In the past, the sudden cancellation of a day of surgical appointments would have been disruptive to my patients and my ophthalmology practice. Given that our schedules are typically booked out at least 4-6 weeks in advance, a cancellation day may postpone a patient’s surgery for more than a month. But, when it happened last April due to a clerical error at a local ASC, I had an excellent backup plan: a seamless pivot to our office-based surgical suite (OBS), where I performed the procedures as scheduled the same day.

That flexibility exemplifies why my practice opened an OBS a year ago. Our modern, fully accredited surgical suite has given us an unprecedented level of control over our schedule, enabling us to streamline our operations, pay fewer facility fees and provide a range of procedures without delay or interruption — sometimes even ordering and performing surgeries in the same week.

In the past half a decade, ophthalmologists have grown accustomed to scheduling-related challenges at hospitals and ASCs, as closures during the first wave of the COVID-19 pandemic caused devastating backlogs that took months or even years to rectify. Today, ASCs are grappling with new challenges — namely, staffing shortages,¹ particularly of anesthesia and certified registered nurse anesthetists, and declining reimbursements.² When those issues result in abridged schedules, it is my experience that ophthalmology cases, which are mainly elective, are often the first to be canceled so that ASCs can accommodate procedures that bring in higher reimbursements.

These delays can be particularly problematic for ophthalmology practices, as our reimbursement numbers have remained fairly static³ despite growing demand from an aging population⁴ for cataract, refractive and oculoplastic surgeries.

Embracing the OBS model could allow us to reach more of the patients who need our help — and with the same level of safety and effectiveness^5,6 enjoyed in traditional settings. A 2023 study found that cataract surgery in the OBS, compared with other settings, demonstrated similar or lower rates of post-surgical adverse events such as corneal edema, unplanned vitrectomy, iritis and endophthalmitis.⁷

While there are about 7,000 ophthalmology practices in the United States,⁸ just 200 or so have office-based operating rooms, according to iOR Partner,s a company that guides ophthalmology practices in developing and managing OBSs. Yet, the gradual but steady growth of this segment over the past several years indicates that a trend is building.

As a cost-effective solution to many of the challenges we face, office-based surgery represents a natural progression for our field. So, it’s no wonder that most of the ophthalmologists in my region have called to ask me about my OBS experience.

Here I will review all the reasons for opening an OBS of your own and considerations when doing so.

OBS BENEFITS

Surgeon flexibility

Across all aspects of surgery, the flexibility associated with OBS enables ophthalmologists to be more present for their patients.

In my mid-sized practice, which includes eight doctors and 53 staff members, we open our OBS on Mondays and for half days on Wednesdays and Thursdays. However, we can easily schedule added days if we have patients who urgently need treatment or we are facing unusually high demand.

We’ve created a workflow that lends itself to fairly quick turnover, and as a surgeon who typically completes a cataract surgery in 6 to 8 minutes, I’ve found I can conduct 14 to 15 surgeries in a full day in the OBS without rushing or feeling stressed — the same number I would log in a day at an ASC.

But in the office, I can also accomplish something additional: Between surgeries, I can make quick clinic visits, stopping in to see patients for postoperative care or emergencies.

Staff benefits

With many ophthalmology clinics short-staffed,⁹ strategies for employee retainment are crucial. Adding an OBS can help by giving staff members a feeling of empowerment as they learn additional skills. Crosstraining regular clinic staff to also manage an OBS not only provides them with an extra skill set, but also maximizes practice efficiency and reduced costs.

While my practice usually needs just three or four technicians to assist in the OBS, we’ve ensured redundancy by training six technicians to prepare the room and equipment. It’s been wonderful to identify staff members with the potential to excel and then watch them rise to the occasion by taking ownership of the process.

More peaceful for patients

Most importantly, patients benefit when we perform surgery in the office. A comfortable, familiar setting puts them at ease, making them more likely to seek the care they need or want.

When clients come in for surgery, they’re happy to see familiar faces, sit down in a massage chair for treatment and sometimes even have a staff member hold their hand for reassurance. They’re allowed to eat breakfast in the morning and have a drink of water when they come in because they don’t have “nothing by mouth” orders, and they walk out lucid rather than loopy. We owe many of these comforts to our use of oral sedation and a topical anesthetic, rather than the IV anesthesia routinely administered in ASCs.

Sedation

Our OBS is fully equipped to handle any surgical complication, and we can administer IV sedation in the OBS if a registered nurse is present. Yet, as cataract surgery is not especially painful, we’ve found that the oral and topical route is more than adequate for most patients who are free of severe comorbidities. In fact, in conducting more than 300 in-house surgeries using this strategy, I have yet to encounter a patient whose procedure had to be aborted or who got too nervous to sit still.

Without the side effects of heavier anesthesia such as nausea/vomiting, worsening dementia and heightened fall risk, our patients leave with the perception that they’ve undergone a minor procedure. It’s a harmonious experience that boosts our business by inspiring clients to recommend us to their friends and relatives.

Increased business

That kind of growth is crucial to practices as Medicare reimbursements drop — and it’s to be expected after adding an OBS. The clients who prefer the comfort of in-house surgery also tend to gravitate toward premium procedures, driving up our volume of high-end IOLs, self-pay refractive procedures and, in the case of medical tourists, out-of-pocket cataract surgeries. In my clinic, the volume of patients seeking the Light-Adjustable Lens (RxSight) has doubled since we opened our OBS.

Taking the OBS route makes financial sense for practices, as reimbursement for surgeries in the office vs outside facilities is comparable, despite different fee structures. That is, while OBS does not have facility-fee reimbursement, it does qualify for enhanced professional fees from Medicare and private insurers. These allow physicians to negotiate with private payers to be reimbursed at amounts comparable to a facility fee.

Ultimately, OBS typically emerges as the more profitable option due to lower overhead costs and a reduced need to pay facility fees. More work needs to be done to allow CMS and private payers to fully recognize OBS as equal footing with ASCs for the care offered.

These savings can enable practices to create incentives for their premium-service customers. With 100% of reimbursements coming to our practice, we’ve been able to pass along our savings by discounting rates for some procedures in the OBS — in addition to providing more charity care.

As the sole facility billing patients, we’ve also boosted our ability to be transparent with patients about costs, setting expectations well in advance of procedures. This is key in keeping ahead of the trend toward financial transparency as a patient right, something that is now mandated in the hospital setting.¹⁰

HOW TO BUILD AN OR

Cost and space

Although it may sound daunting, building an in-office surgical suite is within reach for many practices. We collaborated with iOR Partners, which offers expertise in OBS construction, management, troubleshooting, reimbursement maximization and regulatory compliance.

The cost of launching an OBS can range from a few thousand dollars up into the six figures. Our practice made this relatively large investment, as we had purchased raw space within our building with plans for an expansion that would include an OBS. We spent approximately $150,000 to build our operating suite from the ground up over about 3 months.

For other practices, the process may be as simple as converting an existing exam or LASIK procedure room into a no-frills OBS. Such in-office surgical suites must be at least 500 square feet and include two sterile areas — one for processing and another for equipment — although processing may alternatively take place outside the room if an appropriate area is available nearby.

Finally, an OBS must have flooring that is free of seams to prevent the growth of bacteria.

Then, get the word out

Marketing an OBS can also be uncomplicated. In our practice, we’ve alerted our community about our in-office suite by reaching out to nearby colleagues. We have hosted an open house, sent our marketing manager out to practices to share information and added promotional information on our website. Still, the best marketing by far has been a great patient experience, shared via word of mouth and online reviews. My team has the same patient-centric approach in the OBS as we do in office. From smiles and optimistic words to holding a patient’s hand while I’m operating, the team effort makes a strong impression on our patients.

IT CAN REDEFINE PRACTICE

With a host of factors fueling the growth of OBS, I expect to see big changes across our field in the next 5 to 10 years. The OBS movement brings myriad benefits to ophthalmology, from control over scheduling and staff retention to patient satisfaction that can foster significant business growth.

Another driver is the limited number of ASCs in states with prohibitive certificate of need programs, which can result in scheduling backlogs for ophthalmology practices.¹¹ Although OBSs are regulated and held to high safety and malpractice standards, they face an alternative set of compliance measures, providing another impetus for their growth across ophthalmology.

With these factors in mind, I envision OBS becoming increasingly central to ophthalmology in the years ahead. Along with early adopters, our field’s newest surgeons will likely lead that charge as they graduate into a changing environment and quickly recognize the benefits of in-house surgery.

By celebrating the advantages of this promising new setting, these innovators are poised to redefine the way we practice ophthalmology. OM

REFERENCES

1. Bakerman S. Three ASC healthcare challenges for 2023. IDENTI Medical Data Sensing. Accessed Oct. 17, 2023. https://tinyurl.com/yck7za8e .
2. Gallagher J. Ophthalmologists face 8.5% cut in Medicare reimbursement for 2023. Glaucoma Physician. December 1, 2022. Accessed Oct. 17, 2023. https://www.glaucomaphysician.net/issues/2022/december-2022/web-exclusive-ophthalmologists-face-8-5-cut-in-med .
3. Terveen DC. Ophthalmology numbers cause for concern. American Academy of Ophthalmology. https://www.aao.org/young-ophthalmologists/yo-info/article/ophthalmology-numbers-cause-concern . Aug. 19, 2022. Accessed Oct. 17, 2023.
4. Steinmetz JD, Bourne RRA, Briant PS, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. The Lancet. 2021;9:E144-E160. https://www.thelancet.com/journals/langlo/article/PllS2214-109X(20)30489-7/fulltext#%20 .
5. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-based cataract surgery: Population Health Outcomes Study of more than 21 000 cases in the United States. Ophthalmology. 2016;123:723-728.
6. Kugler LJ, Kapeles M, Durrie DS. Safety of office-based lens surgery: A U.S. multicenter study. J Cataract Refract Surg. Published online June 5, 2023.
7. Kugler LJ, Kapeles M, Durrie DS. Safety of Office-Based Lens Surgery: A U.S. Multicenter Study. J Cataract Refract Surg. Published online June 5, 2023.
8. Nabity J. How to start a successful ophthalmology practice. Physicians Thrive. Updated July 18, 2022. https://tinyurl.com/y7dvyphb . Accessed Oct. 17, 2023.
9. Williams RD. Coping with staffing shortages. aao.org . Published December 2021. https://www.aao.org/eyenet/article/coping-with-staffing-shortages . Accessed Oct. 17. 2023.
10. Thompson D. Fewer surprise bills: Most U.S. hospitals now transparent on prices. U.S. News & World Report. Feb. 20, 2023. Accessed Oct. 17, 2023. https://www.usnews.com/news/health-news/articles/2023-02-20/fewer-surprise-bills-most-u-s-hospitals-now-transparent-on-prices .
11. Palmer E. Everything you need to know about certificate-of-need laws for ASCs. HST Pathways. July 14, 2023. https://tinyurl.com/3xb43smy . Accessed Oct. 17, 2023.

John Josephson, MD, is the founder and medical director of Eye Specialists & Surgeons of Northern Virginia. He is dedicated to assisting in residency training and he devotes time to participating in medical mission trips. Disclosure: Dr. Josephson is an investor in iOR Partners.