Practice Management: Opening Doors
Winter 2025
by Liz Hillman
Editorial Co-Director
According to the 2025 ASCRS Clinical Survey, 49% of respondents perform surgery in an ambulatory surgery center (ASC), 26% at a hospital outpatient department, and 6% at an in-office surgical suite.1 Office-based surgical suites were up 2% compared to 2024.
The reason for growth in office-based surgery (OBS) for cataract procedures is multifactorial. The technology and techniques have improved to instill confidence in the safety and efficacy of office-based cataract surgery, with a growing body of data to support it. Economic and patient expectation factors are major influencers for OBS adoption among some surgeons as well.
Source: iOR Partners
Why an OBS
Rob Melendez, MD, MBA, built and began operating in an in-office surgical suite in 2020 because he wanted to offer patients a more personal experience than what he felt could be offered at an ASC.
“I wanted to create a premium practice,” he said, noting that he wanted a spa-like atmosphere that also offered the convenience of being in a familiar location with more availability for surgery (more surgery days). “The office-based surgery concept lends itself to an enhanced patient experience.”
Lance Kugler, MD, began performing office-based cataract surgery in 2017, primarily for economic, efficiency, and service-related reasons. Prior to OBS, he performed cataract surgery at an ASC but thought it didn’t offer patients the same level of service that his in-office LASIK patients experienced.
For ICL (STAAR Surgical), RLE, and refractive cataract surgery in the ASC, Dr. Kugler said he experienced complications around billing as cash-pay procedures. “Try as hard as they could, they couldn’t figure out how to handle the payments as seamlessly as we could in our own center. I also wanted to have control over the schedule. I had block time at the ASC, which meant I was limited and had to cram people into that day. In our OBS, we have complete flexibility and control over all of it.”
John Hovanesian, MD, and James Loden, MD, both operate at an ASC but shared how they understand the need and appeal for OBS among some surgeons.
“I’m a fan of the concept of OBS, although we don’t have one because we have a very effective ASC that we’ve had for 30 years that is an efficient place for us to operate as a practice, and it’s a part of our business that’s vital,” Dr. Hovanesian said. Some of the advantages he acknowledged of OBS are convenience and familiarity for the patient, continuity of office staff, and scheduling convenience.
Dr. Loden has two ASCs, but for a short period of time, while the second was being built, he performed surgery at an OBS. He specifically spoke about the advantage of OBS in certain states where a certificate of need (CON) is required for a new ASC. Nearly two dozen states have this requirement, making it more difficult to establish an ASC.2
“In states that have major CON restrictions, you basically have to do office-based,” Dr. Loden said. “There are many northeastern states where you cannot get a certificate of need, and you’re going to have trouble doing premium IOLs. You’re not going to have femtosecond lasers in a lot of hospital outpatient departments. You’re not going to have premium technology, and if you do, they’re going to charge you so much for it that you just about lose your profit margin.”
If you’re able to have an ASC, Dr. Loden continued, it’s financially beneficial because you can bill for the facility fee, something that’s not possible (yet) for OBS. Facility reimbursement for OBS has been proposed to CMS in prior years but has thus far been rejected.3
Dr. Hovanesian said for those who already own an ASC that’s easy to manage, that’s comfortable, and is providing good results, there’s not much reason to change to OBS. “But if you are looking at various regulatory, financial, and operational challenges there, and you think, ‘This ASC is not worth having,’ then maybe you do make the switch. … If you’re in a CON state, I’d probably build an OBS.”
Safety of OBS
You go to an external ASC, and no one knows the difference among the IOLs you’re using and what a diopter is or what plus is versus minus. But in our office, everyone knows how critical those things are. They’re all saying the same thing, speaking the same language.
Lance Kugler, MD
Several studies have established OBS as safe. A large-scale, retrospective study of 21,501 cataract surgeries performed at Kaiser Permanente in Colorado found “efficacy outcomes were consistently excellent, with a safety profile expected of minimally invasive cataract procedures performed in ASCs and HOPDs.”4 A retrospective study evaluating the rate of adverse events after office-based lens surgery performed at 36 private practices also found the rate of adverse events in the OBS setting to be more favorable than in an ASC setting.5 Per data presented at the 2025 ARVO Annual Meeting of 656 cataract surgeries performed at an OBS compared to 679 at an ASC, “office-based settings may be associated with a significantly lower rate of adverse events compared to ASC,” according to the abstract.6
“I’ve never had one infection in 5 years,” Dr. Melendez said. “And we’ve done nearly 5,000 surgeries.”
Some of the safety discussion involving OBS revolves around sedation. When operating at an ASC, Dr. Melendez said he had an anesthesiologist and nurse anesthetist. About 20% of his patients were receiving blocks and were heavily sedated. When he first started his OBS, he wasn’t using IV sedation, but he was prepared to do so if needed, with a nurse anesthetist on staff. After a year of only using oral sedation, he found he didn’t need the nurse anesthetist. “We still monitor the patient, even to this day, because I think that’s good medicine, and we want to make sure everyone is healthy and safe. … I still haven’t done an IV [in my OBS]. I haven’t done a retrobulbar block. It’s all been oral. I haven’t had one emergency yet, fortunately, so it’s been very safe and effective for me.”
Dr. Melendez said that coming to the same facility for consultation and preop testing makes patients less anxious for surgery. They know where to drive to. They know and recognize the staff. There is often a less “hospital-like” feel to the surgery rooms. Reducing patient anxiety in this way, Dr. Melendez continued, reduces the amount of sedation needed.
Dr. Kugler pointed out that IV sedation is feasible in an OBS setting if the surgeon prefers, and it is part of a higher-level discussion. “When a facility is designated as a safe place to do surgery, what does that mean? It means that the facility adheres to a list of protocols and standards that must be met to make that a safe place to do surgery,” Dr. Kugler said. “The term ASC is a Medicare term. It is nothing more than a list of standards that CMS came up with years ago that they determined made the space appropriate for multi-specialty surgery. Office-based surgery centers follow a similar list of protocols that have been optimized for safety and efficiency for ocular surgery. But there’s nothing magical that makes an ASC an ASC and an OBS an OBS. They are simply physical spaces that follow a list of rules and standards.”
An OBS, Dr. Kugler continued, in many ways, is better designed for ophthalmic procedures because it’s customized as such, while ASCs are often used for both ophthalmic and non-ophthalmic procedures.
“One of the disadvantages of ASCs are the onerous requirements that have no relevance to ophthalmic surgery. These extraneous requirements make them more expensive to build and establish, which is prohibitive for many surgeons. For practices that already have established, efficient ASCs, there typically is not a reason to switch to OBS.”
Dr. Kugler and Dr. Melendez acknowledged that some patients are not candidates for surgery in an OBS suite due to health conditions.
Setup and staffing
To Dr. Kugler, using a consultant experienced in setting up office-based surgery is non-negotiable. The other thing you need is a practice champion. “You need someone in the practice to really embrace the project. I don’t think you can just delegate it to the practice administrator and say, ‘Build us an OBS,’” he said.
Dr. Kugler encouraged this practice champion who is leading the charge to visit other OBS suites. He said there are “different flavors of [OBS], and you might have a different design or different ideas if you can see it in action.”
Dr. Kugler said he made use of the same staff running his laser center, training them when he began doing intraocular surgery in an OBS, and hiring a few additional people to augment.
“In my case, I don’t have overlap with the clinic staff as much, but some centers do. There are centers that use their clinical staff to cover their surgery as well, which is a model that can work. There are different ways to handle staffing, but OBS gives you flexibility because it’s your own facility,” he said, noting that the same could be done with an ASC as well.
Continuity of staff in an OBS is nice because they are more knowledgeable in ophthalmic procedures specifically. “You go to an external ASC, and no one knows the difference among the IOLs you’re using and what a diopter is or what plus is versus minus. But in our office, everyone knows how critical those things are. They’re all saying the same thing, speaking the same language. There’s consistency from start to finish, and so the entire process is better,” Dr. Kugler said.
Dr. Melendez said in his case, OBS lowered staffing costs because he uses the same staff in clinic and for the OBS. Cost savings also come from not having a separate facility. He likes the control over the atmosphere that OBS provides.
“When you see a surgeon taking a selfie with a patient after surgery in an ASC versus an OBS, the ASC always looks like they’re in the hospital. The OBS feels like a spa,” he said.
OBS expanding access
When you see a surgeon taking a selfie with a patient after surgery in an ASC versus an OBS, the ASC always looks like they’re in the hospital. The OBS feels like a spa.
Rob Melendez, MD, MBA
Dr. Kugler emphasized that there is a role for both ASCs and OBS, with each making sense in certain geographies and climates. In his view, OBS is expanding access to care.
“I get a lot of calls from surgeons in states that are certificate of need states, and they simply don’t have a way to start a surgery center. And they’re being pushed out of the ASCs that they’ve been going to because ophthalmology isn’t a great investment for a lot of open access ASCs compared to other specialties,” he said, adding that hospitals are also limiting OR space to ophthalmology because “it’s not working from a profitability standpoint.”
This coupled with a shortage of anesthesiologists and nurse anesthetists, which are often required by ASCs, is posing a problem for ophthalmologists. “I have some friends who cannot get cases on at ASCs because they don’t have the anesthesia coverage that they’re required to have,” he said.
“OBS offers another way for people to provide high-level surgery when access to ASCs and hospitals is limited,” Dr. Kugler said. “In a lot of these areas, OBS is a way that they can open access to more patients who need surgery.”
About the physicians
John Hovanesian, MD
Harvard Eye Associates
Laguna Hills, California
Lance Kugler, MD
Kugler Vision
Omaha, Nebraska
James Loden, MD
Loden Vision Centers
Nashville, Tennessee
Rob Melendez, MD, MBA
Founder/CEO
Juliette Eye Institute
Albuquerque, New Mexico
Relevant disclosures
Hovanesian: iOR Partners
Kugler: iOR partners
Loden: None
Melendez: Alcon, Bausch + Lomb, Zeiss
References
- 2025 ASCRS Clinical Survey.
- Becker’s ASC Review. These 12 states have CON laws that don’t restrict ASCs. www.beckersasc.com/uncategorized/these-12-states-have-con-laws-that-don-t-restrict-ascs/?utm_source=chatgpt.com. Accessed October 2,2025.
- Outpatient Ophthalmic Surgery Society. CMS Rejects Facility Reimbursement for Cataract and Other Ophthalmic Procedures in OBS. ooss.org/2022/11/01/cms-rejects-facility-reimbursement-for-cataract-and-other-ophthalmic-procedures-in-obs/. Accessed October 2, 2025.
- Ianchulev T, et al. Office-based cataract surgery: population health outcomes study of more than 21000 cases in the United States. Ophthalmology. 2016;123:723–728.
- Kugler LJ, et al. Safety of office-based lens surgery: U.S. multicenter study. J Cataract Refract Surg. 2023;49:907–911.
- Starns MJ. Complication rates of phacoemulsification with intraocular lens implantation surgery in an office-based setting versus ambulatory surgery center. June 2025. 2025 ARVO Annual Meeting.
Contact
Hovanesian: DrHovanesian@harvardeye.com
Kugler: lkugler@kuglervision.com
Loden: lodenmd@icloud.com
Melendez: rfmelendez@gmail.com
