Questions Remain About ASCs

What are the barriers that remain to moving more retinal surgeries into ambulatory surgical centers?

ANDREW E. MATHIS, PhD, MEDICAL EDITOR

Since F. Hampton Roy, MD, FACS, published his article¹ on vitreoretinal surgery in ambulatory surgery centers in the United States in the Summer 2006 issue of Annals of Ophthalmology, many retinal physicians have opened ASCs and the types of surgeries performed in ambulatory surgery centers have in creased. However, many large practices are still not building or adding ASCs. In this article, we'll try to figure out why not.

THE COST ISSUE

In his article, Dr. Roy identified the chief barrier to the growth of ambulatory surgery centers as cost. He proposed several routine cases that he saw as being possible for ambulatory surgical centers — surgical treatment of macular disease (macular hole, diabetic macular edema, etc.), nonclearing vitreous hemorrhage, "straightforward" diabetic retinopathy cases, and primary scleral buckle — but in advocating for 25-g surgery, the initial outlay that Dr. Roy suggested would be necessary came to more than $120,000, once vitrector, laser, and other supplies were included.

This figure has not gone down. According to Pravin U. Dugel, MD, an authority on ambulatory surgical centers, the cost of equipping an ASC for retinal surgeries ranges between $250,000 and $400,000.

The other major cost factor that comes into play when a practice considers adding an ambulatory surgery center is reimbursement. When Dr. Roy wrote his article, reimbursements were not given for intraocular gases, silicone or perfluorocarbon. In terms of procedures, while the outpatient reimbursement rate, for example, for retina repair with scleral buckle was $2,275.29 in 2006, the ASC reimbursement rate was only $717.

The preop room of a European ASC.

Thankfully, the reimbursement rates have gone up since new legislation was approved and went into effect on January 1, 2008. By the time that the new law is fully implemented, in 2011, the reimbursement for surgical repair of a detached retina will have gone from $1,136.36 in 2008 to $1,540.44, not adjusted for increases in the consumer price index (see Table 1). Dugel et al. also advise that an inflation increase in reimbursements should come after 2010.²

Furthermore, Dugel and colleagues3 warn retinal physicians against waiting for better reimbursement rates before opening an ambulatory surgery center, with the key point being that retinal physicians who practice in ambulatory surgery centers stand to gain an increase by 2011 of between 110% and 120% of their current reimbursement rates.

One possible way of avoiding costs is partnering with general ophthalmology practices or with anterior-segment specialists, who may be doing a large number of surgeries — mainly LASIK and cataract removal — already in ambulatory service centers. David F. Williams, MD, PhD, who is president of the American Society of Retina Specialists, wrote in a commentary in this magazine�s March 2009 issue that, in addition to being integrated into general ophthalmology practices, retina specialists could operate in ASCs that also specialize in such subspecialties as otolaryngology or podiatry.⁴

THE LOGISTICS ISSUE

Dugel and colleagues³ have addressed the "myth" that only "easy" cases can be performed in an ambulatory surgery center. They urge surgeons to evaluate the possible use of an ambulatory surgery center not on the complexity of the surgery to be undertaken, but rather on the physical condition of the patient, when evaluated by an anaesthesiologist.

Furthermore, in the last few years, the rates of intravitreal injections have increased dramatically. Moshfeghi et al.⁵ reported that, at the Bascom Palmer Eye Institute in Miami, intravitreal injections had increased from approximately 4,000 in 2005 to nearly 9,000 in 2007. There is good reason to assume that this number has increased in the last two years at academic medical centers and private practices across the country.

There is a downside to this increase, however, and this is based on the cost issue addressed above. According to coding expert Riva Lee Asbell, reimbursement for a single intravitreal injection, as a national average, is $179.97, while in the ambulatory surgery center it is only $84.76 — less than half. As the volume of injections in ambulatory service centers increases, the amount of reimbursement loss increases dramatically.

However, there would, in theory, be an equilibrium point at which the increased volume of intravitreal injections injections given in the setting of an ambulatory surgery center would offset the lost reimbursements. And, because intravitreal injections are among the least complicated surgical procedures (though by no means simple), some physicians may choose to give intravitreal injections in the ambulatory surgery center because they can increase the number of patients treated.

THE LEGAL ISSUE

Another commonly repeated myth that Dugel and colleagues³ cover is that investment in an ASC can cause a physician to run the risk of violating anti-kickback laws. The authors make it clear that federal guidelines have been established — so-called safe harbor regulations — to protect against this legal risk. This can be accomplished rather simply: As long as the physician-investor is the same person who performs the surgery on the patient referred to the ambulatory surgery center, the safe harbor regulations have been followed.

Another cause of concern for many physicians reluctant to open ASCs arose out of a case in New Jersey in 2007, where legislation was proposed that would have required ambulatory surgery centers to be partners with hospitals or university medical centers.⁶ While, on the one hand, this has been seen as an incentive for private practices to team with hospitals and medical schools, there are many retinal physicians in private practice who do not want to team with either.

CONCLUSION

The above impediments notwithstanding, the Practices and Trends survey conducted annually by the American Society of Retina Specialists reported that 34.18% of respondents are currently performing over 76% of their surgeries in ambulatory surgery centers, and 42% see it as probable that they will be performing surgeries most of the time in ambulatory surgery centers within three years. Already one-quarter of retinal physicians responding to the survey reported having a financial interest in a surgery center.

One major factor driving the move toward the opening of ambulatory surgery centers is the growing population of senior patients and the fact that many of these individuals will have serious retinal issues in the coming years. Thus, retinal practices will necessarily face a larger and larger population of patients seeking care, and ambulatory surgery centers can help to handle these increases by providing an alternative to out-patient hospital visits or office-based care.

However, while the aforementioned issues remain, to a great extent, unresolved, it is likely that the majority of patients will continue to be treated outside of ASCs. RP

REFERENCES

1. Roy FH. Vitreoretinal surgery in the ambulatory surgery center in the United States. Ann Ophthalmol. 2006;38:99-101.
2. Dugel PU, Romansky MA. Retina in the ASC: Challenges and opportunities under the new ASC payment system. Retinal Physician. 2009;6(2):22-25.
3. Dugel PU, Romansky MA, Charles S. Retina ambulatory surgery center myths debunked. Retinal Physician. 2008;5(1):48-52.
4. Williams DF. Am American perspective. Comment on "Improving your OR efficiency." Retinal Physician. 2009;6(3):30.
5. Moshfeghi AA, Flynn HW, Murray TG, et al. Rate of endophthalmitis following intravitreal injections in the anti-VEGF era. Paper presented at: Annual Meeting of the American Society of Retina Specialists; December 1-5, 2007; Palm Springs, CA.
6. Blesch G. Navigating around ASCs' legal hurdles. Modern Healthcare. November 24, 2008:28.