Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL


OUTPATIENT SURGERY


MEDICAL NECESSITY


AND QUALITY OF CARE


UWICES. 

Richard P. Kusserow 

INSPECTOR GENERAL 

FEBRUARY 1991 1-

qYd:m 
OFFICE OF INSPECTOR GENERAL


The mission of the Office of Inspector General (OIG), as madated by Public Law 95-452, as 

amended, is to protect the integrty of the Deparent of Health and Human Services ' (HHS) programs as well as the health and welfare of beneficiares served by those programs. This 

statutory mission is cared out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Services, the Offce of Investigations, and the Office of Evaluation and Inspections. The OIG also informs the 

Secretary of HHS of program and management problems and recommends courses to correct 

them. 

OFFICE OF AUDIT SERVICES 

The OIG' s Offce of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

caring out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and effciency throughout the Deparment. 

OFFICE OF INVESTIGATIONS 

The OIG' s Offce of Investigations (01) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiares and of 

unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 

administrative sanctions , or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG' s Offce of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Deparment, the 

Congress, and the public. The findings and recommendations contained in the inspections 

reports generate rapid, accurate, and up-to-date information on the effciency, vulnerability, and 

effectiveness of departmental programs. The report was prepared under the diection of 

Kaye D. Kidwell, Regional Inspector General, and Paul A. Gottlober, Deputy Regional Inspector 

General, Office of Evaluation and Inspections, Region IX. Paricipating in this project were the 

following staff: 

Deborah Harvey, 
 Project Leader Brad Rollin 

Mollyann Brodie Lead Analyst Alicia Simon 

Ruth Carlson W. Mark Krshat Headquarters 

Robert Gibbons Wayne Powell Headquarters 

Corrnne Harol Renee Schlesinger Region II 

Cynthia Lemesh 

Medical review was completed by Forensic Medical Advisory Service under a contract with the 

OIG. 
Department of Health and Human Services


OFFICE OF


INSPECTOR GENERAL


OUTPATIENT SURGERY


MEDICAL NECESSITY


AND QUALITY OF CARE 

f,RVICES' 

Richard P. Kusserow 

INSPECTOR GENERAL 

'0 1- OEI-09- 88-01000 

~qYd:m 
EXECUTIVE SUMMARY


PURPOSE 

This report compares the medical necessity and quality of care of selected outpatient surgeries 

rendered to a 1988 sample of Medicare beneficiares in ambulatory surgical centers (ASCs) and 

hospital outpatient deparments (OPDs). 

This report is the second in a series on outpatient surgery. The first report, issued December 

1989, discussed beneficiar satisfaction. 

BACKGROUND 

Over the past 8 years, the most common setting for surgery has shifted from the inpatient 

department of the acute care hospital to the OPDs and ASCs. In par, this shift has resulted from 

advances in medical technology (which have made the ambulatory setting a safer surgical 

environment), improvements in anesthesia techniques and decreases in the length of 

postoperative care. 

Although most outpatient surgery continues to be performed in OPDs, the number of ASCs and 

their share of the outpatient surgery market are increasing. From 1984 through 1989, the number 

of ASCs increased over 300 percent. Between 1988 and 1989 alone, the number of free-standing 

ASCs increased by 27 percent. As of April 1990, there were 1 177 Medicare-certified ASCs. 

The rapid ASC growth presented hospitals with a business challenge, to which they responded 

by increasing the number of OPDs providing outpatient surgery. Although the hospitals perform 

more outpatient than inpatient surgeries, they are losing their outpatient surgery market share to 

ASCs. The hospital share has decreased from 89 percent in 1984 to about 76 percent in 1989. 

Prior to 1985, outpatient quality of care was not under review by peer review organizations 

(PROs). Subsequently, several legislative bils expanded the PRO authority to include outpatient 

quality of care review. In April 1989, the PROs completed implementation of 100 percent 

pre procedure and 5 percent retrospective review of at least 10 nonemergency inpatient or 

outpatient surgical procedures. The surgeries selected for this inspection were performed before 

the national implementation of PROs ' preprocedure review. 

METHODOLOGY 

For this inspection, we selected 4 high-volume Medicare outpatient surgical procedures from 

10 States and reviewed the appropriateness of setting, medical necessity and quality of care for 

each surgery. We selected cataract surgery with intraocular lens (IOL) implant, upper 

gastrointestinal (GI) endoscopy, colonoscopy and bunionectomy. We identified the 10 States 

that had the highest number of ASCs and selected a random sample of 1 170 Medicare 
beneficiares, hal of whom had their surgeries in ASCs and half in OPDs. Since there were only 

eight bunionectomies in our sample, we excluded them from the analysis and have not included 

any information about them in this report. All procedures were performed between Januar and 

March 1988. We collected the medical records from both the surgeons and the facilities and 

used an independent medical review contractor to review the records. The contractor used 

physician specialists to develop the procedure-specific criteria. The physicians then reviewed 

each record for appropriateness of outpatient setting, medical necessity and quality of care. 

addition, we interviewed several professional medical associations and a sample of ASC and 

OPD physicians in each specialty to identify currently acceptable standards for medical necessity 

and quality of care. 

Based on information we received from Medicare carers, we identified 84 ophthalmologists 

who received more than $1 milion in 1987. We compared the medical necessity and quality of 

care for their patients with the patients of non-high volume ophthalmologists. 

FINDINGS 

The Outpatient Setting Was Appropriate. 

The medical reviewers determned that the outpatient setting was appropriate for 99.5 percent of 

the surgeries and inappropriate for only 0.5 percent. 

While Most Surgeries Were Medically Necessary, Reviewers Questioned More Than 

23 Percent Of Upper GI Endoscopies.


The reviewers determined that 23.3 percent of the upper GI endoscopies, 7.7 percent of the 

colonoscopies and 1.7 percent of the cataract cases were medically unnecessar. 

Approximately 14 Percent Of The Beneficiaries Had Poor Or Questionable Care. 

The reviewers determined that 85.6 percent of the beneficiares had adequate care 

7 percent had poor care and 11.7 percent had questionable care. 

High Volume Ophthalmologists Are More Likely To Provide Medically Unnecessary 

Services And Render Poor Or Questionable Care. 

High volume ophthalmologists (i.e., those who earn at least $1 milion annually) have almost 

twice the rate of medically unnecessar surgery and questionable care as non-high volume 

ophthalmologists. 
RECOMMENDATIONS 

The HCF A Should Add Upper GI Endoscopies To The PRO Review List Of 

Recommended Procedures. 

Our study revealed that more than 23 percent of the upper GI endoscopies were medically 

unnecessar and almost 6 percent of the endoscopy patients had poor care. Therefore, we 

recommend that HCFA should add upper GI endoscopy to the PRO preprocedure review list of 

recommended procedures. 

The HCF A Should Intensify Review Of High Volume Ophthalmologists. 

By intensifying review of high volume ophthalmologists, HCFA could more easily identify both 

questionable practice patterns and ophthalmologists who are providing unnecessar services or 

render poor quality cataract surgery. 

AGENCY COMMENTS 

The HCFA disagreed with the draft report s recommendations to (1) include upper GI endoscopy 

on the mandatory PRO preprocedure review list and (2) intensify the review of high volume 

ophthalmologists. According to HCFA, it would not be cost effective to mandate PRO review of 

upper GI endoscopies. The HCFA suggested adding the procedure to the recommended review 

list rather than the mandatory review list. According to HCFA, intensified review of high 

volume ophthalmologists is not necessar because the current preprocedure mandatory review of 

cataract surgery is sufficient. 

The complete text of the comments is contained in appendix D. 

OFFICE OF INSPECTOR GENERAL RESPONSE 

Based on HCFA's comments, we have modified our recommendation concerning upper GI 

endoscopies. Our recommendation now states that upper GI endoscopies should be included on 

the recommended preprocedure review list rather than the mandatory list. 

We continue to be concerned about high volume ophthalologists and believe that a more 

intensive review of their services is waranted. This could be accomplished in any of a number 

of different ways, including (1) a preprocedure PRO review that is more intensive than currently 

conducted, (2) a postprocedure PRO review, (3) establishment of carer screens that trigger preor postprocedure carer review or (4) a combination of any of the above or similar methods. 
...... .......... ........ ...... ...... ........ .... ............ .......... .... ...... ...... ........ ........ ...... ............. 

.......... ...... ............ ............... ...... ........ ..

TABLE OF CONTENTS


EXECUTIVE SUMMARY 

INTR 0 D U CTI 0 N 

FIND IN G S .................................................................................................................. 4 

The Outpatient Setting Was Appropriate ................................................ 

While Most Surgeries Were Medically Necessary, Reviewers Questioned 

More Than 23 Percent of Upper GI Endoscopies.......................................


Approximately 14 Percent of the Beneficiaries Had Poor 

or Q uesti onabl e Care .. 

High Volume Ophthalmologists Are More Likely to Provide


Medically Unnecessary Services and Render Poor


or Q uesti onabl e Care .. 

REC 0 MMEND A TI 0 NS ........ ................ ........ ........ ...... 

ENDNOTES........................................ .............. ........... 

APPENDICES 

Appendix A: Methodology .... ................................................................ .... .. - 1


Appendix B: Medical Review Criteria ...............................................B - 1


Appendix C: B i bliogra phy ........................................................................ C - 1


Appendix D: Agency Comments ............................................................... D - 1


Appendix E: American Society for Gastrointestinal 

Endoscopy Letter ................................................................. - 1 
INTRODUCTION


BACKGROUND 

Over the past 8 years, the most common setting for surgery has shifted from the inpatient 

deparent of the acute care hospital to the outpatient deparment of the hospital (OPD) and 

ambulatory surgical center (AS C). In par, this shift has resulted from advances in medical 

technology (which have made the ambulatory setting a safer surgical environment), 

improvements in anesthesia techniques and decreases in the length of postoperative care. The 

1983 changes in Medicare inpatient reimbursement under the prospective payment system (PPS) 

also contrbuted to the shift to the outpatient setting. 

Although most outpatient surgery continues to be performed in OPDs, the number of ASCs and 

their share of the outpatient surgery market is increasing. Since the Health Care Financing 

Administration (HCFA) first certified ASCs to receive Medicare reimbursement under the 

Omnibus Budget Reconciliation Act (OBRA) of 1980, the number of ASCs increased 

300 percent from 1984 through 1989. Between 1988 and 1989 alone, the number of 

free-standing ASCs increased by 27 percent. 1 As of Apri 1990, there were 1 177 certified ASCs 

in the Medicare program. The rapid ASC growth presented the hospitals with a business 

challenge. They responded by increasing the number of OPDs providing outpatient surgery. 

Although the hospitals perform more outpatient than inpatient surgeries, they are losing their 

outpatient surgery market share to ASCs. The hospital share has decreased from 89 percent of 

the market in 1984 to 76 percent in 1989. 

Medicare regulations do not specificaly define medical necessity or quality of care. The 

concepts are characterized as providing adequate care accordig to the practices of the medical 

community. Section 1862(a)(1)(A) of the Social Security Act states that no payment may be 

made under par A or par B for services that are not reasonable and necessar. In recent years, 

many professional organizations, such as the American Academy of Ophthalmology, have issued 

guidelines to their members outlining medical necessity criteria and suggesting standards of care. 

Prior to 1985, the peer review organizations (PROs) were not responsible for reviewing 

outpatient qualty care. Several legislative bils expanded the PRO authority since that time 

includig the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 and the Sixth 

Omnibus Budget Reconciliation Act (SOBRA) of 1986. The COBRA authorized PROs to deny 

payment for questionable care while SOBRA mandated PROs to review quality care in postacute 

and ambulatory care settings, including OPDs and hospital-affiliated ASCs. In April 1989, the 

PROs completed implementation of 100 percent preprocedure review of at least 

10 nonemergency inpatient or outpatient surgical procedures. The PROs were given this 

authority under Section 9401 of Public Law 99-272. Cataact extraction is one of two 

mandatory procedures. The PROs can choose 8 other procedures from a recommended list of 

11 surgeries, or they can select other procedures based on historical data. In addition, HCFA 

requires the PROs to review retrospectively the medical records for 5 percent of their 

preprocedure requests on a quarterly basis. The purpose of retrospective review is to verify their 

page 1

determnations of medical necessity. The surgeries selected for this inspection were completed 

before the national implementation of PRO preprocedure review. 

PURPOSE 

This report compares the medical necessity and quality of care of selected outpatient surgeries 

rendered to a 1988 sample of ASC and OPD Medicare beneficiares. This report is the second in 

a series on outpatient surgery. The fIrst report, issued December 1989, discussed beneficiary 

satisfaction. 

METHODOLOGY 

For this inspection, we selected four high-volume Medicare outpatient surgical 

procedures--ataract extraction with intraocular lens (IOL) implant, upper gastrointestinal (GI) 

endoscopy, colonoscopy and bunionectomy. Cataract extraction, the highest volume Medicare 

outpatient procedure, is the surgical removal of a lens that has become cloudy or opaque. The 

lens is most commonly replaced by an arificial lens (the IOL). Upper GI endoscopy is the 

visual inspection of the esophagus, stomach and small intestine using a flexible, fiberoptic tube 

inserted through the mouth. Colonoscopy is the visual inspection of the colon, which is a par 

the large intestine, using a flexible, fiberoptic tube insened though the rectum. A bunionectomy 

corrects the great toe displacement generally by surgically removing a bone wedge and 

realigning the toe. 

The universe consisted of 172 615 outpatient surgeries that were performed in 10 States between 

Januar and March 1988. These were the States with the highest number of Medicare-certified 

ASCs in February 1988. 

page 2 
10 STATES WITH THE MOST ASCs


We selected a random sample of 1 170 Medicare beneficiares, half of whom had their surgeries 

in ASCs and half in OPDs. We chose this sample size to satisfy specific statistical testing criteria 

which are detailed in appendix A. Due to the smal number of bunionectomies, we excluded 

these cases from all analyses leaving a universe of 1, 162 cases. Appendix A includes the details 

of the sample selection. 

We collected the medical records from both the surgeons and the facilities and used an 

independent medical review contractor to review the records. The contractor used physician 

specialists to develop the procedure-specific criteria for appropriateness of setting, medical 

necessity and quality of care. Members of the American Academy of Ophthalmology and the 

American Society for Gastrointestinal Endoscopy reviewed these criteria, and their suggestions 

were incorporated. The criteria for each procedure are included in appendix B. The medical 

reviewers then utilized the criteria and completed a narative assessment for each record. In 

addition, we interviewed representatives of several professional medical associations and a 

sample of ASC and OPD physicians in each specialty to identiy currently acceptable standards 

for medical necessity and quality of care. 

Based on infonnation we received from Medicare carers, we identified 84 ophthalmologists in 

our sample who received more than $1 milion in 1987. We compared the medical necessity and 

quality of care of their patients to the patients of non-high volume ophthalmologists. 

page 3

FINDINGS


THE OUTPATIENT SETTING WAS APPROPRIATE 

For the 90. 1 percent (1,047 of 1 162 cases) that included documentation, the reviewers assessed 

the outpatient setting as appropriate for 99.5 percent (1 042 of 1 047 cases) of all procedures and 

inappropriate for 0. 5 percent (5 of 1 047 cases). (See appendi A for detail concerning 

documented and undocumented records.) Physicians are not required to document in the 

medical record why they chose the ASC or OPD. However, the patient s history and physical 

test results wil be the basis for determning if a patient should be hospitalized. For our sample 

the medical reviewers determined if the outpatient setting was appropriate using objective 

criteria for each surgical procedure. The criteria included assessing the anesthesia category and 

the patient s level of illness. 

The outpatient setting was inappropriate for five beneficiares (0.5 percent)--ne cataract and 

four upper GI endoscopy patients. The medical review comments included the following: 

The patient has numerous medical problems. She was advised to discontinue her 

aspirin and Persantine, whether that was done with medical consultation is not 

clear from the chart, and this could have been dangerous in a person who has had 

carotid surgery three times. It is likely that this is not a good candidate for an 

outpatient setting. (ASC cataract patient) 

I am not certain that this outpatient setting, if the patient was this fragile, was 

correct, particularly since she was transferred to a hospital after the procedure.... 

(ASC upper GI patient) 

Overall, there was no statistically significant difference between the ASC and OPD sites for the 

inappropriate cases. 

There were no major differences between OPD and ASC patients in sex and average age. The 

breakdown by sex for each site was similar-35 percent male and 65 percent female in ASCs 

and 36 percent male and 64 percent female in OPDs. The average age was 75. 8 years for ASC 

patients and 76.0 years for OPD patients. 

The OPD patients in our sample were no sicker than the ASC patients. Sicker patients frequently 

have concomitant conditions, such as diabetes, hypertension or arhythmias. If such conditions 

exist, physicians exercise additional medical precaution when determining if the patient is a good 

outpatient candidate. Even though 31 percent of all sampled patients had concomitant 

conditions, the medical reviewers found no differences in the outcomes for these patients. Of the 

five patients who should have been inpatients, only two of them had concomitant conditions. 

There has been much publicity and concern expressed by the American Association of Retired 

Persons (AARP) and others that patients were being forced to the outpatient setting when they 

page 4 
............................................ ...................... ... ......................................... ...... . . . . . . . .

preferred to b hospitalized or should have been admtted because of their medical condition. In 

our telephone surey, 72 of 837 beneficiares told us they would have preferrd to stay in the 

hospital overnight. Of the 72 cases, 22 were ASC patients and 50 were OPD patients. 

Accordig to the medical reviewers, none of the patients ' physical conditions warted their 

admssion as inpatients. 

WHILE MOST SURGERIES WERE MEDICALLY NECESSARY, REVIEWERS 

QUESTIONED MORE THAN 23 PERCENT OF UPPER GI ENDOSCOPIES 

For the 96.6 percent (1 122 of 1 162 cases) with documentation, medical reviewers deemed 

93.9 percent (1,053 of 1 122 cases) of the surgeries medcaly necessar and 6. 1 percent (69 of 

122 cases) unnecessar. The medical reviewers analyzed the cases and determned whether the 

need for surgery was appropriately and adequately substatiated. The reviewers based their 

decisions on such factors as (1) the decrease in visual acuity caused by the presence of an 

opacity for cataact surgery, (2) upper GI distrss which persists despite an appropriate tral of 

therapy for upper GI endoscopy or (3) an abnormity identied by barum enema for 

colonoscopy. 

Reviewers determned that 23.3 percent (44 of 189 cases) of the upper GI endoscopies, 

7 percent (12 of 155 cases) of the colonoscopies and 1.7 percent (13 of 777 cases) of the 

cataract cases were not medically necessar. 

MEDICALLY UNNECESSARY SURGERIES


Distribution by Procedure


PERCENT 

20 

15 

1 0 

Cataracts Upper GI Colonoscopy


PROCEDURE


_ASC t?OPD 

page 5

The 44 unnecessar upper GI endoscopies were evenly divided between ASCs and OPDs. The 

usual symptoms which would necessitate the procedure include upper GI bleeding, diffculty in 

swallowing, persistent vomiting, persistent hearbur or a history of growths (polyps). The most 

common reasons why the surgeries were found to be medicaly unnecessar were 

(1) substantiation for surgery was inadequate (29.5 percent) and (2) symptoms did not justify the 

procedure (15.9 percent). Inadequate substatiation included cases where the patient did not 

have a tral of medical therapy prior to the procedure. Inappropriate symptom cases included 

ones where the endoscopy was used as a routine follow-up for a previously documented 

noncancerous condition. Our fmding of more than 23 percent unnecessar endoscopies is higher 

than the 17 percent reported in a Rand COrPoration study of Medicare patients who had 

diagnostic upper GI endoscopies in 1981.3 Approximately 77 percent of the cases were 

performed by gastroenterologists and 23 percent were performed by general surgeons and 

internists. 

The 12 medically unnecessar colonoscopies were alost evenly divided between ASCs and 

OPDs. Common reasons for performng a colonoscopy include rectal bleeding (technically 

called occult bleeding), chronic bowel disease, a history of chronic polyps or unexplained 

anemia. In our sample, the most common reason for medically unnecessary colonoscopies was 

that the symptoms did not justify the procedure (66.7 percent). For example, if the patient did 

not exhibit occult blood in a stool sample and there were no other symptoms, the reviewers 

deemed the procedure as medically unnecessar. 

While the overall rate for unnecessar cataact surgery was low (1.7 percent), the rate for the 

13 medically unnecessar cases vared between the sites- 7 percent for ASCs and 0.5 percent 

for OPDs. While this difference is statistically significant, the numbers are too small for any 

further analysis which adjusts for other factors such as age, sex or initial visual acuity. 

We found that medical necessity could not be determined solely on the beneficiary s reported 

symptoms. Of 113 upper GI endoscopy patients who reported symptoms such as heartburn and 

ulcers, medical reviewers determined that only 86 of their endoscopies were medically 

necessar. For the cataract cases, 3 percent of the beneficiares did not report symptoms, yet 

medical reviewers found that their surgeries were necessar. In addition, of 179 beneficiares 

who said that their cataracts did not hinder their daily activities, the reviewers found that 177 of 

the surgeries were medically necessar. 

APPROXIMATELY 14 PERCENT OF THE BENEFICIARIES HAD POOR OR 

QUESTIONABLE CARE 

For the 93.4 percent (1,085 of 1 162 cases) of surgeries with documentation, 85.6 percent of the 

beneficiares (929 of 1 085 cases) had adequate care, 2.7 percent (29 of 1 085 cases) had poor 

care and 11.7 percent (127 of 1 085 cases) had questionable care. Poor care is defined as care 

which does not meet the acceptable standards of the medical community. Two examples of poor 

care for cataract surgeries include (1) a case where the surgery was performed on the 

beneficiar s better eye and the surgery caused worse vision in that eye, and (2) a case where 

more than 2 months after surgery, the beneficiar had poor vision (Snellen test of 20/100). In the 

page 6 
latter case, the medical record indicated no reason for the poor vision, and no tests were 

performed to assess the cause of the problem. Questionable care was defined as some aspect of 

care which the reviewers did not find within acceptable standards, e. , if a cataract patient did 

not have the basic preoperative screens or if follow-up care was not rendered in a timely manner. 

Although ASCs had more cases of poor and questionable care than the OPDs, the difference 

between the sites was not statistically significant. The qualty of care rates for each procedure 

follow: 

Qualiy of Care Rates by Procedure 

ASC OPD OVERALL PROCEDURE 

CATARACTS 

poor 1.3 

questionable 16. 12. 108 14. 

adequate 299 81.3 324 86. 623 83. 

SUBTOTAL 368 100. 376 100. 744 100. 

UPPER GI ENDOSCOPY 

poor 7.4 4.4 

questionable 8.4 

adequate 84. 88. 161 86. 

SUBTOTAL 100. 100. 187 100. 

COLONOSCOPY 

poor 

questionable 1.3 

adequate 96. 92. 145 94. 

SUBTOTAL 100. 100. 154 100. 

TOTAL 540 49. 545 50. 1085 100. 

The upper GI endoscopies had the highest rate of poor care in both sites, 7.4 percent of ASC and 

4.4 percent of OPD cases. 

page 7


1.8 
.........................

. . . . . . .. . . . . . . . . . . . . . . . . . .......... . . . .................,................ ............... .....................__......

Intraoperative and Postoperative Complications 

The overal OPD intraoperative complication rate for the sample was over twice the ASC rate 

(2.4 percent versus 1.0 percent), which is statisticaly signcant Catarct intraoperative 

complications in our sample included vitrous loss from a posterior capsule tear and iris prolapse 

from the patient moving on the operating table. Complications durng cataract surgery occured 

in 3. 1 percent of ASC and 6. 1 percent of OPD cases. All introperative complications in both 

sites were resolved appropriately. 

Postoperative complication rates raged from 0.5 percent (1 of 202 cases) for upper GI 

endoscopies to 6. 1 percent (49 of 802 cases) for cataacts. There were only 2 endoscopy 

complications out of 360 upper 01 and colonoscopy cases. Durng the cataract postoperative period, reactions may occur which range from the expected (e.g., mid pai) to the severe 

(e.g., extreme pain from germ infection). The patient can minimze the expected reactions by

using nonprescription pai medication. The severe reactions can lead to serious infection or 

permanent loss of eyesight, if they are not treated in a timely manner with antibiotics or other 

medications. Medical literature does not contan many well-established or accepted cataract complication rates for different reactions. A few studies cited rates of 0.04 to 5.7 percent for the retention of large amounts of fluid in the cornea (corneal edema), less than 2 percent for 

inflamation of the eye cavities (endophthaltis) and 2 to 3 percent for separation of the thin 

lining at the back of the eye from the hard shell (retinal detachment). 

CATARACT COMPLICATION RATES


By Si te 

PERCENT 

6 ........... A"',_,-,"""'"


2 -.... 

Intraoperative Postoperative 

COMPLICATION TYPE 

_ASC OPD 

page 8

In our study, 6. 1 percent of cataact cases had postoperative complications, including protrusion 

of the colored part of the eye through a corneal wound (irs prolapse), hemorrhage within the 

anterior chamber (hyphema) and elevated ocular pressure. We found that the postoperative 

complication rate for the sampled ASC patients was 8.5 percent for cataract cases, while the rate 

for sampled OPD patients was 4.2 percent, which is statistically significant. Adjustments for 

age, sex and initial visual acuity had no effect on the complication rate. 

Cataract Cases Involving Questionable Care 

There were 127 questionable care cases. The highest number (108 of 127 cases) involved 

cataract surgeries. There are two main reasons why cataract cases were considered questionable: 

Inadequate preoperative tests-About 44 percent (48 of 108 questionable care cases) of 

surgeries were questioned because the medical record did not include documentation of 

basic preoperative tests, e. , A-scan, fundoscopy or tonometr. 

60-day preoperative screening-About 35 percent (38 of 108 cases) of questionable cases 

did not have preoperative ophthalmic screens completed within 60 days prior to surgery. 

The medical review criteria specified 60 days as the outside limit in order to have the most 

current data before surgery. In one case, the biometrc data used to measure the IOL 

power was documented to have occurred 5 years b fore the surgery. 

Of 32 patients who had surgery in both eyes, 17 had the surgeries within 30 days. Surgeons 

generaly do not operate on both eyes within such a short time span. The waiting period should 

allow healing in the fIrst eye and suffcient time to rule out complications, such as infection. An 

ASC patient is 3 times more likely to have both cataract surgeries within 30 days than an OPD 

patient (6 percent versus 2 percent). This practice was prevalent among a few physicians. These 

cases did not have higher rates of medically unnecessar surgery or quality of care problems 

than the rest of the sample. 

About 9. 1 percent of beneficiares did not have visual acuity improvement. We found that 

patients with poor or questionable care were less likely to have visual improvement than the 

patients with adequate care. There is a significant difference by site in the visual acuity 

improvement of the beneficiares. This difference may be accounted for by the difference in age 

and initial visual acuity. As the patients ' age increases, they were 1.4 times more likely to have 

the same or worse postoperative visual acuity. Older patients were almost five times as likely to 

have the same or worse postoperative vision if the initial visual acuity was 20/40 or better. 

In our beneficiary survey, 11 percent (55 of 522 cases) of cataract patients reported their vision 

was the same or worse after surgery. The medical reviewers, however, found that 25 percent of 

this group (14 of 55 cases) had no improvement in visual acuity. 

page 9

HIGH VOLUME OPHTHALMOLOGISTS ARE MORE LIKELY TO PROVIDE 

MEDICALLY UNNECESSARY SERVICES AND RENDER POOR OR 

QUESTIONABLE CARE 

About 22 percent (178 of 802 cases) of our sampled cataract patients had their surgery 

performed by high volume ophthalmologists, or ophthalmology groups. These providers 

received at least $1 millon from Medicare in 1987. Of the 255 ophthalologists the OIG 

identified as high volume providers nationally, 84 were in our sample. Sixty-four percent of the 

84 physicians are solo practitioners, and 36 percent are group practitioners. We conducted 

further analysis to determine whether the quality and medical necessity of the surgeries 

performed by high volume ophthalmologists differed from non-high volume ophthalmologists. 

While high volume physicians do not affect the differences between OPDs and ASCs, they do 

have a higher percentage of medically unnecessar, poor and questionable care cases. Within the 

OPD sample, they have a higher percentage of poor and questionable care than non-high volume 

ophthalmologists. Within the ASC sample, they are responsible for a greater percentage of 

medically unnecessar surgeries. In addition, ASC high volume ophthalmologists operate on 

patients with better preoperative visual acuity. 

Compared to non-high volume ophthalmologists, the surgeries performed by high volume 

ophthalmologists were:


twice as liely to be medically unnecessar (2.9 percent versus 1.3 percent-not 

statistically significant), 

twice as likely to be of poor quality (3.0 percent versus 1.4 percent-not statistically 

significant), 

more likely to be of questionable quality (19.9 percent versus 13.0 percent-statistically 

significant), 

less likely to have intraoperative complications (2.9 percent versus 5.3 percent-not 

statistically significant), 

more likely to have postoperative complications (8.6 percent versus 5.7 percent-not 

statistically significant), 

twice as likely to be performed on patients with a visual acuity of 20/40 or better 

(21.4 percent versus 10. 1 percent-statistically significant) and 

based on changes between pre- and postoperative visual acuity only, more likely to have 

the same or worse visual acuity (15.6 percent versus 7. 3 percent-statistically significant). 

page 10

.......................................................................................... ....................................................................................... ..................................... .

.............. ... ........... .... ..... ..........

COMPARISON OF CATARACT PROVIDERS


High Volume versus Non-High Volume


PERCENT 

100 

80 

60 

40 

20 

Questionable ) 20/40 Improved QOC Vision Vision 

MEDICAL REVIEW FINDINGS 

High Volume Non-High Volume 

NOTE: QOC. Quality of Care 

page 11

RECOMMENDATIONS


THE HCFA SHOULD ADD UPPER GI ENDOSCOPIES TO THE PRO REVIEW LIST 

OF RECOMMENDED PROCEDURES 

Currently, the peer review organizations review 10 inpatient or outpatient surgical procedures on 

a preprocedure and retrospective basis for quality of care. Cataract surgery is one of two 

mandatory procedures. Our study revealed that more than 23 percent of the upper GI 

endoscopies were medically unnecessar and almost 6 percent of the endoscopy patients had 

poor care. Therefore, we recommend that HCFA add upper GI endoscopy to the PRO review list 

of recommended procedures. 

THE HCFA SHOULD INTENSIFY REVIEW OF HIGH VOLUME 

OPHTHALMOLOGISTS 

By intensifying review of high volume ophthalmologists, HCFA could more easily identify both 

questionable practice patterns and ophthalmologists who . are providing unnecessar or poor

quality cataract surgery. 

AGENCY COMMENTS 

The HCFA disagreed with the draft report s recommendations to (1) include upper GI endoscopy 

on the mandatory PRO preprocedure review list and (2) intensify the review of high volume 

ophthalmologists. According to HCFA, it would not be cost effective to mandate PRO review of 

upper GI endoscopies. The HCFA suggested adding the procedure to the recommended review 

list rather than the mandatory review list. According to HCFA, intensified review of high 

volume ophthalmologists is not necessar because the current preprocedure mandatory review of 

cataract surgery is sufficient. 

The complete text of the comments is contained in appendix D. 

OFFICE OF INSPECTOR GENERAL RESPONSE 

Based on HCFA's comments, we have modified our recommendation concerning upper GI 

endoscopies. Our recommendation now states that upper GI endoscopies should be included on 

the recommended preprocedure review list rather than the mandatory list. 

We continue to be concerned about high volume ophthalologists and believe that a more 

intensive review of their services is waranted. This could be accomplished in any of a number 

of different ways, including (1) a preprocedure PRO review that is more intensive than currently 

page 12

conducted, (2) a postprocedure PRO review, (3) establishment of carer screens that trgger preor postprocedure carer review or (4) a combination of any of the above or similar methods. 

page 13

, 

ENDNOTES 

John A. Henderson Surgery centers continue makng inroads, Modern Healthcare, 

May 21 , 1990, p. 99. 

Ibid., p. 99. 

Abstracts-Upper GI Endoscopy: Is It Overused?" Geriatrics, Februar 1989, p. 98. 

page 14

APPENDIX A


METHODOLOGY 

The purpose of the study was to compare the medical necessity, qualty of care and cost of 

selected Medicare outpatient surgical procedures in two settings-ambulatory surgical centers (ASCs) and hospital outpatient deparments (OPDs). We identified the 11 States that had the 

highest number of ASCs-Arzona, California, Florida, Illinois, Louisiana, Marland, North 

Carolina, Ohio, Pennsylvania, Texas and Washington. These States had 61 percent of the ASCs 

certified by the Health Care Financing Admnistration (HCFA) in Februar 1988. We identified 

several high volume outpatient procedures on the basis of (1) the 1985 Par B Medicare Annual 

Data (BMA), (2) HCFA's 1986 ASC surey, (3) interviews with ASC administrators and 

(4) input from the academic community and several medical societies. We selected four 

procedures--ataract extraction with intraocular lens (IOL) implant, upper gastrointestinal (GI) 

endoscopy, colonoscopy and bunionectomy.


To establish the universe of outpatient surgeries performed between Januar 1 and 

March 31 , 1988, we requested procedure code printouts from the 12 Medicare carers that 

process Par B claims for the 11 States. (We chose the first quarer of 1988 to allow the 

intermediares, which pay OPD claims, sufficient time to convert their claims processing systems 

to incorporate the same billng codes used by the carers, which pay ASC claims. ) We manually 

counted ASC and OPD surgeries for the four procedures from the printouts. We eliminated 

Washington from the sample because the carer printouts did not distinguish the specific 

outpatient site (ASC or OPD) for three of the four procedures-upper GI endoscopy, 

co1onoscopy and bunionectomy. The universe of surgeries for the selected quarter are 

distrbuted by site as follows: 

TABLE 1 

Universe of Surgeries - January-March 1988 

PROCEDURE ASC OPD TOTAL 

Cataracts 44299 85. 74121 61.5 118420 68. 

Upper GI Endoscopy 4093 25712 21.3 29805 17. 

Colonoscopy 3287 19938 16. 23225 13. 

Bunionectomy 357 808 1165 

TOTALS 52036 100. 120579 100. 172615 100.

To determne bur sample size, we used HCFA's 5- percent threshold for peer review organization 

(PRO) review of outpatient quality of care. We assumed the same threshold and set a power of 

80 percent to determne a two-fold difference between ASCs and OPDs. We had an 80 percent 

chance to determine if significant positive or negative diferences existed, e.g., if poor ASC 

quality of care exceeded 10 percent or if it fell below 2.5 percent when the OPD rate for poor 

care was 5 percent. Using this criterion, we selected 585 surgeries in each site. We used a 

computer program to generate random numbers and identified a total of 1 170 surgeries. We 

selected a proportionate number of surgeries from each State based on the summed distrbution 

of all outpatient surgeries in that State. Table 2 includes the State sample distrbution. 

TABLE 2 

Distribution of Procedures Among States 

PROCEDURE GROUP 

Cataracts Upper GI 

Endoscopy Colonoscopy Bunionectomy TOTAL 

STATE 

Arizona 1.3 

California 160 20. 33. 40.5 75. 298 25. 

Florida 170 21.2 13. 25. 206 17. 

Ilinois 

Ohio 

Louisiana 

Maryland 

North 

Carolina 

Pennsylvania 14. 15. 118 10. 

Texas 158 19. 12. 10. 200 17. 

TOTALS 802 100. 202 100. 158 100. 100. 1170 100. 

A- 2

We requested beneficiar payment histories from the carers to (1) identify the surgeons and the facilties where surgeries were completed and (2) determne all procedures associated with the 

entire episode of care, including preoperative tests and postoperative services rendered by 

September 30, 1988. We then requested medical records from both the surgeons ' offices and the 

facilities (ASCs or OPDs). The medical data included, at a minimum, a record of both pre- and 

postoperative care rendered by physicians durg office visits, preoperative test results, copies of 

the operative reports, anesthesia reports, x-ray interpretations and any related paperwork 

completed durng the surgery. 

We identified al services associated with the surgeries, e.g., preoperative ophthalmic tests, and 

entered the frequencies and costs into a dBase 111+ progr for further SAS statistical analysis. 

For those OPD surgeries where IOLs were not biled to Par B through the carer, we contacted 

fiscal intermediares to obtan copies of the claims submitted by the hospitals. When the IOLs 

were included in medical supplies or sterile supplies rather than a separate cost center, we called 

the hospitals to obtain the biled and allowed amounts. 

An independent medical review contractor used physician specialists to develop 

procedure-specific criteria. Members of the American Academy of Ophthalmology and the 

American Society for Gastrointestinal Endoscopy reviewed the criteria, and their suggestions 

were incorporated. The medical reviewers utilized the criteria and completed a narative 

assessment for each record. The reviewers assessed each record for medical necessity, 

appropriateness of the outpatient setting and quality of care. 

First, we eliminated the bunionectomies from all analyses due to the small number included in 

the sample. For some of the remaining cases, assessment was impossible when the medical 

records were (1) incomplete due to missing information from the surgeon or the facilty or 

(2) inadequate due to ilegible or poor documentation. For these undocumented records, the 

medical reviewers were unable to assess 9.9 percent (115 of 1 162 records) for appropriateness 

of the outpatient setting, 3.5 percent (41 of 1 162 records) for medical necessity and 6.6 percent 

(77 of 1 162 records) for quality of care. 

Based on infonnation we received from Medicare carers, we identified ophthalmologists who 

received more than $1 milion in 1987. Out of 255 ophthalmologists, 84 performed 178 

surgeries in our sample. We analyzed this subset further to identify any differences between the 

surgeries completed by the high volume ophthalmologists versus the non-high volume 

ophthalmologists in our sample. Table 3 describes demographic data about the sampled ASC and 

OPD patients. 

In addition, we interviewed representatives of several professional medical associations and a 

sample of ASC and OPD physicians in each specialty to identify currently acceptable standards 

for medical necessity and quality of care. 

A- 3

Table 3 describes demographic data about the sampled ASC and OPD patients. 

TABLE 3


Demographic Information for Sample


CHARACTERISTIC ASC 

AVERAGE AGE (years) 75. N/A 

AGE GROUP 

64 years 2.4


65-69 years 14.


70-74 years 167 28.


75-79 years 142 24.


80-84 years 122 20.


85+ years


TOTAL 585 100.


SEX


Female 380 65.


Male 205 35.


TOTAL 585 100.


RACE


White 130 22.


Black 1.0


Asian


Other


Not documented 444 75.


TOTAL 585 99.


OPD 

76. N/A 

15.


136 23.2


156 26.


120 20.


11.3


585 99.


375 64.


210 35.


585 100.


357 61.0 

2.4


180 30.


585 100.

APPENDIX 

MEDICAL REVIEW CRITERIA 
APPENDIX 


BffLIOGRAPHY 

Abstracts-Upper GI Endoscopy: Is It Overused?" Geriatrics, February 1989, pp. 98 and 100. 

Agreed: Outpatient PPS by 1991 Health Policy Week, 
 May 14, 1990, p. 3.

AHA Voices Concerns about HCFA' s Severity Index Hospitals, October 5, 1988, pp. 26-28.

Ambulatory Surgery-Conducting a Feasibilty Analysis for Free-Standing Ambulatory


Surgical Centers, AORN Journal, December 1986, pp. 1026- 1033.


American Academy of Ophthalology, Dry Eye, 
 March 1988.

American Academy of Ophthalmology, Glaucoma, March 1984. 

American Academy of Ophthalmology, 
 Laser Surgery of the Eye April1987. 

American Academy of Ophthalmology, Macular Degeneration, 
 Februar 1988. 

American Academy of Ophthalmology, Seeing Well, 
 May 1988. 

American Academy of Ophthalmology, "Policy Statement-An Ophthalmologist s Duties 

Concerning Postoperative Care " September 27, 1987. 

American College of Surgeons, Socioeconomic Affairs Deparment, Socio-Economic Factbook 

for Surgery 
 1988, 1988.


American Society for Gastrointestinal Endoscopy, 
 Appropriate Use of Gastrointestinal 

Endoscopy, June 1986. 

American Society for Gastrointestinal Endoscopy, 
 Preparation of Patients for Gastrointestinal 

Endoscopy, January 1988. 

American Society for Gastrointestinal Endoscopy, 
 Some Answers to Questions about 

Colonoscopy and Polypectomy, June 1987.


American Society for Gastrointestinal Endoscopy, 
 Standards of Practice of Gastrointestinal 

Endoscopy, March 1986. 

American Society for Gastrointestinal Endoscopy, 
 Therapeutic Gastrointestinal Endoscopy-An 

Information Resource Manual no date. 

C - 1 
, 

, , , 

Are Some Surgical Procedures Overpaid, Health Affairs, 
 Summer 1987, pp. 124- 130.

Beneficiares Happy with Outpatient Surgery-Study, Modern Healthcare, Februar 12, 1990 

pp. 18, 22. 

Berler, David K., M. , and Robert Peyser, M.D., "Light Intensity and Visual Acuity Following 

Cataract Surgery, Ophthalmology, August 1983, pp. 933-936.

Betz, Robert, "Hospita Outpatient Payment Policy: Beginnings and Endings, Federation of American Health Systems Review, 
 November/December 1989, pp. 12- 17. 

Brook, Robert H. , M.D., and Kathleen N. Lohr, Ph.D., "Monitoring Quality of Care in the


Medicare Program-Two Proposed Systems, lAMA December 4, 1987, pp. 3138-3141.


Capital Digest: Ambulatory Surgery Rates May Rise Only 5. Modern Healthcare


June 3, 1988, p. 18.


Classen, M. and K. Knyrm Electronic Endoscopy-The Latest Technology, Endoscopy, 

1987, pp. 118- 123. 

Committee Claims PRO Data Show Drop in Quality, Hospitals November 20, 1987, p. 36.


Complexities Likely to Delay Enactment of PPS System for Outpatient Services, Modern
 Healthcare, November 25, 1988, p. 16.


Competition Helps Cap Costs Study, Hospitals, November 11 , 1988, p. 5.


CPT 4 System Puts Additional Burden on Hospitals, Hospitals, May 5, 1987, p. 30.

Customer Perception Counts in Quality Assurance, Hospitals January 20, 1989, p. 84. 

Davis, James E., M.D., "The Future of Major Ambulatory Surgery, Surgical Clinics of North 

America, August 1987, pp. 893-901. 

Davis, James E., M.D., and Kenneth Sugioka, M. Selecting the Patient for Major 

Ambulatory Surgery-Surgical and Anesthesiology Evaluations, Surgical Clinics of North 

America, August 1987, pp. 721-732. 

Surgical Evaluation Surgical CZinics of North America August 1987 , pp. 721-731. 

DHHS, Office of Inspector General National DRG Validation Study, Quality of Patient Care in 

Hospitals," July 1989, #OAI-09- 88-00870. 

DHHS, Offce of Inspector General The Utilzation and Qualty Control Peer Review 

Organization (PRO) Program: Quality Review Activities," August 1988, 

#OAI-01-88-00570. 

C ­
pp. , 

, 

Droste, Therese, "Quality Care: Elusive Concept Deserves Defining, Hospitals, June 5, 1988, 

pp. 58-59. 

EPA Should Get Guidelines for Medical Wastes-AH Modern Healthcare, 

August 12, 1988, p. 29. 

Expert in Error Over Medicare Payment, Modern Healthcare, July 22, 1988, p. 126. 

Farber, M.A. and Lawrence K. Altman A Great Hospital in Crsis, The New York Times


Magazine, Januar 24, 1988, pp. 18-21, 38, 40, 50 and 57.


Foulds, Wallace S., Chapter I-Tests of Visual Function The Eye in General Medicine, 1983, 

12. 

General Accounting Offce, 
 A Comparison of VA and HCFA Methods for Analyzing Patient Outcomes, June 1988, pp. 1­

General Accounting Office, 
 Improved Patient Outcome Analyses Could Enhance Quality 

Assessment June 1988. 

General Accounting Offce, 
 Improving Quality of Care Assessment and Assurance May 1988. 

General Accounting Offce, 
 Limited State Efforts to Assure Quality of Care Outside Hospitals, 

Januar 1990. 

General Accounting Offce, 
 Medicare Preliminary Strategies for Assessing Quality of Care 

July 1987.


General Accounting Office, 
 Medicare Reviews of Quality of Care at Participating Hospitals, 

September 1986. 

Goes, F., M.D., Modern Trends in Ophthalmology-roceedings of the 18th European Congress 

of Ophthalmology ECLSO/SOBEVECO: Personal Complications After I.OL. Surgery, 

1989, pp. 179- 189. 

Graney, Marshall J., Ph.D., "A Clinical Index for Prdicting Visual Acuity After Cataract 

Surgery, May 1988, pp. 460-465. American Journal of Ophthalmology, 


Hamilton, Jon Specialized Minicenters-Shopping-Mall Medicine, American Health 

March 1988, pp. 106- 111. 

HCFA: Ambulatory Surgery Rates May Hurt Hospitals, Hospitals, July 5, 1987, p. 26. 

Health Policy Week November 28, 1988, pp. 1­

C - 3 
, 

, pp. , , 

Hedden, Michael and K. Donald Wolfe, "Experience from a New Wave Ambulatory Surgery


Center Florida Medical Association, 
 June 1987, pp. 411-416.


Henderson, John A., "Freestanding Centers Gaiing on Surgical Suites, Modern Healthcare


June 3, 1988, pp. 84-87.


Surgery Centers Continue Makng Inroads, Modern Healthcare May 21 , 1990 

pp. 98- 100. 

HHS Inspector General Report- 6% of Medicare Patients Said to Receive Poor Care at Costs 

of $1.2 Bilion Health Daily, 
 August 10, 1988, pp. 1­

Holloway, James J. et al. Clinical and Sociodemographic Risk Factors for Readmission of 

Medicare Beneficiares, Health Care Financing Review Fall 1988, pp. 27-36. 

Jaffe, Norman S., M.D., Symposium on Cataract SurgeryTransactions of the New Orleans 

Academy of Ophthalmology: Chapter 24-urgical Results of Cataract and Lens Implant Surgery, 1984, pp. 226-235. 

Jaffe, Norman S., M.D., et aI., Chapter I-The Decision to Operate, Cataract Surgery and Its 

Complications, 1990, pp. 3- 11. 

Jay, J. L. et aI., "Effect of Age on Visual Acuity after Cataract Extraction British Journal of 

Ophthalmology, 1987, (71), pp. 112- 115. 

Jennings, LTC Bonnie M. and MAJ Richard A. Sherman, "Anxiety, Locus of Control, and 

Satisfaction in Patients Undergoing Ambulatory Surgery, Miltary Medicine April 1987 

206-208. 

John, Maurice E., M. , and Timothy D. Edsell, B.S., "Advanced Versus Immature CataractsPreliminary Report, Annals of Ophthalmology, June 1989, pp. 222-224. 

Kahn, Katherine et al. Indications for Selected Medical and Surgical Procedures-A Literature 

Review and Ratings of Appropriateness: Diagnostic Upper Gastrointestinal Endoscopy, 

May 1986. 

The Use and Misuse of Upper Gastrointestinal Endoscopy, Annals of Internal Medicine 

October 15, 1988, pp. 664-670. 

Kelman, Charles D., M. Cataracts: What You Must Know About Them, 1982. 

Kim, Howard Competition Helps Cap Cost Study, Modern Healthcare November 11 , 1988 

King, Kathleen M., "Medicare Payment for Services in Hospital Outpatient Departments 

Congressional Research Service August 15, 1989, pp. 1-25. 

C ­
, 

, pp. , , , , 

Koska, Mar T. HCFAExamnes Ambulatory Payment Options Hospitals, July 20, 1988 

pp. 86-87. 

HCFA Monitors Outpatient and Home Care Growth December 20, 1988 , p. 27. Hospitals, 

Push Is On for Ambulatory Quality Assurance, Hospitals, September 20, 1988, p. 66.

Krentz, Susanna E. and Maran C. Jennings, "Prcing Strategies for Hospital-Based Ambulatory 

Care Services: Case Study of an Ambulatory Surgery Program Journal of Ambulatory Care Management, August 1986, pp. 15-30. 

Krger, Sidney H., M.D., et al. A Review of Extracapsular Cataract Extraction and Intraocular


Lens Implantation Combined with Trabeculectomy, Annals of Ophthalmology, 
 July 1989


266-268. 

Kroenke, MAJ Kun, M.D., "Preoperative Evaluation: The Assessment and Management of 

Surgical Risk Journal of General Internal Medicine July/August 1987, pp. 257-269. 

Lagoe, Ronald J. , Ph. , and John W. Milliren, Ph.D., "A Community-based Analysis of 

Ambulatory Surgery Utilzation American Journal of Public Health, February 1986 

pp. 150- 153. 

Larson, Gerald M., M. , et aI., "Evaluation of Endoscopy Training in a General Surgery 

Residency, February 1988, pp. 64-67. The American Surgeon, 


Leaming, David v., M.D., "Practice Styles and Preferences of ASCRS Members-1988 Survey, 

Journal of Cataract and Refractive Surgery, 
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Leape, Lucian L. Unnecessar Surgery, Health Services Research August 1989, pp. 351-407. 

Less Money, More Players in Outpatient Market, Hospitals, Januar 20, 1989, p. 26.

Lion, Joanna, Ph. , et al. The Case Mix of Ambulatory Surgery as Measured by Ambulatory 

Visit Groups, Journal of Ambulatory Care Management, February 1990, pp. 33-45. 

Louden, Teri L., "The Last Word-Customer Perception Counts in Quality Assurance 

Hospitals, Januar 20, 1989, p. 84. 

Lutz, Sandy, "Changing Rules for Ambulatory Care Reimbursement Fuel Shifts in Industry, 

Modern Healthcare, 
 July 22, 1988, pp. 58-59. 

Freestanding Recovery Centers Growing, Januar 8, 1988, p. 35. Modern Healthcare, 


Systems Find Ambulatory Care No Longer a Niche, But a Chasm Modern Healthcare, 

May 21 , 1990, pp. 90, 92 and 94. 

C - 5 
. p. , 

, , , , 

Margo, Curis E., M.D., "Sounding Board-Sellng Surgery, The New England Journal of 

Medicine June 12, 1986, pp. 1575- 1576. 

Mitchell, Janet B. et al., "DataWatch-Are Some Surgical Procedures Overpaid?" Health Affairs, Summer 1987, pp. 121- 131. 

Nathanson, Susan N., Ph. Ambulatory Surgery-Characteristics of a Successful Ambulatory 

Surgery Program, AORN Journal, Februar 1988, pp. 592-593, 596 and 598.

Ambulatory PPS: More Hospitals Wil Track Costs, Hospitals, June 5, 1988, p. 106.

News Digest: Johns Hopkins to Study Quality of Care Modern Healthcare July 1 , 1988, p. 8. 

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Outpatient Services Examied, Hospitals, May 22, 1988, p. 28.

Outpatient Surgery Prospects Bullish, Health Policy Week, 
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Park, Rolla Edward et aI., Physician Ratings of Appropriate Indications for Six Medical and 

Surgical Procedures, 1986. 

Payment, Hospitals, May 20, 1989, p. 28. 

Powils, Suzanne, "Consumers Snub Freestanding Surgical Centers, Hospitals, July 20, 1986

73. 

Prospective Payment Assessment Commission Medicare Payment for Hospital Outpatient 

Surgery: The Views of the Prospective Payment Assessment Commission April 1989. 

Regional News Digest, Modern Healthcare, 
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October 20, 1988, p. 27. 

Outpatient Services Examned, Hospitals, May 20, 1988, p. 28.

Renewed Pressure to Cut Outpatient Surgery Costs, Hospitals, May 20, 1989, p. 18.

Romansky, Michael A. and Diane S. Milman The Prospects for Outpatient Surgery, 

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C ­
, 

, pp. , , , , , , , 

Sanders, Donald R. , M.D., Ph. OSN Editorial-New Government Study Introduces the


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Sappenfield, David L., M. Resident Extracapsular Cataract Surgery: Results and a 

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Sonneborn, Charles B. Ambulatory Center Rates and IOL Prcing, Insight Focus Februar 1990, pp. 1­

MD/OD Post-op Care Deemed Equal to Surgical Effort Insight Focus


Februar 27, 1990, pp. 1­


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Cataract Patients, Annals of Ophthalmology, 
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Tokarski, Cathy, "Ambulatory Surgery Pay Rates Issued, Modern Healthcare, 

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Complexities Likely to Delay Enactment of PPS Systems for Outpatient Services, Modern Healthcare, November 25, 1988 , p. 16. 

Report Predicts Battle Over Ambulatory Surgery Payment, Modern Healthcare 

July 22, 1988, p. 30. 

Vuori, Hannu, M.D., "Editorial: Patient Satisfaction-An Attrbute or Indicator of the Quality of 

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Wagner, Lynn and Cathy Tokarski Standardized Guidelines for Treating Medical Conditions 

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C ­
Weiner, Jonathan P. , D. H., et al., "Elective Foot Surgery: Relative Roles of Doctors of 

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C - 8 
APPENDIX D


AGENCY COMMENTS


D - 1

APPENDIX 


AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY LETTER


E - 1