Ophthalmology practices are discovering the benefits of office-based surgery
The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Ophthalmology 360.
By John Josephson, MD
Most doctors are familiar with the old maxim that guides the diagnostic process: When you hear hoofbeats, think horses, not zebras.
That phrase gained new meaning for me 2 years ago, when my ophthalmology practice became 1 of the first in the United States to step into the world of office-based surgery (OBS). While I might have been tempted to label our group a zebra, I soon learned that we were less exotic than we seemed.
While about 200 of America’s 7,0001 ophthalmology practices have created their own operating rooms (ORs), an OBS trend is clearly building across our field.
At least 2.5% of cataract surgeries are now conducted in the office,2 a significant proportion considering that this strategy was not even a consideration for ophthalmologists 5 to 10 years ago. The growing interest in OBS took the spotlight this fall when I and some colleagues were invited to speak about the concept at the American Academy of Ophthalmology (AAO) Annual Meeting.3
Ophthalmologists who have been practicing for more than a decade remember the transition of eye surgery from hospitals to ambulatory surgery centers (ASCs). Now, we’re witnessing a natural progression toward OBS—not only among practices like mine, which conduct cataract, cornea, and oculoplastic procedures in their offices but also among those that perform retinal surgeries on-site.
As an early adopter, I’m excited to help foster a growing dialogue about OBS by sharing my perspective about its potential to transform ophthalmology practice.
3 Reasons for the Growth of OBS
I was excited to see OBS included in AAO’s agenda because I believe the strategy will become increasingly crucial for ophthalmologists due to several factors that are changing our practice.
A national shortage of anesthesiologists
It has become quite challenging to book the services of anesthesiologists at ASCs, where most ophthalmology procedures are done. As of late 2022, according to the American Society of Anesthesiologists, 78% of ASCs were experiencing an anesthesiologist shortage.4
Even when these doctors are available, they tend to prioritize procedures like knee replacements, which require general anesthesia, over eye surgeries, which don’t. Fortunately, most routine ophthalmic surgeries can be done comfortably, safely, and effectively with topical anesthetics and oral sedation. Either strategy can be used in OBS suites, where surgeons have the advantage of being able to choose the level of anesthesia based on the needs of each patient rather than according to mandated facility guidelines.
Scheduling problems
With a growing population of older people driving increased demand for eye surgery in the United States, it’s becoming more difficult for ophthalmic surgeons to secure blocks of time in ASCs, with patients often waiting 2 to 3 months. The good news is that patients scheduling at OBS suites are likely to have shorter waits of 6 to 8 weeks.
In addition, ophthalmologists who have OBS suites are likely to find it much easier to fit in emergent cases. While we typically perform surgery 2 days a week at my mid-sized practice, we have no problem adding a half or full day when needed.
A desire for financial control
Practices with their own surgical suites don’t need to pay for time in the ASC, can conduct a higher volume of procedures for a better overall return, and can control their expenditures by negotiating the costs of everything from disposable cannulas to machines. This not only boosts profitability for practices but saves money for patients.
There may also be a cohesive Medicare reimbursement strategy on the horizon for ophthalmologists who offer OBS.
Currently, reimbursement for OBS is determined regionally. Instead of receiving reimbursement for surgery conducted in a facility under Medicare’s national Physician Fee Schedule, surgeons who operate in OBS suites are reimbursed under local Medicare Administrative Contractor codes in 12 jurisdictions. However, Medicare is expected to standardize OBS reimbursement nationally in the coming years.
Real-World Experience With OBS
At AAO, I shared my real-world experience in the OBS suite, both in a podium talk and as part of a panel discussion with other ophthalmic surgeons.
I noted that in the suite I share with my practice’s 3 other surgeons, we have completed over 1,500 surgeries—increasing to 80 to 90 per month recently. Across these procedures, we’re proud to have logged a 0% infection rate, a signal that OBS can match or exceed the safety of that conducted at an ASC.5,6
Having an in-house OR has also given us the freedom to expand our menu of surgical services without having to jump through the bureaucratic hoops of an ASC. For instance, when we decided to start performing corneal tissue addition keratoplasty in our OBS suite, we purchased the necessary equipment and were offering the procedure 2 months later.
So far, my colleagues and I have performed all office-based procedures without bringing in an anesthesiologist or a nurse, although we certainly would if that support was ever warranted. Instead, we rely on the skills of our 6 surgical technicians who rotate in to prepare our room and equipment and help attend to patients—the kind of strategy typically used during LASIK surgery.
This has distinct advantages, with cost-effectiveness topping the list. In addition, we prefer the reliability of our dedicated technicians to the traveling nurses we sometimes encounter at ASCs who may have trouble locating equipment during procedures. Fortunately, my practice has retained all our trained surgical technicians over the past 2 years—despite staffing shortages across our field—because they feel invested in our center and empowered by their work.
Patients appreciate our OBS suite just as much, telling us they’re glad to be able to eat and drink before coming in and not needing an EKG or an IV—for many, the most frightening part of surgery. They also love to relax in our massage chairs while they’re being prepared for procedures. Because we don’t use general anesthesia, our patients tend to be less groggy after their surgeries, enabling them to go home sooner.
Due to these factors, many of our patients self-select OBS—even if an ASC is closer to their home. Fortunately, we can almost always accommodate these requests, except in the cases of some patients with heart or unstable medical conditions who may benefit from the extra precaution of constant monitoring during surgery at an ASC.
Because patients tend to find the OBS suite less frightening than an ASC, they often perceive their surgeries in the office as minor. At our practice, that has helped drive a boost in premium procedures—a win for everyone involved.
Pursuing an OBS Strategy
Which practices should consider opening an OBS suite? Groups that conduct at least 15 surgeries per month—especially those engaged in premium lens work and looking to do more—are likely to find this strategy advantageous.
The main requirement is the ability to commit at least 700 square feet of space to an in-house OR. At my practice, our suite is 1,800 square feet.
While a full build-out is not necessary, practices will need to make some infrastructure changes, including the installation of seam-free flooring that discourages bacterial growth and the creation of sterile areas for instrument decontamination and sterilization. This can cost from several thousand dollars to over $100,000, depending on the project’s scope.
It’s also a good idea for practices to seek accreditation for their OBS suites, as we did in 2023. Earning the approval of an accreditation program such as The Joint Commission lets patients know that their doctors have pledged to uphold the same safety standards in every surgical setting.7
While ophthalmology practices can build and launch OBS suites independently, they can also work with a consulting team, as we do, for guidance. Collaborating with iOR Partners, a company that helps ophthalmology practices develop and manage OBS suites, made the launch of our OR a turnkey experience, from equipment to safety to accreditation. Through this ongoing teamwork, we’ve been able to run our OBS suite with the wisdom that comes from years of comprehensive experience.
We’ve been very happy with our outcomes, even finding that our OBS suite markets itself. Between our website and word of mouth, we’ve had many patients leave other practices to schedule in-house surgeries with us—often after an ASC canceled their procedures or hit them with exorbitant facility or anesthesia bills.
The Setting of the Future
As the national anesthesiologist shortage continues and Medicare considers adjusting reimbursements for office-based eye surgery, opening an in-office OR is becoming a more viable strategy for most ophthalmology practices.
While ASCs will remain a suitable setting, I envision that 30% to 40% of ophthalmic procedures will shift to the OBS environment within 5 to 10 years.
Ultimately, I won’t be surprised if OBS settings are established as the top location for surgeries across ophthalmology, as this premium experience boosts affordability and convenience while supporting the safety and effectiveness our patients have come to expect.
John Josephson, MD, is the founder of Eye Specialists & Surgeons of Northern Virginia and an associate professor of ophthalmology with the Georgetown University Residency program, where he devotes time each quarter to training surgeons. He also has a passion for participating in medical mission trips. Disclosures: Dr. Josephson is a consultant for RxSight and Ziemer. He is a consultant and a minor investor for iOR Partners.
References
- Nabity J. How to start a successful ophthalmology practice. Physicians Thrive. Updated July 18, 2022. Accessed October 17, 2023. https://physiciansthrive.com/private-practice/ophthalmology/#:~:text=There%20are%20roughly%207%2C000%20private,ophthalmology%20practices%20in%20the%20U.S.
- Market Scope Ophthalmic Market Perspectives. 2023:27(9).
- AAO 2024 Meeting Guide. Scientific Program Search. Accessed October 29, 2024. https://aao.apprisor.org/apsSearchES.cfm
- American Society of Anesthesiologists. Anesthesia workforce shortage poses threat to health care. June 17, 2024. Accessed October 25, 2024. https://www.asahq.org/about-asa/newsroom/news-releases/2024/06/anesthesia-workforce-shortage-poses-threat-to-health-care
- Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-based cataract surgery: population health outcomes study of more than 21 000 cases in the United States. Ophthalmology. 2016;123(4):723-728. doi:10.1016/j.ophtha.2015.12.020
- Kugler LJ, Kapeles M, Durrie DS. Safety of office-based lens surgery: a U.S. multicenter study. J Cataract Refract Surg. 2023;49(9):907-911. doi:10.1097/j.jcrs.0000000000001231
- The Joint Commission. Office-based surgery accreditation fact sheet. Updated 2024. Accessed October 25, 2024. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-office-based-surgery-accreditation/
