Jerome H. Levy, MD, managing director of the Ambulatory Surgery Center of Greater New York, an ophthalmic ASC in the Bronx, and president emeritus of the Outpatient Ophthalmic Surgery Society, makes seven observations about the future of ophthalmic ASCs.
1. More cataract surgeries in ASCs. Surgery volume is rising as baby boomers age, and more of that surgery will flow into ASCs. About 40 percent of cataract surgeries are performed in ASCs now, and with professional fees stagnating, cataract surgeons are expected to move a greater proportion of their cases to ASCs, Dr. Levy says. Surgery centers have two big draws for cataract surgeons: ASC efficiencies will help them move their cases along faster and as surgeon-owners, they will be able to substantially supplement their income by capturing part of the ASC facility fee.
2. More retina surgery in ASCs. The Medicare facility fee for retina surgery was raised as of the beginning of 2011 and another increase is expected in 2012, meaning that more retina surgery is feasible in the ASC, and retina volume in ASCs is expected to rise.
3. Medicare cuts may not affect ASCs. There have been numerous proposals out of Washington to cut Medicare reimbursements, and Congress' debt reduction "super committee" will likely trim Medicare payments this fall. Dr. Levy expects that any Medicare cuts are more likely to affect professional fees rather than surgery centers, but he adds: "There are no guarantees that ASC rates will not be affected and that's why we must become involved in the political process."
4. Premium services won't boom in this economy. Sales of premium intraocular lenses and use of the new femtosecond laser, both of which require higher out-of-pocket payments from patients, cannot surge in this economy. "Our practice and ASC are in a lower middle income area and our patients don't have money for extras," Dr. Levy says. "The practice has a low premium IOL conversion rate, and ASCGNY is not interested in purchasing a femtosecond laser at this time. However, as the technology improves and the cost decreases, it may become more practical."
5. ACOs may have little impact. It is not clear how much accountable care organizations will affect ASCs. "We're just reviewing ACOs and we're not doing anything in a serious manner yet with them," Dr. Levy says. "The concept hasn't jelled well enough."
He thinks ACOs appear to be a lot like HMOs, which did not catch on in New York for commercial payment. However, the prospect of ACOs has spurred mergers and alliances in the area, such as the new alliance between North Shore/Long Island Jewish and Montefiore Medical Center/Albert Einstein Medical College in the Bronx. "If ACOs ever become dominant, they would favor large institutions," he observes.
6. ASCs need a better reimbursement model. CMS uses the CPI-U marker to update ASC payments, which provides consistently lower rates than the market basket rate applied to HOPDs, Dr. Levy says. This means that ASC payments, already 57 percent lower than HOPD payments, will continue to slip further behind. "The Outpatient Ophthalmic Surgery Society is deeply involved in trying to have ASCs included in the market basket update," he says.
7. Yag rates will fall. Rates for Yag capsulotomy, to correct lens capsule clouding after cataract surgery, are likely to fall more. "Many patients need a Yag after cataract surgery," Dr. Levy says. "It is likely that with the lower facility fee, it will still be efficient and profitable for this procedure to continue in the ASC."
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