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Opinion

Wills Eye's Medicare predicament

    by Harold Brubaker, STAFF WRITER | Columnist
    Published 

Wills Eye Hospital's top East Coast rivals in Miami, Baltimore, and Boston operate as hospitals under Medicare, even though most of their patients are outpatients.

Wills, despite its name, is not a hospital under Medicare. The Center City institution gave up that designation in July 2006 when it sold its inpatient business to Jefferson, operating instead as an ambulatory surgery center at Eighth & Walnut Streets.

Now, Wills is fighting to get that hospital certification back, after completing a $6.5 million renovation three years ago that included a four-bed inpatient unit.

But Medicare officials have resisted since 2013, insisting that Wills is an ambulatory surgery center because it does not have enough inpatients.

Experts said it is rare for an ambulatory care center be certified as a hospital under Medicare, which generally pays hospitals more for the same services.

Such a  move faces severe resistance at a time when one of Medicare's top priorities is keeping people out of the expensive hospital beds. Even so, Medicare has certified at least 30 hospitals with 10 or fewer beds since 2013, including a one-bed hospital in Minnesota, according to agency data.

A decision by an appeal board is expected any day.

"It's a no-brainer that we should have exactly the same status as everyone else in Medicare's eyes," Julia Haller, Wills' ophthalmologist-in-chief, said Wednesday, referring to competitors in eye care.

Haller said she realized immediately when she arrived in November 2007 - just 15 months after the sale of the inpatient business - that Wills  would be handcuffed without a hospital license.

It's not about the money, Haller said.

"A procedure that takes over four hours has to be done in a hospital," Haller said. Those are the cases that take advantage of Wills' breadth of specialists, she said.

Wills' appeal of  the Medicare denial is now at the second level of appeal within the U.S. Department of Health and Human Services, which regulates Medicare. If Wills loses against regulators, it could appeal to U.S. District Court.

Meanwhile, Wills, which has a state hospital license, faces termination from Medicare on Nov. 1 because its treatment of inpatients violates its Medicare certification as an ambulatory surgery center.

"This Catch 22 that Wills has fallen into is emblematic of a greater problem, which is that the payment mechanisms that we have in health care that don't make any sense," said David Shapiro, an anesthesiologist in Florida and past president of the Ambulatory Surgery Center Association.

What happens if Wills loses Medicare?

"We'll figure out a solution," chief executive Joseph P. Bilson said.

Pennsylvania poltical supporters, including Sen. Bob Casey and Rep. Patrick Meehan, have been advocating for Wills at the federal level, arguing that the specialized care at Wills warrants hospital status.

Wills is a "national treasure," Meehan said last week. Whatever qualifies as a hospital "ought to be similar across the country," he said.

That is not the case.

The Anne Bates Leach Eye Hospital, which is part of the University of Miami Health System and is the primary practice site for the Bascom Palmer Eye Institute, is certified by Medicare as a 100-bed hospital. A bond prospectus last year said that "subtantially all" services there are outpatient.
Spokeswoman for the Wilmer Eye Institute in Baltimore, which is different because it is part of Johns Hopkins Medicine, said that "99 percent or more of services that we provide are exclusively outpatient."
A third rival in the top echelon of eye care, Massachusetts Eye & Ear in Boston, performed 11,648 eye surgeries in operating rooms in the year ended Sept. 30, 2015, but had only 235 inpatient ophthalmology inpatient discharges. Some are inpatients for reasons other than surgery. The facility is certified as a 42-bed hospital.
Medicare could be worried about setting a precedent for the switch from ambulatory surgery center to hospital.
"Tacking four inpatient beds onto a high volume outpatient surgery ASC does not magically transform an ASC into a Medicare hospital," government attorney Suzanne Yurk argued at an Aug. 11 hearing, using an abbreviation for ambulatory surgery centers.

Regulations are vague, saying only that a hospital is "primarily engaged" in "inpatient diagnostic and therapeutic services or rehabilitation services." CMS has no official quantitative parameters and says it decides on a case-by-case basis.

Dan Grauman, CEO of Veralon, a Philadelphia health care consulting firm said he can see both sides. "It's a difficult situation they got themselves in," he said, referring to Wills.

"I am sure from a medical and clinical perspective it's completely necessary for them to do the fine work that they do to have access to inpatient capacity. It's probably not a lot," he said.

    HB
    Harold Brubaker, STAFF WRITER