670 per outpatient fee. CMS does not reimburse for MPR operations.

Kaiser’s logic

So why did Kaiser move to in-office surgeries? Prior to 2006, all cataract surgeries at KP-Colorado were performed in its multi-specialty Medicare-certified ASCs or hospitals. Because Kaiser is a Medicare Advantage participant, CMS payments for cataract surgery are capitated. That is, the surgeon’s fee and facility fee are rolled into the per member per month allowance for the diagnosis of “cataract.” Kaiser does not receive Medicare reimbursement based on the procedure. According to coauthor Richard Stiverson, MD, “there was no financial disadvantage in moving from the certified-ASC environment to an office-based environment as we had already been paid to take care of the member’s cataract.”

Dr. Stiverson says the primary reason Kaiser made the change was to improve efficiency. “As ever more complex procedures in all surgical specialties moved from hospitals to ASC’s, increasing regulations followed,” he explains. “While many of these policies and requirements were appropriate for riskier procedures, they were overkill for cataract removal.” Examples of this would include extended postoperative recovery requirements, required anesthesia services, what qualifies as an acceptable surgical mask, etc. “We felt over-sedation by anesthesia was more of a problem than under-sedation. We voluntarily participate in the same audit processes as our certified-ASC.”

Why haven’t more doctors adopted office-based surgery? Dr. Stiverson says they can’t afford to. Again, the traditional way that Medicare reimburses for cataract surgery is based on the procedure, not the diagnosis.

Dr. Packer agrees that for surgeons dependent on the facility fee, in-office cataract surgery does not make financial sense, save for doing elective, premium, refractive-cataract surgery — for which the out-of-pocket fees will more than make up for the loss of the Medicare facility fee.

The infection control issue

Even if your practice has the patient base, should you build a minor-procedures room? What follows are the pros of keeping the ASC.

Scott LaBorwit, MD, a principal at Select Eye Care and assistant professor, part-time faculty, at Wilmer Eye Clinic of Johns Hopkins Hospital, Baltimore is concerned about infection. “I don’t believe, despite best efforts, that an office can attain the level of sterility that’s necessary compared to an OR.”

ASCs have special ventilation and other built-in safeguards against infection, such as high turnover of air; washable, nonporous ceiling tiles, and linoleum floors that extend a few inches up the wall to prevent dust and debris from accumulating in the corners where the walls meet the floor. Converting office space to ensure a sterile environment won’t come cheap [For more on the advantages of ASCs, see Sidebar].

Not your everyday ophthalmic tech

The shift also requires a change in the perspective of practice staff, Dr. LaBorwit explains. They must undergo extensive training to appreciate the seriousness of a sterile operating room environment. And, along with documenting maintenance for the autoclaves and setting up the phaco machine, Dr. Packer says staff need to understand the regulations and handle the paperwork.

“These are not typical ophthalmic office staff,” who are qualified to assist in MPRs, Dr. Packer says. “It’s a big job that is usually handled by nursing staff at a surgery center. If you don’t have that type of person, it’s tough.”

The patient expectations factor

An additional concern surgeons should consider before building their own MPR are the excellent visual outcomes that patients expect from modern cataract surgery.

“I’m a retinal surgeon, but in cataract surgery as well, I know what we’re doing now in terms of visual rehabilitation is much more progressive than it’s ever been in terms of precision,” says Pravin Dugel, MD, managing partner, Retinal Consultants of Arizona, Phoenix, and clinical professor, USC Eye Institute, Keck School of Medicine, Los Angeles. Because visual outcomes have become so much better and because patient expectations are so much higher, Dr. Dugel maintains, “In my mind, at least for retina, there’s no doubt the higher skill and specialization of a surgery center and staff are required.”

Can you provide emergency care?

Opting not to use anesthesia may reduce the likelihood of unforeseen medical events, but as Dr. LaBorwit notes, “With or without sedation, you can have medical issues.” In order to meet any emergencies, nurses hired to assist with in-office cataract surgery should have Advanced Cardiovascular Life Support training, says Dr. Stiverson — as should physicians, as Kaiser requires.

Still, the specter of a life- or vision-threatening event is another reason Dr. Dugel sees ASCs as the safer alternative for even “routine” cataract cases. “Remember, when we start out performing surgery on something that we think is just a simple case, it’s not always a simple case. Should complications arise that you don’t expect, you want to be in a situation where, if equipment breaks down, you have more equipment,” he says.

Money spent, money saved

Costs to begin an MPR could be about $250,000 according to Dr. Packer. Then there are the ongoing costs — salaries and equipment. “You’d need everything from a wavefront aberrometer, an ORA, the surgical microscope, the phaco machine, the patient bed, etc.,” says Dr. Packer.

Beyond those expenses, he says that in-office surgery offers significant savings due primarily to salaries.

But whether abandoning the ASC for an in-office set-up makes financial sense for any surgeon depends on volume and patient mix. “It comes down to figuring out how many of these refractive cataract procedures you can do, whether that volume will pay for itself,” says Dr. Packer.

In Dr. Stiverson’s opinion, office-based cataract surgery will never succeed in the United States without a reasonable facility fee. The data he and his co-authors provided could help make that more likely. “What was compelling about our data is the volume of it and that it was equivalent to what we were doing in a certified environment,” says Dr. Stiverson. “But we don’t have an axe to grind here. We just thought cataract surgery could be done safely, effectively and cost-efficiently in a much lower acuity environment than our ASC.” OM

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