Office-based surgery coming sooner than you think

Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Mark Packer, MD, FACS, CPI. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Advanstar.

At Kaiser Permanente Medical Centers in California, Washington, and Colorado, ophthalmologists are performing cataract surgery in minor procedure rooms, with only a registered nurse assisting-no nurse anesthetist, anesthesiologist, IV, or injections-and are operating on both eyes of each patient on the same day in most cases.

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Surgeons say that patients love the convenience, and Kaiser is reaping the benefit of significant cost savings.1 

(Photo courtesy of National Eye Institute, National Institutes of Health)

At the 2014 meeting of the American Society of Cataract and Refractive Surgery, Kent Stiverson, MD, reported on the experience that he, David Litoff, MD, and others have had performing same-day bilateral cataract surgery in the minor procedure room of Kaiser Rock Creek in Lafayette, CO.

More than 20,000 cataract cases have been performed since 2006 in Kaiser minor procedure rooms in Colorado.  He states that 60% to 70% of these are performed in both eyes on the same day, using only topical anesthesia and oral sedation with sublingual Halcion.

“We have had no endophthalmitis,” he noted.

All bilateral cases are performed as strictly distinct procedures, with separately sterilized instrument trays and different lot numbers of solutions and medications, as well as new drapes, gloves, and gowns.[1]  Surgeons are also now performing glaucoma and corneal procedures in the minor procedure room as well.

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Of course, the vast majority of cataract surgeons in the United States do not perform same-day bilateral surgery in minor procedure rooms, perhaps because Medicare and commercial third-party payers only cover the facility costs for cataract surgery (CPT codes 66984 and 66982) in an ambulatory surgery center (ASC) or hospital outpatient department, and only pay 50% for any second procedure on the same day.

Next: Dr. Lindstrom: 'It will be up to us . . .  to responsibly do our surgery' 

However, the presence of these restrictions does not imply that surgeons would not perform surgery in this manner if it were financially feasible.  In fact, around the world, countries without a financial disincentive are witnessing significant utilization of same-day, bilateral surgery.

Daniel Durrie, MD, director of refractive surgery services at the University of Kansas Medical Center, Kansas City, has noted, “I am not doing in-office IOL surgery at the present time, but I will be. This is a movement. Femtosecond laser-assisted cataract surgery will drive more people to do in-office surgery because it automates parts of the procedure that were done manually. The new diagnostic technology, electronic medical records, and many other things are going to add to the overall quality and move us toward in-office intraocular procedures.”[3]

Richard Lindstrom, MD, past president (2007-2008) of the American Society of Cataract and Refractive Surgeons, has written, “I believe the primary barriers to moving more ophthalmic surgery into the office are more related to tradition, habit, and inappropriate regulation than anything evidence based. I expect these barriers to crumble as volume and cost-per-procedure pressures escalate for those procedures reimbursed by the government and other third-party payers. It will be up to us, the ophthalmic surgeons, to responsibly do our surgery in an environment safe for our patients. It can be in a major hospital, an ASC, an office, or even in an airplane, such as utilized by Project Orbis, or a tent, as utilized by our military on the front lines.”[4]

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At least one surgeon performing cataract surgery in a minor procedure room has been shut down.  After 21 years in practice, as of March 7, 2012, Lee Birchansky, MD, of Cedar Rapids, IA, is no longer permitted to perform cataract surgery in his office at the Fox Eye Laser and Cosmetic Institute.  Since 1998, nearly 10,000 surgeries had been performed at the institute in an office-based setting.[5]

As Outpatient Surgery News reported, “Dr. Birchansky's practice is no back-room operation-it has marketed itself on a local billboard-but the Iowa Department of Public Health sees it as an uncertified surgical center and has ordered it to stop providing cataract surgeries, fining it $20,000 in the process.”

At a recent appeal, state officials argued that the surgery required a sterile environment, which inspections had shown the office-based setting was not, and that cataract surgery was not often performed outside of surgical operating rooms.

Dr. Birchansky replied, “Laser surgery, blepharoplasty, vasectomy, and even cosmetic procedures were allowed in office settings.”[6] Lee Birchansky was also cited for “operating a surgery center without a certificate of need” and settled charges with the Iowa Board of Medicine on April 4, 2013.  He had attempted four times to get a certificate of need.[7]

Next: 'Appears to be a small, but growing trend'

Other surgeons, such as Cory Lessner, MD, and Andrew Shatz, MD, of Florida, are establishing office-based cataract surgery in their practices.  They note, “the idea of opening an office-based surgery center was born from the need to address two major concerns that we had: one financial and the other philosophical. On the financial side, building out an ASC that would follow Medicare's requirements for operating room size, elevator weight, egress, and others would have necessitated moving our cataract practice off-site, thus separating it from our LASIK center. This would have made it more difficult to share our technical and administrative staff, and would have unacceptably inflated our costs. Additionally, we felt that a cataract and premium IOL-only center could be run more efficiently, with a smaller physical plant and staff than an ASC.

“Philosophically, SightTrust Eye Institute has built its reputation as a premium lens center both by providing excellent surgical results and by creating a calming atmosphere for our patients. Since our office is accredited by the Accreditation Association of Ambulatory Health Care, as well as licensed by our state Board of Health, we are held to the same standards as ASCs. This should make it appealing for insurance companies to allow their insured members to use our center.”[8]

Office-based surgery for cataract extraction and IOL implantation appears to be a small, but growing trend, obstructed primarily by tradition and regulation.  Given the cost savings, efficiency, and increased patient satisfaction, the trend may soon become a movement.

However, surgeons should pay extremely close attention to safety requirements, particularly regarding same-day bilateral surgery.[9]  Liability issues may loom large for those who undertake innovative procedures without due preparation, documentation, and certification.  As I have heard Howard Fine, MD, one of the fathers of phaco, comment repeatedly, “The only difference between a buccaneer and a pioneer is two years.” 

References

[1] Personal communication.  David Litoff, Feb. 20, 14.

[2] Arshinoff SA. Same-day cataract surgery should be the standard of care for patients with bilateral visually significant cataract. Surv Ophthalmol. 2012;57:574-579. doi: 10.1016/j.survophthal.2012.05.002. Epub 2012 Sep 18.

[3] Durrie D.  Should surgeons perform intraocular surgery in their offices rather than in an ASC?  Ocular Surgery News U.S. Edition, March 10, 2012 http://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7B3af73e83-7997-4efa-be95-9f48e82c0c86%7D/should-surgeons-perform-intraocular-surgery-in-their-offices-rather-than-in-an-asc.  (Accessed Feb. 20, 2014). 

[4] Lindstrom RL.   As long as precautions are taken, in-office procedures safe for patients.  Ocular Surgery News U.S. Edition, March 10, 2012.  http://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7B06d1e509-f052-4c7a-b63c-88e6f2d473ac%7D/as-long-as-precautions-are-taken-in-office-procedures-safe-for-patients.  (Accessed Feb. 20, 2014).

[5]http://www.foxeye.com/asc.htm  (Accessed Feb. 20, 2014).

[6] State Rules Force Office-Based Surgeon Into Hospital ORs.  Outpatient Surgery News. March 7, 2012.  http://www.outpatientsurgery.net/surgical-services/office-surgery/state-rules-force-office-based-surgeon-into-hospital-ors--03-07-12.  (Accessed Feb. 20, 2014).

[7] Iowa CON Law Foils Eye Surgeon for the Fourth Time.  Outpatient Surgery News. Sept. 1, 2010.  http://www.outpatientsurgery.net/outpatient-surgery-news-and-trends/general-surgical-news-and-reports/iowa-con-law-foils-eye-surgeon-for-the-fourth-time--09-01-10.  (Accessed Feb. 20, 2014). 

[8] Negotiating Reimbursement in Office-Based Surgery Centers: Q&A with Dr. Cory Lessner and Dr. Andrew Shatz of SightTrust Eye Institute.  Becker’s ASC Review, June 1, 2012.  http://www.beckersasc.com/business-office-/-accounting-/-hr/negotiating-reimbursement-in-office-based-surgery-centers-qaa-with-dr-cory-lessner-and-dr-andrew-shatz-of-sighttrust-eye-institute.html.  (Accessed Feb. 20, 2014).

[9] See, for example http://www.omic.com/policyholder/what-is-omics-position-regarding-simultaneous-bilateral-cataract-surgery-sbcs/