This article is more than 5 years old. Information may no longer be current.
Ophthalmology continues to move toward ASC and office-based surgery
Click Here to Manage Email Alerts
In my now 40 years of ophthalmology practice, I have always had access to a hospital-based operating suite, an ASC-based operating suite and an office-based operating suite. I have also always done some minor surgical procedures in my clinic examination lane and worked in a hybrid, a corporate-owned ASC with HOPD designation and reimbursement. So, for me, I have five choices for every surgical procedure I schedule.
I started in Dallas in private practice from 1978 to 1980 and worked in several hospitals, an ASC designated as an HOPD (Mary Shiels Eye Hospital), and we had an office-based OR with a Zeiss microscope where we did minor intraocular procedures including limbal and pars plana needle posterior capsulotomies (pre-YAG laser era). We also did some minor procedures in our examination lanes. I then joined the faculty at the University of Minnesota for 10 years from 1980 to 1989. We also had all five OR environments available, and we used them all. In our office-based OR, we did many intraocular procedures including anterior chamber and vitreous cultures, intraocular injections, and glaucoma filtration revisions and needling.
Then on to Minnesota Eye Consultants for 28 years, where we still work in several regular hospitals, a corporate-owned ASC, the Phillips Eye Institute, which is a hybrid currently designated as an HOPD for reimbursement, eight MEC-owned ASCs, six office-based ORs and hundreds of examination lanes. So, having the option of doing surgery in a standard hospital, an ASC with HOPD reimbursement, a physician-owned ASC with ASC reimbursement, an office-based OR or even in my clinic examination lane is nothing new to me.
Our plastic surgeons and most ophthalmologists doing intravitreal injections are very comfortable doing lesion excisions and intraocular injections right in the standard office eye examination lane. So, how do we decide which of the five different OR environments to use for our surgical procedures? It is partially driven by case mix including complexity, equipment required, patient comorbidities and risk of complications such as infection. But my surgeon partners and I are as afraid of an infection after an intravitreal injection in the office or a sight-threatening corneal infection after LASIK or a cornel inlay in the office-based OR as we are of endophthalmitis after cataract surgery in our ASC or at any of the hospitals where we work. We do not use anesthesia standby for our office-based OR or examination lane procedures, but we routinely give oral sedatives and have a scrub nurse/technician and circulating assistant available, just as we do in the ASC and HOPD. Our air exchange and filtration is actually at a higher level in our office-based OR than in our ASC to reduce to a minimum the chance of diffuse lamellar keratitis after LASIK, and we employ similar standards for sterile technique.
I recently underwent right total knee surgery by a first-class group of orthopedic surgeons. They work both in a physician-owned ASC and in several hospitals. My surgeon encouraged me to have my surgery in the ASC because the infection rate for the same surgeons was 10 times lower in their ASC than in the hospitals where they also operate. I looked up the typical hospital-based infection rate for a total knee replacement, and in a high-quality institution, it is 0.4%. In many less experienced hospitals, infection rates approach 1%. In my orthopedic surgeon’s physician-owned ASC, it is less than 0.04%, more than 10 times less than the best hospitals, including those they personally utilize. In addition, their patient-reported outcomes/patient satisfaction scores are much higher for patients operated in the ASC vs. the HOPD, and the cost to the patient/insurer is 40% less per procedure. Same surgeon, same prosthesis, same community, a better experience, a lower risk of infection and 40% less cost. As my friend Eric Donnenfeld, MD, would say, “This is a pretty simple IQ test.” I had my surgery in the ASC.
From the ophthalmic surgeon’s perspective, for most of what we do, an OR is an OR is an OR. A cataract surgery is not the same as a heart transplant, nor is an intravitreal injection or LASIK the same as a neurosurgical brain tumor resection under radiographic control. With high-quality equipment, good assistants and excellent infection control, I do not care if I am in an office-based OR, an ASC with ASC reimbursement, an ASC with HOPD reimbursement or an HOPD. I would not do cataract surgery in one of my examination lanes, but on missionary trips I have operated in cruder environments than that with good outcomes. Blindfold me and drop me in behind the operating microscope with a patient on the table, and I could not tell you what facility I was operating in, nor would I care. I do still use anesthesia standby in my ASC-based intraocular procedures, but the OR in an office and the OR in an ASC, like the OR in a hospital, can easily be designed to accommodate the space and equipment needs of anesthesia standby. We do need a place to transfer the one per several thousand patients who suffer cardiac arrest or the like during surgery, but that is the same as for any dentist, other office-based physician or the public in general.
So, why do we operate in expensive ASCs and HOPDs? Not including the occasional need for management of a complex morbidly obese patient and those requiring high-risk general anesthesia or postoperative admission to the hospital, we do it out of custom and habit and because of perverse reimbursement incentive issues inherent in our complex health care payment system. The transition from doing most elective cataract surgery in a Medicare-certified ASC is a perfect example of how innovation in care delivery can achieve the federal government’s so-called “triple aim”: excellent patient outcomes, highly satisfied patients and reduced cost per unit of care. The typical facility cost for a cataract surgery in an HOPD or ASC designated as an HOPD is $1,795 per eye and in an ASC $975. Using cataract surgery alone at 4 million procedures per year in the U.S., that is a potential savings to the health care system of $820 per case times 4,000,000, or $3.28 billion per year. And that is only cataract surgery. Add in everything else we ophthalmic surgeons do, and it reaches more than $5 billion a year in potential savings.
So, at the risk of making some friends and a lot of special interests unhappy, if tomorrow I were designated America’s health care czar, I would just pay the same facility fee for cataract surgery no matter where it was performed. To ease the heartburn, I would pick a reimbursement number between what is currently paid in an ASC and HOPD for all facilities, not cram everyone down to the lowest fee in the category. Reasonable reimbursement is necessary to allow quality care and support innovation. While I am not a big advocate of overregulation, I would want reasonable oversight regarding quality standards in the ORs where cataract surgery is performed, but as we all know, what is reviewed today in most ASCs and HOPDs by our regulators is often not useful or relevant. It would be quite easy to follow simple outcome variables such as infection rate and readmission rate to any facility for complications within 90 days to compare the outcomes achieved in one OR type vs. another or even compare each of the 10,000 ORs where cataract surgery is performed one to another. I am confident an office-adjacent ASC or office-based OR would win hands down overall. We could also fairly easily follow patient-reported outcomes/patient satisfaction.
There is no doubt in my mind, whether we call it an ASC or an office-based OR, that the surgery suites that we ophthalmologists own adjacent to our offices would win on every parameter vs. any hospital and most corporate-owned ASCs: providing better objective patient outcomes, higher patient satisfaction and, until reimbursement is changed, a significantly lower cost. I see the trend in ophthalmology of moving away from the HOPD to an ASC or office-based OR as in motion, accelerating, appropriate and necessary. In smaller rural communities where volumes are too low to support a free-standing ASC, we will need a hybrid model, but patients can have outpatient surgery in an HOPD, and I have worked in many small community hospitals using mobile cataract equipment with excellent outcomes and efficiency. If reimbursement drops for HOPDs and ASCs receiving HOPD fees, it will be painful for those with HOPD reimbursement, but they will adapt or be replaced by standard ASCs and office-based ORs.
What my dentist puts me through when he does a root canal, tooth implant or crown using significant injectable, not topical, anesthesia — to me very invasive techniques including in some cases scalpels, lasers, drills, cautery and sutures — is much more invasive than the typical cataract or LASIK surgery I do every week. I am not saying it requires more training, more skill or more surgeon intensity, just that it is much more invasive. And the dentists do it with no anesthesia standby, a rare application of oral sedation, a single assistant, no post-anesthesia recovery room or nurse, good outcomes and a low complication rate. I see the future for the eye surgery facility environment, reimbursement incentives aside, as being much more like dental surgery than any other analogy. And dental surgery is done routinely every day in the smallest of rural cities with no nearby hospital. As with most megatrends, we each get to decide whether we will lead, follow or be forced to get out of the way. In my opinion, the near total transition to ASC/office-based eye surgery will take another decade, but those that ignore this trend will do so at much peril.