Over the last 50 years, our profession has witnessed a significant transition from hospital to outpatient surgery centers for routine ophthalmic procedures, including cataract, refractive, retina, cornea, and certain microinvasive glaucoma surgeries (MIGS). Currently, more than 86%1 of the 4 million cataract surgeries2 and most of the 200,000 glaucoma procedures performed each year3 take place in ambulatory surgical centers (ASCs). An additional 800,000 refractive surgical procedures are performed in the 1,000 laser vision correction centers throughout the United States.4
Today, we are seeing the next evolution in ophthalmic surgery as doctors pivot from ASCs to office-based surgeries (OBS). To date, there have been about 70,000 successful ophthalmic procedures performed in office-based surgical suites. This number is likely to grow because of the benefits surgeons and patients experience, especially for glaucoma, cataract, and refractive procedures.
What is office-based surgery?
Technically speaking, OBS refers to any surgical or otherwise invasive procedure conducted by a licensed physician in any location other than another licensed facility, such as a hospital or ASC. In the case of OBS, the location is typically a suite located within the treating physician’s office, where procedures such as cataract surgery, refractive lens exchange, oculoplastic procedures, and even minor glaucoma and retina surgeries can be performed utilizing minimal to moderate anesthesia.
OBS suites follow the same safety standards as ASCs and hospitals, are regulated in all 50 states, and operate under the physician’s license governed by the individual State Board of Medicine using either Class A (oral sedation, e.g., diazepam) or Class B (monitored) anesthetics. Just like hospitals and ASCs, OBSs are accredited by The Joint Commission, Accreditation Association for Ambulatory Healthcare, or The American Association of Accreditation of Ambulatory Surgery Facilities, all of which can qualify a facility for ophthalmic surgery.
Challenges that accelerated the OBS movement
Most ophthalmologists are familiar with scheduling challenges of hospitals and ASCs, whether having to accommodate the block surgical time assigned or dealing with a backup in the recovery bay that can disrupt an entire day’s schedule.
Compounding the scheduling crunch, the number of patients requiring outpatient surgery is growing as the “Baby Boomers” and “GenX” populations age. Today, over four million cataract surgeries are performed in the United States each year by about 9,000 ophthalmic surgeons.2 This number is increasing by 3-4% annually, and is expected to reach six million by 2030.7 At the same time, many ASCs are de-prioritizing cataract procedures in favor of more lucrative surgeries (many of them orthopedic), creating one of the greatest imbalances of supply and demand that our healthcare system has experienced to date.
Another challenge restricting access to hospital and ASC surgical time is anesthesiologist shortages. This is a greater concern than many realize; the Association of American Medical Colleges (AAMC) predicts that there will be a shortfall of 12,500 anesthesia providers in the United States by 2034, which is nearly 30% of the current number.8 That is likely to impact cataract surgeries and other procedures significantly in both hospitals and ASCs, where primarily Class B and Class C anesthesia are used for procedures.
Even ASCs are experiencing the squeeze that comes from an aging demographic and a waiting list for ophthalmic procedures. While there are more than 5,400 ASCs (with more than 1,000 specializing in ophthalmic surgeries), that number is insufficient to keep pace with projected demand.9
An additional benefit to office-based surgery is that it allows a physician to more rapidly integrate advancements in technology that can benefit patients. Hospitals and ASCs have extensive protocols for approving new technology or techniques. This can potentially result in delays or lost opportunities for ophthalmologists involved with phase 2 or phase 3 studies or premarket approval studies in the case of class 3 medical devices.
Hospitals aren’t always the optimal choice
OBSs will never completely supplant hospitals or ASCs, as there will always be scenarios involving complex conditions or comorbidities that require general anesthesia and greater levels of medical support. In such cases, ASCs and hospitals are the logical choice to perform these surgeries. However, the fact remains that millions of patients undergo routine cataract, glaucoma, retina, and refractive procedures each year, and hospitals simply aren’t equipped to handle such a demand on their resources. This is especially true in rural areas where generally, there are fewer options; hospital schedules can be impacted, ASCs may not be present or have a significant backlog, or patients may have to travel great distances. In such cases, OBSs can increase access to care, without unnecessarily exposing individuals to the potential for hospital-acquired infections.
Office-based surgery can enhance the patient experience
One of the biggest benefits of OBS for many surgeons is the improved comfort level afforded to the patients. Both hospitals and ASCs can induce anxiety for patients; they may have to visit a new location, don a surgical gown, have an IV inserted into their arm, receive strong anesthetics, and be attached to multiple monitors to continuously check vital signs. All of these clues compound the message that they are undergoing a major procedure. And since the body responds similarly to both physical and emotional stress,5 eliminating some of these factors can help to keep patients calm and relaxed.
Office-based surgery changes the current paradigm considerably. For example, patients typically see the same support staff as they would during a routine visit. Also, there is no need for patients to fast or receive strong narcotics. The patients are in a comfortable, familiar environment, and typically the only medications administered are mild sedatives and/or antibiotics, eliminating the need for extended post-operative recovery time.
Anesthesia level is the surgeon’s choice in OBS
The office-based surgery setting reduces patient anxiety from the start, leading to less need for sedation. OBS suites utilize either Class A or Class B anesthetics and follow national accreditation standards:
- Class A (Light oral sedation) – Patient monitoring is not required in any setting and there is no need for medical clearance. 99% of OBS cases are performed with Class A.
- Class B (IV or other monitored sedation) – Patients are monitored by a licensed anesthesia provider and must obtain medical clearance. Less than 1% of OBS cases are performed with Class B.
Many doctors are coming to the consensus that patients have long been over-sedated for some of the more routine ophthalmic procedures. Office-based procedures are just as safe as procedures performed in any other setting because the level of anesthesia is entirely appropriate to the procedure being performed. Ultimately, the less anesthesia given, the lower the risk of adverse responses to systemic anesthesia. With IV sedation, the breathing response decreases, there is less control over body movements, and patients can’t always follow directions well. Because of these factors and others, research shows that mild sedation is usually a better course of treatment for the patient.
For surgeries performed in a hospital or ASC, a Class B anesthetic is delivered through an IV, which can reduce the ability of a surgeon to have a conversation with the patient and communicate with them about what is happening once the drug is administered.
The vast majority of ophthalmic surgeries performed in OBS are performed with Class A anesthesia, virtually eliminating these risks and obviating the need for an anesthesiologist.
Research validates safety of OBS
While OBS is a relatively recent development, its utility has been validated in a recent safety and outcomes analysis with multiple data sets. A 2023 study6 by Kugler and associates found that the rate of adverse events for office-based cataract or refractive lens surgery is similar to or less than the reported adverse event rate for cataract surgery in the ASC setting.6 The study reviewed 18,005 cases of office-based cataract or refractive lens surgery performed at 36 clinical sites across the United States. The rate of postoperative endophthalmitis, toxic anterior segment syndrome, and corneal edema were 0.028%, 0.022% and 0.027%, respectively. Unplanned anterior vitrectomy was performed in 0.177% of patients. Additionally, 0.067% of patients returned to the OR, and 0.011% of patients were referred to the hospital.
OBS is primed for huge growth
Of the approximately 7,000 private ophthalmology practices in the US, less than 3% currently have an in-office surgical suite,10 signifying a huge growth opportunity in this niche. Not only has OBS been exceedingly positive for patients, it allows surgeons to seamlessly integrate both clinic and surgical patients within the comfort of their practices. Additionally, surgeons are free to select the equipment they wish to use, whether it’s the latest phacoemulsification machine, an intraoperative OCT, or an excimer or YAG laser.
Financial viability: Start-up costs and reimbursements
Office-based surgery is able to function at a lower overhead relative to hospitals and ASCs. These savings can be passed on to patients, especially those who desire premium IOLs. As most of us know, premium IOLs aren’t typically covered by third-party insurers like Medicare; when the procedure is performed in an ASC, patients may receive a bill for the IOL as well as additional bills for the facility and the anesthesiologist as well as any additional nurse anesthetist (CRNA) fees. When surgeries are performed within a practice, patients tend to receive a more inclusive estimate that covers – in the case of cataract surgery – the diagnostic exams, advanced technology lens, laser (when necessary), anesthesia, and all other costs in a single package without ancillary fees.
Doctors can typically be reimbursed for OBS from all major payors, including Medicare. However, reimbursement methods may be more complex since a national code has not yet been established. Instead of the traditional primary-national Medicare facility fee, surgeons receive a secondary-local reimbursement of the professional fee in addition to the standard professional fee. A billing consultant with office-based surgery expertise is highly recommended to navigate the complexities.
In this regard, iOR Partners provides comprehensive billing support, including reviewing every claim, providing required documentation, and helping to maximize your return.
iOR reimbursement mix:
- 39% Medicare
- 34% Medicare Advantage
- 27% Commercial
An OBS build-out is affordable
What may surprise surgeons is that building an OBS is easier on the budget than they might realize. While always a major investment, the cost to build an OBS will likely be far below the range of what it is to build an ASC. For some practices, the process may even be as simple as converting a 700-square-foot existing space such as a LASIK procedure room.
The second point that may assist ophthalmologists with their decision is that having an OBS suite doesn’t eliminate other options. In fact, the ability to perform surgeries in a hospital, schedule procedures in an ASC, and then come home to an OBS can maximize efficiencies and provide opportunities for practice and revenue growth.
iOR Partners builds turn-key solutions customized for your practice
iOR Partners is transforming healthcare by leading the movement towards office-based surgery with a rare model that aligns physicians, patients, and payors. Doctors can increase revenue per case and prepare for future growth, while iOR Partners helps providers make the transition with confidence. An iOR Suite® integrates clinic and surgery into one location to increase surgeons’ flexibility and improve the patient experience while providing the highest level of safety. From Joint Commission accreditation to OSHA compliance and staff training, iOR Partners handles every detail so that a proposed space can be successfully transformed into a surgical suite, including:
- Space planning
- Accreditation and compliance
- Quality assurance and performance improvement (QA/PI)
- Billing support
- Materials management
- Ongoing support for long-term success
Accreditation and compliance – iOR Partners’ highly trained team of experts removes the burden of accreditation from you and your staff. They ensure your new surgical suite adheres to the highest standards for OBS.
With iOR Partners, you can be up and running within 6 months. Plus, you save time and money by avoiding the pitfalls of creating an office-based surgical suite on your own.
Benefits of OBS for surgeons and staff
Beyond the logistical and scheduling hurdles solved by an OBS and the benefits patients experience, there are other lesser known advantages. For example, even the most skilled ophthalmic surgeon may encounter a case where a cataract cannot be removed completely, especially if trauma is involved, or if the cataract is very firm. When an unanticipated return to the operating room is necessary for a patient, it can be complex to negotiate the additional time, space, and anesthesia coverage in a hospital or ASC. The patient may have to wait and deal with discomfort or travel a distance back to an ASC or hospital.
In an OBS, the experience is very different. A patient can return to their familiar practice, and a doctor can likely see the patient immediately in the OBS to remove the retained fragment or treat any secondary condition that may arise after surgery. One of the other benefits reported anecdotally by surgeons is how much their staff appreciates working together in an OBS environment. When operating in a hospital or ASC, a surgeon may have to use hospital or ASC staff and technicians with whom they may not be familiar. In an OBS, the camaraderie that can make a practice so welcoming to patients and efficient to manage can also be leveraged into a streamlined OR team.
Even though this might require a new role for staff, many enjoy growth opportunities. Technicians may want to coordinate scheduling or help prepare patients for surgery. Another member of the staff may enjoy keeping up with new technology and taking a more active role in a practice subspecialty. Accompanying a patient on their surgical journey from beginning to end doesn’t just give comfort to patients—it also helps to make the staff feel autonomous and accountable, which can be empowering and lead to a positive work environment for all.
We are incredibly fortunate to be working at a time that offers so many unique advantages. While we will never eliminate hospital or ASC surgical centers for patients who need them, being able to offer an office-based surgical suite that can provide a greater level of comfort, convenience, and efficiency while meeting or exceeding safety standards is a wonderful opportunity for our patients, our staff, and ourselves.
Even when the project is finished, iOR Partners provides ongoing support for supplies, billing, coding, performance metrics, and other administrative functions needed for a successful program.
Learn more about how iOR Partners can create an office-based surgical solution for your practice.
* Dr. Hindman and Dr. Kugler are advisory board members and consultants for as well as stock holders of iOR Partners.
