Reimbursement issues hold up widespread adoption of ISBCS
Click Here to Manage Email Alerts
Doctors worldwide are debating the risk-benefit ratio for immediate sequential bilateral cataract surgery, or ISBCS, vs. performing second eye surgery 1 or more days later.
I recently asked David Harmon at Market Scope for data on the current level of U.S. ophthalmic surgeon adoption of ISBCS. Rounded off for 2021, 9% are performing ISBCS, 13% are considering it, and a whopping 78% currently do not plan to adopt ISBCS. So, we are only at the innovator/early adopter stage for ISBCS.
As I talk with my partners and colleagues, the major barrier is not so much concerns about safety, but primarily challenges regarding reimbursement. Today, when practicing ophthalmology in the U.S., we all strive to use evidence-based medicine to create a personalized medical care plan for each individual patient. Twenty years ago, even 10 years ago, that was relatively straightforward, as we doctors simply selected the treatment plan we thought was best for each patient. Today, it is much more complicated, as we have a significant elephant-sized third party in the room, whether it be our offices or our surgery suites. That third party is the payer.
Every day with nearly every patient seen, doctors are forced to modify and adapt their treatment plan to the reimbursement specifications of their patients’ third-party payers. For the cataract patient, the payer is usually CMS. We all know that CMS facility fees for cataract surgery are approximately two times surgeon fees in an ASC and three times surgeon fees in a hospital outpatient department and, at best, one times surgeon fees in an office surgery center (OSC). Surgeon and facility fee reimbursements are critically important in cataract surgery, and current CMS guidelines create a significant penalty for the surgeon and the facility that choose to perform ISBCS or do surgery in an OSC. Reimbursement is the greatest current barrier to ISBCS and OSC adoption.
One of Charles Kelman, MD’s, famous quotes was: “Doctors debate, patients decide.” Such was the case for phacoemulsification, IOLs and laser corneal refractive surgery. On the debate side regarding ISBCS and OSC-based surgery, I find myself quite comfortable with both in noncomplex, uncomplicated cataract surgery. Immediate sequential bilateral eye surgery is not new to ophthalmology and is performed routinely by corneal refractive surgeons, oculoplastic surgeons and pediatric ophthalmologists, often in an OSC. I believe the safety and outcomes of modern-day cataract surgery support their use when selected by the patient with good informed consent.
What about the patient? Evidence is growing that when offered the opportunity, the patient preference is clear: ISBCS in an ASC or OSC. Experience in high-volume settings such as Kaiser Permanente, where ISBCS in an OSC is routine, and many VA hospitals shows that the vast majority of patients chose ISBCS over sequential cataract surgery days or weeks apart when offered the option. So, while we doctors are debating, I believe our patients have already decided. Unfortunately, our third-party payers have most of us and our patients in the reimbursement penalty box. So, perhaps today’s quote should be: “Doctors debate, but patients and their payers decide.”
I anticipate in the next decade that so-called alternative payment plans, increased enrollment in Medicare Advantage, increased capitated payment plans and perhaps a more enlightened CMS and commercial payer will modify our current cataract surgery reimbursement system to better support ISBCS and OSCs. If so, we can anticipate significant growth in both ISBCS and office-based cataract surgery to the great benefit of both the debaters and the deciders: surgeons, patients and payers.
Collapse
Click Here to Manage Email Alerts