Eyeworld

3 EW NEWS & OPINION by EyeWorld staff ASCRS members split on whether they would perform in-office surgical suite cataract surgery October 2015 37% had no ownership of an ASC or HOPD. Surgical scheduling Of the respondents, 17% indicated that they currently have trouble scheduling cataract procedures in the facilities used. For those who had trouble scheduling cataract procedures in their current facility (76 people), 88.16% said they would consider performing cataract surgery in an office-based surgical suite, while 10.53% said they would not. Impact of Certificate of Need (CON) state laws Respondents also indicated if they lived in a Certificate of Need (CON) state, where it can be difficult to build an ASC depending on how strict the law is. Fifty-six percent do, while 44% do not. Similar to the overall results, it was very close to evenly split in those who do and do not live in CON states as to whether or not they would consid- er performing cataract surgery in an office-based surgical suite. For residents in CON states, 50.02% said they would consider performing cataract surgery in an office-based surgery suite and 48.81% would not. Meanwhile, in non-CON states, 50.07% would consider this option, while 47.76% would not. The next steps As noted above, CMS has not made an official proposal regarding office-based surgical suite cataract ASCRS conducted a membership survey to assist in developing a response to CMS' request for information on the topic I n response to CMS' recent request for information on office-based surgical suite cataract surgery, which was included in the 2016 proposed Medicare physician payment rule, ASCRS conducted a membership survey. The survey, which garnered 493 responses, asked members for their position on the issue, why they may or may not support it, and how and where they currently practice. ASCRS used the survey outcomes to develop its response to CMS' request for information on office-based surgical suite cataract surgery, which was included in its comments on the proposed rule. To reiterate, this was not a formal proposal, but a request for information. ASCRS' comments noted that in the proposed rule, CMS states as its reason for considering office-based surgical suite cataract surgery that "advancements in technology have significantly reduced operating time and improved the safety of the procedure and patient outcomes." ASCRS acknowledged it is true there have been significant advances in technology over the years, but cataract surgery is still surgery—and is a complicated procedure with a high surgical intensity. ASCRS went on to remind CMS that the patient population is usually very elderly, with comorbidities and significant medical issues. Therefore, patient safety is an important factor, and ASCRS cautioned CMS to think through all possible complications and issues associated with perform- ing this procedure when considering non-facility cataract surgery. ASCRS recommended CMS con- sider these issues, clarified some of their misconceptions, and identified additional issues. ASCRS members almost evenly split; patient safety is key The survey asked if respondents would consider performing cataract surgery in an office-based surgical suite if it was appropriately reim- bursed and permitted by state law. Responses from members were almost evenly split, with 52% indicating they would be willing to perform surgery in an office-based surgical suite, while 48% said they would not. Respondents were also asked about potential concerns and rea- sons that would keep them from performing cataract surgery in an office-based surgical suite. Concern for patient safety was the major reason respondents gave, with 64% choosing this option. Already owning an ASC was another reason that 21% indicated. Other reasons for not wanting to perform cataract surgery in an office-based surgical suite were the cost to set up and maintain regulatory requirements, reimbursement issues, concern that CMS would drive down non-office- based reimbursement and make it non-profitable, and several others. Specific concerns for patient safety included risks with anesthesia and infection; pulmonary, and cardiac issues; life support, wrong site sur- gery, fire safety; and the need for an anesthetist. As a result of the evenly split survey results, ASCRS did not take a formal position on office-based surgical suite cataract surgery, but recommended CMS consider addi- tional issues before moving forward. Specifically, ASCRS emphasized the high surgical intensity of cataract surgery and stressed the importance of patient safety due to the elderly patient population with comorbid- ities and significant medical issues. In focusing on patient safety issues, the comments explain the need for intravenous sedation, as an addition to local or topical anesthesia, that is carefully monitored by appropriate staff, including certified registered nurse anesthetists and anesthesiol- ogists. CMS inaccurately stated in the request for information that the anesthesia is only topical or local. ASCRS also discussed the need for appropriate infection prevention and control, which requires proper regulation of in-office surgical suites at both federal and state levels, as well as the development of certifica- tion requirements. In addition, CMS states "routine cases in patients with no comor- bidities could be performed in the non-facility surgical suite, while more complicated cases could be scheduled in the ASC or HOPD [hospital outpatient department]." However, ASCRS clarified in its com- ments that many complications do not arise until the cataract surgery is already taking place. Often, surgeons are unaware whether a particular cataract surgery will be complicated until they have begun the proce- dure. Since what may be considered routine initially may not turn out to be routine, all locations where cat- aract surgeries are performed would need to be equipped to deal with both complicated and non-compli- cated cataract surgeries, including in-office surgical suites. ASCRS also recognized some possible potential benefits, such as increased flexibility in scheduling for the surgeons who are currently performing surgery in either a multi- specialty facility or hospital outpa- tient department and convenience for the patient who only has to visit one location for all points of care. The survey also asked members for information on several other factors pertaining to current prac- tice, which were factored into the comment letter. Current surgical facilities When asked where they perform cat- aract surgery, 34% of respondents in- dicated that they performed surgery at an ophthalmic-only ASC, 24% used a multispecialty ASC, and 13% indicated an HOPD. Twenty-nine percent performed cataract surgery at one or more of these facilities. Of the respondents, 62% owned or had partial ownership of an ASC, while continued on page 11 If appropriately reimbursed and permitted by state law, would you consider performing cataract surgery in an office-based surgical suite? ASCRS analysis • For respondents who have ownership in an ASC or HOPD, 40.95% would consider performing cataract surgery in an office-based surgical suite; 57.33% would not. • For respondents who have no ownership in an ASC or HOPD, 65.88% would consider performing cataract surgery in an office-based surgical suite; 32.94% would not. No 48% Yes 52% Responses from members were almost evenly split, with 52% indicating they would be willing to perform surgery in an office-based surgical suite, while 48% said they would not.

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