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Up Front | Sep 2015

Office Space

Recently, the Centers for Medicare & Medicaid Services (CMS) provided its proposed 2016 Medicare fee schedule regulations. Deep within this document was a Request for Information on Non-facility Cataract Surgery.1 CMS states, “We believe that it is now possible for cataract surgery to be furnished in an in-office surgical suite, especially for routine cases. Cataract surgery patients require a sterile surgical suite with certain equipment and supplies that we believe could be a part of a nonfacility-based setting that is properly constructed and maintained for appropriate infection prevention and control.”

The agency goes on to argue that technology has advanced to the level where cataract surgery can be performed in an office setting, which CMS says offers potential advantages to patients in terms of convenience and potential savings to the Medicare system. The implication is that, without the regulatory and overhead burdens of an accredited facility, cataract surgery could be performed more cheaply. Because cataract surgery is the highest-volume surgical procedure performed on Medicare beneficiaries, it is an area of interest to CMS. Again, this is only a request for information, and there has been no CMS policy change regarding cataract surgery.

The disruptive concept of office-based cataract surgery will provoke strong opinions from all players involved. Obviously, many patients simply are not candidates for office-based surgery, owing to their overall health or the complexity of their proposed cataract procedure. That stated, CMS raises a valid point when many cataract procedures take place over the course of minutes under topical or intracameral anesthesia. Across multiple medical specialties, far more invasive medical procedures occur in offices every day. Furthermore, as technology has advanced in several specialties, procedures based in hospitals and ambulatory surgery centers have steadily migrated into an office environment. Cataract surgery, however, requires special attention to sterile technique, rigorous protocols for cleaning instruments, and strict guidelines regarding which medications can be placed inside the eye. If cataract surgery were to move to an office environment, high standards for all of these components of surgery would be vital.

Some owners of outpatient surgery centers have already expressed concern that the potential change could threaten their very existence. The owners cite patient safety concerns regarding the performance of surgery in the unregulated environment of an office. Hospital outpatient surgery departments have shared similar worries. Others have suggested that this CMS strategy is a covert way to lower the reimbursement for all cataract surgery. The simple truth is that CMS will soon face some stark realities regarding demographics and age-related conditions such as cataracts. With the number of cataract surgeries set to skyrocket over the next 2 decades, the agency has to do something to mitigate ballooning costs. The options include cutting professional fees, shifting costs to the patient, rationing services, or fundamentally changing the cost structure of outpatient cataract surgery.

Some practices have already embraced the concept of performing in-office cataract surgery in the same facility used for their laser vision correction procedures. There are sound arguments for upgrading a LASIK operating suite to serve this function, points ranging from the patient’s experience to the dual use of staff and expensive technologies like a femtosecond laser. There are also many hurdles. The regulatory environment regarding in-office surgery varies from state to state. Embarking on a project like in-office surgery introduces a completely new level of complexity to any practice, from inventory management of IOLs and other supplies to emergency protocols for complications.

The current state of cataract surgery will always be in flux. In 2010, CRST Editor Emeritus Stephen Slade, MD, and I joked that a meeting of the entire US user base for laser cataract surgery occurred when the two of us jumped into a taxicab. Today, things are very different, and 5 years from now, they will probably be more different still. Patients deserve cataract surgery at the current high level of safety and efficacy found in accredited facilities. Any fundamental change to the way the procedure is provided must demonstrate that it can meet that standard. If that can be achieved, the shift toward office-based surgery may only be a matter of time.

Steven J. Dell, MD
Chief Medical Editor

1. Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2016. Federal Register. July 15, 2015. http://1.usa.gov/1EFx4iV. Accessed August 20, 2015.

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