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BLOG: How we will get to office-based surgery
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When a patient asks, “When can we do my surgery, doctor?” wouldn’t it be great if you could answer, “Have you got 15 minutes now?”
In the cover story of this issue of OSN, we discuss the coming reality of office-based pars plana vitrectomy surgery, which is already being practiced in limited environments. Previously we have explored office-based bilateral same-day cataract surgery in a cover story, which is increasingly practiced in Canada and at some U.S.-based Kaiser Permanente medical centers. Office-based surgery saves time for patients and physicians and costs much less than hospital or ASC-based surgery.
What will it take for this to become common practice in the U.S.? Here are three must-haves for office-based surgery to achieve widespread adoption:
1. A completely new regulatory/payer environment. What matters most is patient safety. Studies establishing standards for office-based surgery should continue in facilities already having success with these methods. Prospectively measuring patient outcomes should be mandated because safety outliers must always be identified. But we simply can’t burden a medical office with all the documentation currently required of ASCs or, worse yet, hospitals. We need to define what’s really important; infection rates and major adverse events are good starting points.
Medicare and other payers must also recognize and reimburse the value of office-based surgery, and the numbers must be high enough to incentivize even ASC owners to move their cases. Reimbursement will need to easily cover the cost of equipment, medications and expensive disposables. In other words, doctors need to feel pulled into rather than pushed into office-based surgery.
2. Better, more affordable equipment must become available. To do this, the FDA will also need to relax restrictions on equipment manufacturers, allowing simple but safe equipment to perform surgery for a few dollars per case. Reusable tubing, in widespread use all over the world as it used to be in the U.S., is a must.
3. Attitudes must change. If we can overcome the first and second barriers above, this may be easiest, but ASC owners must be open to office-based surgery as an opportunity rather than a threat. Surgeons must understand that we are raising rather than lowering our standards with this chance, and patients may need to be open to sharing in the cost of office-based surgery if it adds significant convenience for them.
The move of “major” eye surgery to the office setting will not only lower costs for the most commonly performed surgery in the United States — cataract — as well as vitrectomy procedures, it will also drive forward the adoption of lens-based refractive procedures and implantable contact lenses, in which the cost barriers are currently inflated because of the cost of doing them in operating rooms. It will accelerate our treatment of “dysfunctional lens syndrome” (earlier cataract surgery), which, when paired with improving implant technologies, will be good for both patients and surgeons.