A vicious Presidential campaign. A divided America. One party rule in the legislative and executive branches of government. The impending repeal of The Affordable Care Act. What does this portend for our healthcare delivery system? And, importantly, what can we, as progressive surgeons and owners of ophthalmic ASCs, expect from Congress and the Center for Medicare and Medicaid Services (CMS) in the year ahead?

Here, I offer a few comments about the political implications of an Obamacare repeal and discuss the priorities of OOSS and our strategies for engaging with health policymakers to ensure that ophthalmic ASCs not only survive, but thrive, in an increasingly competitive, regulatory, and cost-conscious environment.

Obamacare Repeal

A few days before his inauguration, President-elect Trump issued provocative statements about healthcare reform, promising an immediate repeal and replacement; insurance for everyone; no Medicare cuts; and much lower deductibles.

How will the government pay for a new program without increasing taxes or cutting benefits? Should Congress implement immediate repeal, repeal-and-delay, or repeal-and-replace? Is the GOP seeking universal coverage or universal access? Does lower patient cost-sharing contravene the principle that citizens should have a wallet stake in choosing their healthcare plan? Should policymakers mandate that drug manufacturers engage in competitive bidding with the Medicare and Medicaid programs? These questions aren’t emanating from the Democratic party. These concerns are being raised by Republicans on Capitol Hill who are historically wed to some key principles that would seem to conflict with those embodied within the president’s plan.

Is it realistic to enact a substantive plan in a matter of weeks or months, given the complexity of the delivery system? One of the great myths of our times is that major reforms come to fruition within the “first 100 days” of a new administration. The reality is that, with few exceptions, such as the advent of the Great Society in 1965 and the Reagan Revolution in 1981, the process of legislating has been more deliberate in terms of policy formulation and consensus-building.

Republicans today, while having taken dozens of essentially meaningless votes to limit or repeal Obamacare over the past 6 years, face a Hippocratic challenge of sorts — to “first do no harm.” The non-partisan Congressional Budget Office has reported that repeal without replacement (an increasingly unlikely scenario) would result in 18 million Americans losing coverage immediately, and for people buying individual non-group coverage, health insurance premiums would double within a decade. Given the flack that President Obama incurred when falsely promising that individuals would not lose their health plans, Republicans are wary of being characterized as effectuating the even more draconian result of no access to coverage at all. The bottom line is that the issues encompassed in healthcare reform are extraordinarily complex, and the GOP will receive little favor from Democrats who are witnessing their prize public policy initiative gutted.

The new Republican leadership in both chambers and the White House can still advance much of their agenda in relatively quick order. On Inauguration Day and in the weeks thereafter, we can expect to see a plethora of health regulations and executive orders withdrawn or repealed. However, don’t expect a quick and easy answer with respect to Obamacare.

What Does This Mean for ASCs?

At the end of the day, I suspect that the policies that ensue will have only a nominal impact on ASCs. Our industry is but a flea on the back of a flea on the back of the healthcare provider elephant. ASCs enhance access to high-quality health care, a key objective of any reform model. ASCs, paid for surgical care at rates that are half that of hospitals, already provide significant savings over alternative care. Indeed, the need for savings to pay for any major reform could provide incentive for policymakers to further incentivize the furnishing of surgical services in the ASC, perhaps by limiting hospital rates to the amounts paid to ASCs, as OOSS has advocated for years. As for having friends in high places, the nominee for Health and Human Services Secretary, Tom Price (R-Ga), is a surgeon and a longtime advocate for our industry, having cosponsored The ASC Quality and Access Act for many years. Although ophthalmic ASCs will need to be smart and nimble with respect to market forces such as consolidation, the basic fee-for-service framework for payment and regulation of our facilities should remain intact.

We surveyed the OOSS membership last year, and based on your direction, will focus on the following as our top priorities.

• “No” to office cataract surgery. We will continue to oppose any effort by CMS to implement payment of a facility fee for cataract surgery performed in the physician’s office. In its recent physician payment rulemaking, CMS was silent as to pressing forward with payment for office cataract surgery. This is a positive sign that our message has been received, and OOSS will remain vigilant in representing our members.
• Higher ASC facility fees. In some reasonably positive news, the final rule includes a 2017 update factor of 1.9%, which compares favorably to the 1.2% update included in the proposed rule. OOSS and the ASC community will continue to urge — by regulation and legislation — that CMS update rates to ASCs by the Hospital Market Basket, which is provided to HOPDs and is typically about one point higher than the CPI-U.
• Leveling the Playing Field for ASC and HOPD Rates. Hospitals are paid about twice as much to perform surgical procedures as ASCs. Reducing hospital payments to match surgery center payments would save billions of Medicare dollars. Policymakers will, I believe, seriously consider implementing such a policy as a means of paying for new healthcare initiatives. Why should ASCs care about this development when our rates might not increase? It’s a volume proposition: Services will undoubtedly migrate from the HOPD to surgery centers — many hospitals already are less than enamored about ophthalmic surgery, and this concern will be heightened if payment rates are substantially reduced.
• Sane and reasonable sterilization and infection control policies. For the past 2 years, CMS has implemented requirements that would significantly increase the costs of sterilizing ophthalmic instruments and actually compromise the health and safety of our patients (i.e., requiring facilities to use enzymatic cleaners.) OOSS, with ASCRS and AAO, will continue to educate CMS, FDA, and standard developers as to the special needs and circumstances of the ophthalmic ASC, press manufacturers to adopt appropriate directions for use, and present clinical evidence that our practices and procedures are just as effective as those utilized in hospitals.
• Meaningful quality and patient experience reporting. Over the past several years, OOSS has been instrumental in thwarting CMS’ efforts to adopt irrational and unduly onerous quality measures. We have recently focused, with great success, on developing, testing, and advocating for appropriate ophthalmic measures that are not burdensome and that will generate meaningful data for our facilities and patients.

Help OOSS Succeed

These represent just a few of our priorities. In my 35 years of experience with OOSS, I’ve found that almost half of my time over the course of a year is devoted to issues that weren’t even on the radar screen in January. I have every reason to believe that this will be the case in 2017 and beyond.

How do we maintain — in fact, accelerate — our progress in meeting the challenges emanating from regulators at the federal and state levels and from the market place? I would offer a few suggestions:

• Join OOSS. It starts and ends with a strong and vibrant OOSS, comprised of ophthalmic ASCs that are steadfastly committed to delivering the best in surgical quality, efficiency, and affordability.
• Educate your elected officials. As healthcare providers, we accomplish our legislative and regulatory objectives by educating policymakers about the benefits of innovative ophthalmic surgical care and of the quality, convenience, and cost benefits of ambulatory ophthalmic surgery.
• Provide your views to policymakers. Legislators need to hear from their constituents and CMS needs to hear from stakeholders. You have been remarkably effective in communicating the OOSS message over the years. With respect to our thus-far successful effort to forestall payment for office surgery, more than a hundred OOSS members sent comments to CMS articulating the patient health and safety implications of the policy.
• Political action. The Outpatient Ophthalmic Surgery Political Action Committee (OOSPAC) is the only PAC whose sole purpose is to advance the interests of surgeons who own and practice in ophthalmic ASCs.

OOSS is the only organization dedicated exclusively to the interests of the ophthalmic-driven ASC. Through a new and robust Advocacy Center, OOSS will provide you with all of the tools to stay current, develop relationships, convey effective messages, and deliver on our priorities. For more information about how you can get more involved, visit OOSS.org . Contact me at mromansky@ooss.org, or our Executive Director Kent Jackson, at kjackson@ooss.org. ■