The remarkable changes that have occurred in ASC reimbursement must be viewed in proper context. The casual reader will focus only on the increased reimbursement. The intent of Centers for Medicare & Medicaid Services (CMS) in its ruling, however, is far more significant: The expanded access and linkage to hospital outpatient departments recognizes and validates the services provided in ASCs as on par with those in a hospital setting. In order to achieve this recognition, a community of passionate and dedicated organizations was necessary. Foremost among those organizations is OOSS. I have had the privilege of working with Michael Romansky, JD, who serves as Washington Counsel and Senior Lobbyist for OOSS, for the past few years. His devotion to providing ophthalmologists with the tools to allow for the best patient care is infectious. Mr. Romansky has agreed to detail the legislative history, its evolution, and its current implications in this column in two parts.
Three decades ago, virtually all surgical services, including cataract and other ophthalmic cases, were performed in the hospital. A confluence of phenomena resulted in surgery provided in the ambulatory surgery center (ASC) becoming the "standard of care." What transpired to so indelibly alter the surgical landscape? Technologically, in the late 1970s and throughout the 1980s, extracapsular cataract surgery and phacoemulsification, complemented by the broad adoption of IOLs, enabled surgeons to perform surgery with better results and reduced risk to the patient. Entrepreneurial ophthalmologists and surgeons in many specialties, frustrated with the hassles of operating in the hospital, sought control of the operative environment by developing and furnishing surgical care in freestanding centers. Moreover, in 1983, CMS issued a regulation, providing for the first time a facility fee (in addition to a professional surgical fee) to certified ASCs.
A BRIEF HISTORY
The program implemented a quarter-century ago was barely satisfactory. Medicare would pay for only those services that were specifically approved for conduct in the ASC environment; for years, the list was sparse and infrequently updated to account for new technology and innovations in surgical technique and anesthesia. Payment rates might as well have been pulled out of thin air: the government did not know how to develop a survey instrument that would garner reliable ASC cost data, ASCs did not know how to capture such data, and the green eyeshade types in the government were not enthusiastic about expanding rates. As such, base rates were unchanged from 1989 until 2008, and only rarely were ASCs afforded cost-of-living adjustments. For years, vitreoretinal services were excluded from the list of services that were eligible for facility reimbursement in the ASC. Moreover, once retina procedures were put on the list, payment rates were prohibitively low, necessitating their performance in hospitals.
I commenced representing the Outpatient Ophthalmic Surgery Society (OOSS) in November of 1983. At our very first meeting with CMS, just months after the advent of the new Medicare ASC program, we vehemently argued for major changes in the system. First, the surgeon, in consultation with the patient, should determine the appropriate surgical site, not the government. Second, ASC rates should be linked to those paid to hospital outpatient departments (HOPD) for the same services. Third, ASCs should be afforded the same annual payment updates as hospitals. It would take almost 25 years to fully accomplish these objectives. Yet, the ASC industry, led by ophthalmology, flourished from the outset.
THE CURRENT STATUS
This year, over 20 million procedures will be furnished in the nation's 5,200 ASCs, where patients will return home on the day of surgery and resume normal activities within hours or days. Regardless of the specialty of services provided in these centers, patients have flocked to ASCs because of superb surgical outcomes, the convenient patient-centered environment, and reduced out-of-pocket costs. Regardless of whether they have an ownership interest in the ASC, physicians relish the ASC because they enjoy greater control over staffing, selection of equipment and supplies, and administrative and operating room processes and scheduling. Payers have embraced ASCs because, virtually without exception, every procedure performed in the ASC results in lower expenditures than were the service furnished on an inpatient or outpatient basis in a hospital.
Nowhere has the proliferation of ambulatory surgery been more evident than in ophthalmology. In 2008, at least two-thirds of all cataract procedures will be performed in ASCs, the vast majority in the 750 to 900 facilities dedicated exclusively to eye cases. Why have so few vitreoretinal cases been performed in ASCs over this period? Can we expect this to change with new and higher Medicare facility payments for retina surgery? Will the revolution in the development of cataract-oriented ASCs transform into a new renaissance in outpatient ophthalmic surgery, highlighted by the migration of retina surgery from the hospital to the ASC? We will explore these issues in next issue of Retina Today.
Michael A. Romansky, JD, is Washington Counsel and Senior Lobbyist for OOSS. He has practiced exclusively in the area of health law for 30 years, representing healthcare providers, companies and organizations before Congress and all federal agencies with jurisdiction over health programs.
Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona and Founding Member of the Spectra Eye Institute in Sun City, AZ. He is a Retina Today Editorial Board member. He can be reached at pdugel@gmail.com.
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