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Comment & Response
July 2015

Effect of Conversion to Immediate Sequential Cataract Surgery on Ambulatory Surgery Centers in the United States in the Cost-Analysis Model

Author Affiliations
  • 1Eye Clinic PC, Jackson, Tennessee
JAMA Ophthalmol. 2015;133(7):856-857. doi:10.1001/jamaophthalmol.2015.0941

To the Editor An additional comment on the cost-analysis model comparing immediate sequential cataract surgery (ISCS) with delayed sequential cataract surgery (DSCS) in the United States from the societal and physician perspectives would be beneficial.1,2 Physicians were shown to have a decline in physician practice–derived income with a conversion to ISCS.2 Because many physicians have an ownership stake in ambulatory surgery centers (ASCs), an additional negative impact on physicians’ incomes could occur if ASCs experience a decline in profitability from ISCS conversion. The cost-analysis model was updated to examine the financial impact of ISCS conversion on ASCs.

The update used Medicare cataract surgery volume estimates,1 Medicare 2012 ASC cataract surgery fees ($874.59), and estimates of expense differences between ISCS and DSCS for a West Tennessee multispecialty ASC using the previous model’s data1,2 along with data obtained from the ASC. A 75% ISCS eligibility base case level was used.1,2 Eight DSCS cataract operations and 10 ISCS cataract operations per 4.5-hour half day were based on literature data.3 The 2012 surgical supply costs of DSCS and ISCS were compared using a microcosting method. Analysis of operating room (OR) personnel costs used a 1- and 2-OR scenario for DSCS and a 1-OR scenario for ISCS. A minimum and maximum cost method was used for preoperative, postoperative, and medical record personnel costs.

In the base case, the ASC had a $168 358.58 decline in revenue. A potential expense reduction of $16 891.86 to $36 404.98 using the minimum method or $30 288.17 to $49 801.29 using the maximum method did not offset this revenue loss. The cataract surgery supply cost reductions ($6.41/eye) and medical record cost reductions were minimal for ISCS. Total preoperative, postoperative, and OR personnel cost reductions were $19.96 to $45.30 per eye using the minimum method and $32.56 to $57.90 per eye using the maximum method and accounted for most ISCS cost reductions. Fixed costs were equivalent for ISCS and DSCS. A net margin loss of $118 557.29 to $151 466.71 occurred. No adjustment was made for increased OR availability with ISCS; however, significant additional surgical volume, if available, could potentially offset this margin loss. The ISCS eligibility level sensitivity analysis results are summarized in the Table.

Table.  Base Case and Sensitivity Analysis of Revenue Lost, Potential Expense Reductions (Minimum and Maximum Methods), and Net Margin Gain or Loss With Conversion to ISCS From DSCSa
Base Case and Sensitivity Analysis of Revenue Lost, Potential Expense Reductions (Minimum and Maximum Methods), and Net Margin Gain or Loss With Conversion to ISCS From DSCSa

With conversion to ISCS, ASCs will have a profit margin decrease. This will affect ASC physician owners’ incomes negatively, in addition to the negative financial impact on their practice incomes from ISCS conversion. Our current reimbursement system’s dual negative financial impact could increase the risk of gaming, supplier-induced demand, and physician resistance to ISCS with financial considerations trumping patient benefits.

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Article Information

Corresponding Author: Sean T. Neel, MD, MSc, Eye Clinic PC, 668 Skyline Dr, Jackson, TN 38305 (sneel@eyeclinicpc.com).

Published Online: April 23, 2015. doi:10.1001/jamaophthalmol.2015.0941.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Neel reported receiving compensation as medical director of and owner in Physicians Surgery Center, an ambulatory surgery center.

Additional Information: This article is an extensively revised and rewritten portion of an unpublished master’s thesis at the London School of Economics and Political Science to fulfill the MSc in Health Economics, Policy, and Management degree requirements.

Additional Contributions: Neal Rager, MBA, BS, and Kim Haynes, RN, Physicians Surgery Center, Jackson, Tennessee, assisted with data collection; they received no compensation.

References
1.
Neel  ST.  A cost-minimization analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the payer, patient, and societal perspectives in the United States.  JAMA Ophthalmol. 2014;132(11):1282-1288.PubMedGoogle ScholarCrossref
2.
Neel  ST.  A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States.  JAMA Ophthalmol. 2014;132(11):1359-1362.PubMedGoogle ScholarCrossref
3.
Arshinoff  SA, Chen  SH.  Simultaneous bilateral cataract surgery: financial differences among nations and jurisdictions.  J Cataract Refract Surg. 2006;32(8):1355-1360.PubMedGoogle ScholarCrossref
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