July 19, 2016
4 min read
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Office-based cataract surgery: Pros and cons of a controversial idea

Melissa Toyos, MD, FACS, explains why she thinks the time has come for office-based cataract surgery.

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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

The concept of in-office cataract surgery has garnered much attention recently. While there are many perceived benefits to this, there are also numerous drawbacks. This month, Melissa Toyos, MD, FACS, discusses the pros and cons of office-based cataract surgery. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

The hardest part about talking about office-based cataract surgery is that the term itself means different things to different people. Just say the words “office-based cataract surgery” and some people immediately envision illicit backroom operations with untrained staff, sketchy lighting and an anesthesia program consisting of a single Valium rolling around in a soufflé cup. To others, office-based cataract surgery means an accredited ambulatory surgery center housed within an existing ophthalmology practice, an entity that can couple the benefits of a proficient specialty staff with the convenience of a clinic. To many, the concept also includes the possibility of same-day bilateral procedures.

Melissa Toyos

Office-based cataract surgery has been a theoretical controversy for many years, and surgeons were understandably wary. Patient safety has been cited as the overall biggest concern. How do you guarantee a “routine” surgery? Many studies show that even “routine” cataract surgery patients have one or more comorbidities. Can ophthalmologists alone handle the liability of routine cases that go awry? The skills needed to interpret rhythm strips and run codes atrophy if unused, and most ophthalmologists abandoned them decades ago when they left their internships for ophthalmology residency. Another reason office-based cataract surgery has been slow to leave the gate is that surgery centers required significant investments of time and money to staff and comply with safety and compliance regulations imposed by Medicare and other agencies. Many surgeons have already made investments in existing centers and are comfortable with the processes and outcomes of operating there. The proverbial elephant in the surgery center is, of course, the current Medicare reimbursement model. As it stands now, CMS pays surgeon fees for cataract surgery in hospitals, ASCs and offices but does not pay facility fees for in-office cataract surgery. With decreasing reimbursements, it is hard to see how a business could remain afloat after eliminating this fee. Adding to that is the fact that Medicare pays for only 50% of the second eye cataract reimbursement when done on the same day, causing declining cataract reimbursements to go into outright freefall.

And yet declining Medicare reimbursements are precisely the reason why office-based cataract surgery is inevitable. In part because Medicare is out of money (with the situation worsening daily) and also because cataract surgery is one of the biggest budget line items within Medicare, in 2015 CMS itself began soliciting opinions on the feasibility and safety of office-based cataract surgery. Yes, it would have been easier to transition all or most of the 20% of cataract surgeries that are still done in hospitals to ASCs, but Kaiser took on the challenge of examining the economic feasibility and safety of office-based cataract surgery. In April, Kaiser published a consecutive, retrospective analysis of more than 21,000 cases performed in Colorado over a 3-year span. Understand that this is no lone cataract cowboy pushing the envelope; it is a large-scale health care company, and an HMO at that. And its results, published in Ophthalmology, were great.

Even though a little more than half of patients had hypertension and a quarter of them were diabetic, 100% of surgeries were completed with no life- or vision-threatening intraoperative or perioperative adverse events. Less than 1% of patients had a capsular tear, and fewer than that had vitreous loss. Postoperatively, less than 2% of patients were diagnosed with iritis, corneal edema or retinal pathology. Not one case of endophthalmitis was reported, and incidentally, a lot of money was saved in the process.

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So there it is. Medicare now has hard data of the largest U.S. study to date of office-based cataract surgery and is already formulating new policies and reimbursement models based on it. Third-party insurers will follow Medicare. The reality of office-based cataract surgery is already in play, and our task as physicians is to preserve patient safety and optimal surgical environments while adapting to the economic realities of our time.

The benefits of this new model are not strictly financial. Patients appreciate the convenience and the familiarity of their doctor’s office and not having to navigate a new or different health care setting. Doctors love the enhanced access and convenience. Office-based surgery may lower the hurdle for obtaining health care for those in outlying areas, and physicians and patients would no longer be constrained by existing certificate of need laws.

Besides Medicare, there are other factors pushing office-based cataract surgery to the forefront. Obamacare and other insurance trends mean that more people than ever before are paying more out-of-pocket costs for their health care. More people than ever before are paying higher deductibles, becoming aware of hidden insurance fees and finding themselves under- or uninsured. All of these patients would benefit from the cost savings of an office-based model. The move toward transparency means that patients themselves are deciding the value of their health care dollar. It is time to think together about office-based cataract surgery because I, for one, am not ready to let Kaiser out-innovate me.

Over the years, we have seen cataract surgery moved from hospitals to ASCs and now to the office. Stepwise changes in technology, the insurance industry, the economy and transparency have created the perfect environment for office-based cataract surgery. Now, evidence exists to prove that it can be done safely and effectively in an office setting. It is our task to manage the transition into this next chapter in cataract surgery.

Disclosure: Toyos reports owning part of an office-based surgery center, Green Hills Surgery Center.