5 Trends Affecting the Future of Ophthalmology in Surgery Centers

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Mark Packer, MD, FACS, CPI, ophthalmologist at Oregon Eye Surgery Center in Eugene, Ore., discusses five issues impacting the future of ophthalmology in the ASC setting.

1. Technological developments in cataract surgery. According to Dr. Packer, one of the most significant changes in surgery center ophthalmology comes with the introduction of the femtosecond laser. "The laser essentially automates the principle steps of cataract surgery that are traditionally done by hand," he says. "It's going to change the way we do cataract surgery because the technique is so different. There's no question that we're moving in this direction." He says the biggest issues for ophthalmology-driven surgery centers, now that the femtsecond laser has been approved, are cost and adaptation. The laser is expensive (around $400,000) and large, an issue for surgery centers with limited capital and space. According to Dr. Packer, these obstacles to implementation might account for the limited use of the laser in surgery centers across the country. He says the movement toward femtosecond adoption will likely take place in the next five years. "In five years, it'll seem like it happened overnight," he says.

For Oregon Eye Surgery Center, adoption depends on adjusting workflows and financing the purchase. "We've got two rooms for cataract surgery, and we'll put the laser in one of those rooms," he says. "I know [other surgery centers] are thinking about having the laser outside the operating room, since they perform all the steps of the procedure without violating the surface of the eye. You don't need to be in a sterile environment to do that, so some have talked about having patients circulate past the laser." He says the surgery center is planning to purchase the laser toward the end of 2011, though the biggest obstacle is still the $400,000 price tag and cost of maintenance.

2. Rise of premium services. In 2005, Dr. Packer says CMS ruled that Medicare beneficiaries would be allowed to pay for extra services associated with lens implants that reduced or eliminated the need for eyeglasses or contact lenses after surgery. "Initially, in 2005, it was presbyopia-correcting lenses, and then it became toric lenses, which correct astigmatism," he says. He says the ruling means that providers can charge patients more out-of-pocket for "premium services" that enhance the services covered by Medicare. "This creates a kind of avenue to incorporate [equipment like] the femtosecond laser, because the thinking is that the outcomes with the laser are going to be better, and since the laser is expensive, we don't have any way to pay for it out of standard Medicare reimbursement," he says. "But if we incorporate the use of the laser for patients undergoing surgery for presbyopia and astigmatism, we can build the cost of the laser into the cost of performing those services."

He says he expects the provision of "premium services" to increase as physicians struggle to survive on current reimbursement rates. "We can offer these premium services that are paid out-of-pocket, and that creates a whole separate revenue stream that provides great value to patients and high levels of satisfaction," he says. "It's kind of akin to a plastic surgeon who may do reconstructive work that is covered, but also does all these cosmetic, non-covered, out-of-pocket procedures." He says these services may help physicians survive as Medicare reimbursement rates continue to drop.

3. Age and volume of cataract surgery patients.
Dr. Packer says he has seen an increase in younger cataract surgery patients, or patients who choose to undergo cataract surgery before age 65. "People elect to have surgery earlier because it's perceived as safer," he says. "They think, 'Why should I put up with difficulty driving at night? My neighbor had it done and had a great outcome.' I think we'll see a bit of a downward drift in mean age for cataract surgery."

He says despite the increase in younger patients, however, the majority of cataract patients are still over 65, the age at which Americans become eligible for Medicare. As the baby boomer population approaches retirement age and the number of insured Americans increases following health reform, he says he expects to see an increase in patient volume — though it may not be the drastic leap that some expect. "Here in Oregon, it's more of a gradual rise," he says. "It's not like we're going to double our volume this year. I think we will start to see a more gradual increase as the population ages and a positive flow of retiring people comes to the area."

4. Increasing use of EMR. A 2006 study by the American Academy of Ophthalmology showed that 12 percent of surveyed practices had EMR systems in place, with 7 percent in the implementation process and 10 percent with plans to implement EMR within the next 12 months. Dr. Packer says while those numbers have undoubtedly increased in the last five years, he still believes the percentage of EMR adoption among ophthalmologists to be relatively low. "The vast majority still have that hill to climb," he says.

He says ophthalmologists implementing electronic medical records should prioritize integration with the surgery center or hospital system. "It really was important for us to have our clinical system fully integrated with our ASC system," he says. "I was visiting a major academic medical center recently, and I was horrified to find out that the EMR used in their clinics was different from the one used across the street at the surgery center." Dr. Packer says when he wants to schedule a cataract surgery, it takes "two clicks" to create an H&P and an order set, and the surgery is communicated immediately. He says if ophthalmology-driven ASCs expect to see an increasing volume of patients, they need to prioritize EMR implementation to improve patient flow.

5. Stricter Medicare regulations. Regulations introduced by Medicare in May 2009 will almost certainly impact surgery centers; Dr. Packer's ASC has already undergone an inspection that the center passed with flying colors. The regulation changes and impending inspection meant that the ASC had to tweak several processes to show compliance, Dr. Packer says. "We instituted additional documentation for infection control, and we had to start having more frequent meetings of our QA committee with more minutes produced," he says. "We also had to buy new autoclave trays with the covers locked down. We had been carrying instruments in an open tray."

He says while the center had to change very little in terms of patient care, there were some necessary fixes. "The way we had been doing our YAG laser procedures, we hadn't been admitting the patients and checking their vitals. We have to do that now," he says. "We had to hire another half-time equivalent nurse to make everything work out." In order to prepare for the survey, the center hired a consultant to perform a mock audit and outline the ASC's deficiencies. Dr. Packer says the investment paid off when the surgery center passed the inspection with zero deficiencies.

Related Articles on Ophthalmology:
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Tiny, Injected Robots Could Revolutionize Eye Surgery


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