A Niagara Falls, N.Y.-based ASC performs retina surgery two to three times a month and could do much more.
“If we break even, it’s a miracle with retina,” Kimberly Fullone, administrator of Ambulatory Surgery Center of Niagara, told Becker’s.
Ms. Fullone said the center keeps offering retina surgery as a service to the community and to its own clinic’s patients, even though it doesn’t make money on the cases.
More than 70% of retina specialists reported difficulty getting enough operating room time, especially for emergency cases at night or on weekends, according to the American Society of Retina Specialists’ Preferences and Trends Survey.
Ms. Fullone said retina cases cost far more to perform than the cataract cases that fill most of the center’s schedule. Retina surgery relies on costly implants, silicone oil, gas and medications.
The center is paid roughly $2,500 per retina procedure, she said. Payers, including Medicare, don’t pay anything extra when the surgeon uses gas or silicone oil, so the center loses money on those cases, she said.
Medicare pays ASCs $2,203.87 in 2026 for vitrectomy, for example, according to figures compiled by the Outpatient Ophthalmic Surgery Society. CMS’ proposed 2027 payment rule would raise ASC rates 2.4% on average, but many ophthalmic procedures would see cuts. The vitrectomy rate would fall about 3% to $2,135.94. Final rates are expected in November.
Hospitals lose money on these cases too. Medicare pays hospital outpatient departments $4,222.95 for retinal detachment repair, against an average cost of $4,818.85, according to Retinal Physician.
“We would love to grow our center and do a lot more retina,” Ms. Fullone said. Payment levels won’t support it, she said.
Ms. Fullone has met with commercial payers to push for better retina rates, without success. Most of the center’s contracts are based on the Medicare fee schedule, so a low Medicare rate carries over to every payer, she said.
“If Medicare is paying bad for it, then everyone’s paying bad for it,” she said. “So it starts with Medicare.”
The center works with an outside billing company whose contract team has won better rates in other areas, she said. Retina remains out of reach.
“There’s a limit to what can be done, so it still doesn’t solve our retina problem,” she said.
Geoffrey Emerson, MD, PhD, then-president of the American Society of Retina Specialists, raised concerns about the 2026 final rule.
“We, however, remain concerned about the flawed APC methodology, which by design creates winners and losers,” he said, according to Retinal Physician.
With local centers unable to afford more cases, retina specialists are sending patients to Rochester, N.Y., about 90 minutes away, Ms. Fullone said. Getting a slot there is difficult.
Those delays matter most for retinal detachments. Ms. Fullone previously worked at a retina surgery center in Rochester, where patients whose detachment hadn’t yet reached the macula were brought in within four hours. Those patients have a better chance of regaining their vision.
Under the current system, that speed isn’t possible, she said. Delays can let the detachment spread over the macula and leave the patient with permanent vision loss.
“It’s really a disservice,” she said. “It really bothers me just because I know how important it is for those patients to have surgery right away, and if they would reimburse us, we would be willing to do it.”
Ms. Fullone said the current arrangement doesn’t save money either. Payers end up paying more to send patients to Rochester, and delayed cases can turn into more advanced surgery.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
