Cedar Rapids doctor, state clash over cataract surgeries

At first glance, Dr. Lee Birchansky's in-office cataract surgery appears to be an innovative model for lowering health care costs, but state health officials don't see eye-to-eye with the Cedar Rapids ophthalmologist.

The Iowa Department of Public Health denied a rehearing on Birchansky's notice to perform the common procedure in his office at Fox Eye Laser & Cosmetic Institute, 1136 H Ave. NE, sending his staff scrambling last week to reschedule dozens of patients into hospital surgical rooms.

“We are open. We're seeing patients. We're doing surgeries that we normally do in the office,” said Birchansky, 53, who has practiced 21 years in Cedar Rapids. “What's changed is that we are no longer doing cataract surgeries in the office.”

The issue extends beyond the doors of Birchansky's clinic to the pocketbooks of patients and taxpayers.

Birchansky estimates saving his patients and Medicare $3 million in the three years he performed the procedure in-office.

Those savings, spread over 2,143 patients, are from the $1,000 to $4,000 in facility fees that hospitals and outpatient, or ambulatory surgical centers, collect, he said.

Most patients undergoing surgery for cataracts - a cloudiness that forms over the normally clear lens of the eye - are elderly, so Medicare picks up the tab ultimately paid by taxpayers.

The state, however, considers Birchansky's office to be an uncertified surgical center, built at a cost of more than $1 million.

State health officials fined Birchansky $20,000 and ordered him to cease performing cataract surgery at Fox Eye.

Center inspections

In 1997, eight certified ambulatory surgical centers operated in Iowa. Now there are 25, including one each in Cedar Rapids and Iowa City.

The centers, overseen by the Iowa Department of Inspections and Appeals, are for patients not requiring hospitalization.

Department spokesman David Werning said only centers participating in Medicare are subject to inspection.

Others could exist that do not have that oversight, he said, just as some doctors perform in-office procedures under their medical license that the department does not oversee.

Testimony at Birchansky's appeal on behalf of the state included a Minnesota ophthalmologist who said cataract surgery must be performed in a sterile environment and a doctor's office is not typically sterile.

The president of the Iowa Academy of Ophthalmology noted in written testimony that cataract surgery is only performed in surgical facilities and is not an office procedure.

Other surgeries

Birchansky countered that LASIK surgery - vision correction to the cornea using a laser - and cosmetic eyelid surgery are both performed in eye doctors' offices, where patients are in more convenient, comfortable settings and chances of hospital-acquired infections are lower.

Vasectomies, breast enhancement surgery and other procedures formerly performed in hospitals are moving into doctors' offices, he said.

Birchansky wasn't hiding his in-office cataract surgeries, as evidenced by a billboard on Interstate 380, near his clinic.

Polly Carver-Kimm, spokeswoman for the Iowa Department of Public Health, said the Iowa Board of Medicine and other accrediting bodies determine if a particular surgery is medically appropriate to be performed at a given location.

“The sole issue the department reviews is whether a certificate of need is required for a physician to perform the surgeries at the location,” Carver-Kimm wrote in an email. “If the type of surgery is ordinarily performed in a private physician's office a (certificate of need) will likely not be required. If the surgery at issue is not ordinarily performed in a private physician's office - like cataract surgery - a (certificate of need) to operate an outpatient surgical facility generally will be required.”

Birchansky has applied four times for a certificate of need with Iowa's Health Facilities Council, but was denied each time.

Those applications were cited in the department's review of Birchansky's appeal.

The purpose of the program is to avoid unnecessary duplication of services and to control medical costs, but Birchansky said in this case, the certificate of need is doing the opposite, creating a monopoly for larger institutes.

St. Luke's Hospital and Mercy Medical Center objected to Birchansky's applications, saying enough capacity already existed in the area.

Previously, Birchansky performed cataract surgery at his Advanced Surgery Center under an agreement with St. Luke's until he filed to do business on his own.

Birchansky said he will abide by the state's final order and only perform cataract surgeries in a hospital, but thinks Iowa should adjust as medicine evolves and as health care costs increase.

“I've seen how the system works,” he said. “I'm just tired of fighting.”