The nation’s ophthalmic ambulatory surgical centers (ASCs) are committed to providing Medicare beneficiaries with access to the highest quality surgical care while lowering their cost-sharing obligations and assisting the Medicare program in the containment of health expenditures. Since 1982, ASCs have expanded their role in meeting the surgical needs of the Medicare population and have saved billions of taxpayer dollars annually. Simply stated, at a time when public policymakers are searching for meaningful health-care reform—improving quality and access, while reducing costs—ASCs embody the potential to be a significant part of the solution. This is the message I convey to regulators and legislators every day: that ASCs are the solution!
I have had the privilege of representing the Outpatient Ophthalmic Surgery Society (OOSS) before Congress and the executive branch for 40 years. I can state unequivocally that 2022 was our busiest year as well as one of our most successful legislative and regulatory campaigns. This upcoming year promises to be even more challenging. As your voice in Washington, D.C., OOSS will continue advocacy that enables ophthalmic ASCs to not just survive, but to thrive in today’s competitive, budget-conscious, and regulatory environment. In this column I’d like to summarize a few of the highlights of the past year, as well as lay out some of OOSS’s objectives for 2023.
OFFICE-BASED CATARACT SURGERY
As you know, in 2022 a promoter of office-based cataract surgery proposed that the Centers for Medicare and Medicaid Services (CMS) should consider paying a facility fee for cataract, retina, and glaucoma procedures performed in physician offices. OOSS has absolutely and unequivocally opposed payment for office-based cataract surgery and other procedures since CMS first considered implementing such a program in 2015.
Throughout the year, OOSS raised its patient health and safety concerns with federal health policy makers, including in a meeting with representatives from CMS and the Office of Management and Budget. All the major ophthalmology and ASC organizations—AAO, ASCRS, AGS, ASRS, and the Ambulatory Surgery Center Association—joined OOSS in articulating the position that office facilities should not receive reimbursement unless they meet the same patient health and safety standards as ASCs. OOSS took other steps to improve understanding of this issue, such as:
- Developing a thorough comparison of Medicare ASC requirements versus office surgery standards, leading to the conclusion that patient health and safety is potentially compromised in the office setting.
- Submitting comments to CMS objecting to office cataract surgery reimbursement. Kudos to the many OOSS members who submitted individual comments to the agency as well.
- Conducting a comprehensive survey, with input from hundreds of ophthalmic ASCs, regarding the comorbidities associated with cataract patients. The results of this survey highlighted the need for application of rigorous patient health and safety standards, such as anesthesia, nursing care, emergency capabilities, and hospital transfer arrangements. Such mandates do not apply in the unregulated office surgical suite.
In a victory for our patients and our ASCs, CMS resoundingly rejected payment for office-based ophthalmic surgery, citing many of the concerns raised by OOSS and the ophthalmology and ASC communities.
LOOKING TO THE FUTURE
Where do we go from here? We can expect advocates for office surgery to become even more aggressive in pressing for payment for cataract and other procedures, perhaps as soon as this year. We would expect that the earliest serious reconsideration of this issue by the federal government would be the next Relative Value Update Committee review, which commences in 2025 for payment determinations in 2027. Notwithstanding the OBS promoters’ statements that payment is just around the corner, I would not expect that CMS would approve such a policy until the following conditions are met:
- Peer-reviewed clinical literature supports OBS patient health and safety.
- The major ophthalmology and ASC organizations support OBS.
- OBS facilities are subject to patient health and safety standards that are comparable to those applied to ASCs.
In addition, given the substantially higher economic and regulatory costs of building and operating an ambulatory surgical center, if OBS payment rates are ever approved they should be considerably less than ASC facility fees.
OOSS will continue to be vigilant in protecting the health and safety of our patients and will keep you abreast of all further developments.
ASC FACILITY PAYMENTS
A few years ago, CMS agreed to update ASC payment rates by the Hospital Market Basket rather than the lower Consumer Price Index-Urban. OOSS has been a leader in the effort to effectuate this change for over 20 years, seeking to persuade both CMS and Congress of its merits. Under this policy, during the five-year period from 2019 to 2023 ASCs have received the same payment rate as hospitals, subject to certain adjustments. However, we are entering the final year of the five-year period and CMS states that it intends to “update the public on our assessment of service migration and other factors” next year. OOSS will be aggressive in recommending that CMS maintain application permanently of the Hospital Market Basket in computing the annual ASC payment update.
Under this year’s final rule, ASC payment rates will be increased by 3.8 percent in 2023 (reflecting the hospital market basket index of 4.1 percent, less the multifactor productivity adjustment of 0.3 percent). This represents the 24th consecutive year of increases in ASC payment rates.
ASC QUALITY REPORTING
CMS administers the Ambulatory Surgical Center Quality Reporting (ASCQR) program, which requires ASCs to provide data on certain procedures. Last year, CMS finalized a rule that would have required ASCs to report on measure ASC-11, “Cataracts: Improvement in Patient Visual Function Within 90 Days of Cataract Surgery,” beginning in 2025. (Currently, ASC-11 is a voluntary reporting measure.)
OOSS vehemently opposed making ASC-11 reporting mandatory, noting that the measure is not related to an episode of care in the ASC, the data required is not available in ASC records, and the endeavor would not produce data that would be actionable to improve the quality of care in the ASC. In a positive development, CMS has decided to suspend mandatory adoption of ASC-11 due to the ongoing COVID public health emergency. OOSS will continue to lobby for permanent withdrawal of this misguided quality measure.
AND THAT AIN’T ALL…
Office-based surgery, increased facility payments, and changes to quality reporting are important topics, but OOSS has made progress on several other initiatives that will help ASCs in the future. They include:
- For each of the past few years, we have persuaded CMS to improve payments for intracameral drugs. OOSS and the ophthalmology community will be seeking a substantial expansion of this policy in the year ahead.
- We have forestalled efforts by MedPAC to require ASCs to file cost reports with CMS, a costly and unnecessary regulatory burden.
- More and more devices have been approved by CMS for payment above and beyond our basic facility fees.
- OOSS supports legislation that would eliminate the application of budget neutrality adjustments that artificially and arbitrarily reduce our payment rates.
- We will continue to fight in Congress and CMS for our long-term objective of “leveling the playing field” between the rates paid to ASCs and those paid to hospital outpatient departments.
The OOSS leadership and staff are grateful to you, our members, for your support of the organization. If you are not a member of OOSS, please join. Develop relationships with your legislators. Contribute to OOSSPAC, the only political action committee dedicated exclusively to the interests of our patients and our facilities. I am bullish regarding our prospects of continuing to improve the legislative, regulatory, and reimbursement environments for the ophthalmic ambulatory surgery center in 2023. OASC
