Office-based surgery suites emerge as an attractive alternative for surgeons

By Daniel S. Durrie, MD

Innovations in health care have led to major changes in cataract surgery, including the shift from a hospital setting to ASC in the mid-80s. The change was disruptive at the time, but soon became recognized as a safe, affordable and familiar choice for both doctors and payers. Fast forward to 2020, when interest in office-based cataract surgery has arisen due to the cost effectiveness, seamless patient care and control over the surgical experience.

As chairman of the board for iOR Partners, a company that provides consultation, development and management for office-based surgery (OBS) suites, I have seen a surge of ophthalmologists taking the steps to move cataract surgery into their offices. The advantages of cataract surgery moving from a remote ASC to OBS include patient and surgeon safety and convenience, reduced anesthesia utilization and retention of surgical fees within the practice. In addition, the current COVID-19 pandemic, which disproportionately affects older adults, adds another layer of complexity for managing patient flow and social distancing. OBS has emerged as an increasingly appealing choice, both for cost and flexibility. In this article, we will discuss the considerations, along with the pros and cons, of office-based cataract surgery.

SAFETY

Accreditation

Office-based surgical suites employ the same safety standards as ASCs. They are accredited by the same national organizations as any ASC or hospital, including The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC) or the American Association of Accreditation of Ambulatory Surgery Facilities (AAAASF).

Supporting data

As of late 2015, more than 95% of cataract surgeries performed by Kaiser Permanente Colorado were done in an office setting. All surgeries were routinely performed with topical and intracameral anesthesia with oral triazolam sedation.

In 2016, they published a large-scale retrospective report involving 21,507 eyes of 13,507 patients aged 72.6 ± 9.6 years who underwent elective office-based cataract surgery.

These patients also presented with comorbidities, including hypertension (53.5%), diabetes (22.3%), chronic obstructive pulmonary disease (9.4%), macular degeneration (12%) and glaucoma (18%). Adverse events (AEs) included 0.55% of capsule rupture or tear, 0.34% of vitreous loss, 1.53% of iritis/uveitis and 0.14% of retinal detachment within 90 days of operation. No cases of endophthalmitis were observed within 30 days of surgery. Of the AE cases, 0.7% required surgical interventions within 6 months. Overall vision outcomes were excellent, with mean BCVA 20/28 Snellen. The study demonstrates that OBS is a safe alternative to ASC conducted cataract surgery.¹

Data from iOR Partners, a company that facilitates OBS suites, shows similar outcomes. In more than 5,000 procedures performed in iOR surgical suites, the safety profiles (AEs) are consistently as good as those in the Kaiser study.²

CLINICAL CONSIDERATIONS

Anesthesia requirement

In-office surgery suites can be either Class A (oral topical and local) or Class B, where oral, IV sedation and local and topical anesthesia are allowed, but intubation and general anesthesia are prohibited. Accredited OBS suites are typically Class B with a standby option of using IV sedation. Multi-specialty ASCs are Class C facilities where oral, topical, local and general anesthesia can be performed. Surgeries in this setting must be supervised by a licensed anesthesia provider. In fact, reduced anesthesia usage can make surgeries much more efficient and cost-effective in general.

Anesthesia choice depends on your preference, comfort level and risk assessment for each case. Lance Kugler, MD, of Kugler Vision in Omaha, Neb., performs 90% of his office-based cataract surgeries with oral sedation as he would for LASIK in his office. Typically, oral and topical anesthesia are his preferred choice, but Class B facilities give the option of doing standby anesthesia, which are available in both OBS and an ASC.

Comorbidities

Comorbidities in cataract-age patients may warrant a surgery in an ASC. These may include obesity, diabetes, cardiovascular disease, hypertension, pulmonary disease and cancer. As demonstrated in the Kaiser study, even cases with comorbidities can be safely operated in an OBS setting. However, since patient safety is a priority, my colleagues still assess risk based on comorbidities on a case-by-case basis. Initially, Dr. Kugler moved his patients with hypertension to an ASC to be monitored. Over time, he realized the extra monitoring was unnecessary and he became more comfortable keeping these cases in-office.

Patient preference and comfort

When office-based surgery was implemented at Durrie Vision in Overland Park, Kan., we felt that patient anxiety was significantly reduced and the overall experience improved because patients were familiar with our staff and facility. It is also less confusing to a patient if they can have surgery in the same building as their doctor’s office, whether it is an OBS or attached ASC. When sedation is limited to oral medication and a hospital gown is not used, the patient may view the experience as less invasive.

Control

A physician gains control of surgery with OBS. You can have your choice of furniture, equipment, supplies and staff. The cost savings over an ASC and a more simplified decision-making process may allow you to invest significantly more on the most advanced cataract surgery equipment than you could in multi-specialty ASCs. Many OBS suites are equipped with advanced surgical equipment including 3D microscopes and femtosecond lasers.

COVID-19 mitigation

In March, all elective procedures were postponed as ASCs and hospitals across the country closed to curb the spread of COVID-19 and conserve medical resources for the anticipated overrun of the health-care system. During this period, many ophthalmologists started to think about moving their cataract surgeries in-office for more flexibility and control over their practices. Alan Brown, MD, of Surgical Eye Care in Wilmington, N.C., states, “I am glad I started this process before the outbreak. My ASC has moved ophthalmic procedures to another facility 45 minutes away, causing a major inconvenience for my patients, and my OR time was cut in half. The fact that I was already in the process of implementing an OBS has literally saved my practice.”

As elective surgeries resume, multi-specialty ASCs may be busy with the backlog of non-cataract elective procedures, which may extend time between cases. An ophthalmologist’s office can better control the patient flow, making it easier to maintain physical distance and result in more control over COVID-19 mitigation protocols. Same-day bilateral surgery is another way to minimize the number of patient visits to the office.

REIMBURSEMENT AND PAYMENT CONSIDERATIONS

Policies

Reimbursement policies may vary by state or even by county. Many private insurers have recognized that OBS surgeries are both safe and cost-effective. Commercial insurers and Medicare Advantage, which is processed by commercial insurance, reimburse for most OBS cataract surgeries.

Currently, Medicare pays facility fees only for hospital and ASC cataract surgeries, but I believe it is only a matter of time before they reimburse for OBS based on the safety data and positive outcomes. It is the most commonly performed outpatient procedure for the Medicare demographic, and OBS can provide savings to Medicare by reducing the need for an anesthesia provider while maintaining the surgeon’s overall reimbursement.

Advocacy

In 2016, CMS put out a “Request-For-Feedback” memorandum to ask the industry about office-based cataract surgeries.³ I have been advocating for this in Washington and also working with congressmen and CMS. I am hopeful for CMS to cover cataract surgeries in the future.

OBS AND ASC COMPARISONS

Differences

A surgeon’s OBS is different from an ASC since it is not a separate facility under a separate license. An OBS is part of the practice and functions under the same license. With OBS (as well as physician-owned ASCs), you have more flexibility to schedule surgeries and are not restricted to specifically reserved time blocks as in a shared ASC. An OBS enables the surgeon to schedule surgery to accommodate changes in demand, such as for snowbirds during the winter in Florida or right after the COVID-19 restrictions ease.

OBS creates a more personal environment than a typical ASC, making it easier to offer premium services. Most OBS practices have found that with the boutique-feel and the convenience of OBS, conversions to premium upgrades have increased.

OBS startup costs are very low compared to an ASC, which can cost more than a million dollars to develop. Additionally, an OBS allows you to retain all surgical facility fees in your practice.

Will OBS replace ASC for cataract surgery?

There are two ways to add in-office cataract surgery to your practice — with an ophthalmic-specific ASC or with OBS. Ophthalmologists who have opened ophthalmic specific ASCs over the last 20 years have already made a smart business decision. For those considering their options today, OBS presents an attractive alternative.

OBS will not replace the ASC, as there will always be cases that require additional monitoring that the ASC provides. Therefore, most ophthalmologists who own OBS suites operate both in their office and in an ASC, depending on the case.

If you do not have ownership in an ophthalmic-specific ASC, now may be a good time to consider other options, as many ASCs are restricting or eliminating surgery schedules for cataract surgery due to the pandemic. COVID-19 has brought forth societal changes that are likely not going away, so there has never been a better time to reevaluate the usual way of doing things. Regardless of where we operate, we should all be seeking more control over our surgical experience while streamlining the patient experience with extreme safety and social distancing.

REFERENCES

1. Ianchulev T, Litoff D, Ellinger D, et al. Office-based cataract surgery: Population health outcomes study of more than 21,000 cases in the United States. Ophthalmology. 2016;123:723-728.
2. Durrie D. iOR Partners. Office-based surgery: In current times and beyond. April 30, 2020. Webinar.
3. Federal Register. Medicare Program; revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2016. https://www.federalregister.gov/d/2015-16875 . Accessed Sept. 16, 2020.

About the Author

Daniel S. Durrie, MD, is the founder of Durrie Vision, in Overland Park, Kan., and chairman of the board for iOR Partners, located in Kansas City, Mo.

An intersection of benefits continues to make ASCs a good choice

By Cathleen McCabe, MD, and Jeffrey Whitman, MD

Cataract surgery is one of the greatest success stories in medicine, with low complication rate and significant impact on the daily lives of patients. The majority of the 3.8 million cataract procedures performed annually in the United States are done in the approximately 1,200 ASCs specialized in the provision of cataract and other ophthalmic surgeries.

ASCs are Medicare-certified, state-licensed, accredited and highly regulated and offer a cost-effective means to meet the growing demand of cataract surgery in a high-tech operating space overseen by ophthalmic-care professionals.

Outpatient Ophthalmic Surgery Society (OOSS) conducted an evaluation of surgical facilities that examined the following elements:

1. PATIENT HEALTH AND SAFETY

The cataract surgery OR is a comprehensive, high-tech environment housing phacoemulsification equipment (with or without femtosecond lasers), operating microscopes, delicate surgical instruments and sterilization systems that have been designed for the ophthalmic microsurgical setting. The ASCs may also contain sophisticated equipment such as head-up surgery technology or AI-driven intra-operative guidance systems. Staff are licensed and trained in ophthalmic care and the use of this specialized equipment. The surgeon, anesthesia professionals and clinical staff focus on emergent care needs, including patient monitoring equipment, medical gases (eg, oxygen), crash carts, defibrillators and all other airway and medication requirements. Creating this complex environment of trained professionals and costly equipment is an expensive endeavor and requires substantial attention to detail.

A survey of OOSS member and non-member ophthalmic ASCs confirms that virtually all facilities are Medicare-certified; 85% are accredited by a CMS-approved agency as an ASC, and 81% are licensed by their states as ASCs. Meeting these requirements enables facilities to receive Medicare facility fee reimbursement of more than $1,000 per cataract case.

For patient health and safety purposes, advocates for OBS note that their facilities are “accredited.” However, these facilities are accredited as “offices,” and they adhere to standards pertaining to infection control, life safety, environment, anesthesia, nursing and supervision that are not as strict as those applied to ASCs.

2. FINANCIAL PERFORMANCE

The ASC has proven economic strengths based on receiving a fair facility fee with suitable volume and a predictable cost structure. The investment in building a new ASC, furnishing it with the necessary technology and equipment in addition to operating it with professional, dedicated, trained staff0 is significant. Some physicians prefer a multiple-owner ASC while other high-volume surgeons opt for an individually-owned ASC. Having multiple physicians invest in and use the ASC provides the opportunity for member physicians to share costs, to benefit from the growth of colleagues’ practices and to optimize the use of the facility and resources. Individual owners assume all the risk, control and benefit of the ASC.

When a surgeon buys into an existing ASC, the investment can provide immediate return on investment (ROI) — possibly receiving distributions the next month based on proven operations, proven revenue stream and proven past distributions, ultimately resulting in an accelerated ROI. In contrast, an OBS’ financial performance can be significantly limited by lower surgical volumes that generate minimal to no facility fees, with surgery performed exclusively by physicians of the practice — at least, in the current payer environment.

The ASC will likely obtain better pricing of supplies, implants, instruments and equipment given its higher volume and will have a more robust and diverse lens/implant consignment, providing the surgeons with more flexibility in providing a variety of treatment options.

3. RISK ASSESSMENT – FINANCIAL/CLINICAL

Syndicating into an existing ASC costs less and may yield a bigger return faster than building a new one. For both new and existing ASCs, the financial risk can be shared by a group of physician owners. In a partnership scenario, the ASC revenue and productivity grow as each physician’s volume increases. All partners benefit from each physician’s use of the facility. The ASC can recruit new ophthalmologists to use the center, add sub-specialties and/or add new specialties to be performed to grow volume and revenue. The financial risk of owning an ASC is shared with the other owners also performing procedures. Any vacations, illnesses, long-term absences or closures due to external reasons (such as COVID-19) are absorbed and shared by the group of owners. In a single-owner ASC scenario, the physician can operate a very efficient, profitable, independent ASC while building a separate asset from the practice.

The surgeons’ clinical risk is mitigated when performing surgeries in a Medicare-certified, state licensed or accredited (as an ASC) facility committed to providing optimal care in the ASC. An OBS may seek accreditation as an office, but these standards are less rigorous than those for ASCs.

4. AVAILABILITY OF AND ACCESS TO DESIRED TECHNOLOGY

ASC physicians-owners share costs helping them to invest in the latest innovative technologies. In an individual-owner ASC or OBS, the owner has the freedom to select desired technology but bears the full cost burden.

An additional consideration is that ophthalmic devices and implants such as minimally invasive glaucoma surgery, or MIGS, that clinically benefit the patients and provide an additional physician fee of $300 to $500 are approved in the ASC as the place of service.

5. DEDICATED PROFESSIONAL, TRAINED STAFF

With a dedicated professional staff at the ASC, physicians can perform the highest volume of procedures in minimal time, optimizing efficiency in the OR. The ASC staff is specifically recruited and trained for this surgical environment as their unique focus. The staff is prepared for emergencies and complications. In an OBS, the staff has surgical duties such as scrub tech support and administering of anesthesia on a part-time basis, secondary to their primary clinic functions.

6. LIFE BALANCE

Spending less time to do a higher volume of surgeries in an ASC frees up more time for practice management, clinic or family. In an ASC, the physician is uniquely focused on performing surgeries, assisted with specialized staff dedicated to surgical care. Most surgeons will utilize multiple ASC ORs to optimize their efficiency. In an OBS, the surgeon is responsible for the care of patients, medical emergencies, anesthesia complications, management of staff and operations of practice and office surgical suite.

7. ASSET BUILDING

The ASC has the potential to generate significant ROI for the physician-owner. With the ever-changing health-care environment and reimbursement rates, it is in the physician’s best interest to own two separate entities — the practice and ASC — and to align with a leading, progressive ASC. The physician who builds a practice that includes an OBS has one business yielding less flexibility and more risk.

For both new and mature surgeons, ASC-ownership is a key component of building long-term financial security. To enable new surgeons to own an ASC, current owners must prepare to sell ownership shares to them. Adding productive owners will increase the ASC surgical volume from new surgeons, grow the business and continue the high performance of ASCs. Mature surgeons have the opportunity to divest ownership shares in an accretive method that reduces their percentage of ownership while potentially increasing their distributions because of the incremental volume from new partners — building opportunity for the prosperity of new surgeons and rewarding experienced surgeons for their contribution over the years of ownership.

CONCLUSION

Cataract patients deserve safe, effective and affordable care. They expect limited risk of complications and an improvement in their daily lives. ASCs and hospitals deliver the established cataract standard of care in appropriately accredited facilities tended by specially trained professional staff. The ophthalmic ASC remains, after decades of proven results, the best solution for patients and physicians. OM

For more info and resources, visit www.OOSS.org .

About the Authors

Cathleen McCabe, MD, is the chief medical officer of Eye Health America and medical director of The Eye Associates in Bradenton, Fla. She is the president of OOSS and co-chief medical editor of The Ophthalmic ASC.

Jeffrey Whitman, MD, is president and chief surgeon of Key-Whitman Eye Center in Dallas. He is past president of OOSS and past president of American College of Eye Surgeons.