The Centers for Medicare and Medicaid Services issued their final payment rates on Nov. 1 for services provided at ASCs and hospital outpatient departments in calendar year 2008.

The final rule confirms the rates proposed in August of this year, which the agency announced as part of its sweeping revisions to the ASC payment system, also announced in August.

As proposed, ASCs will be paid 65 percent of the corresponding rates provided by the hospital Outpatient Prospective Payment System. The new ASC payment rates for previously allowed procedures will be phased in over the course of the next four years, from 2008 to 2011, in order that facilities can accommodate the changes, while procedures newly added to the ASC list will begin at the designated rates.

"There are few surprises in this rulemaking," writes Michael A. Romansky, JD, senior lobbyist for the Outpatient Ophthalmic Surgery Society in an e-mail to industry observers. He reminds providers, however, that the final rule doesn't include regional adjustments and that the "fully implemented rates" planned for 2011 will include as-yet-uncalculated annual inflation updates and base rate recalibrations.

ASC industry group FASA points out that two types of cases are exceptions to the 65 percent of hospitals' rates rule.

Using local anesthesia on conscious patients undergoing surgery for fractures, carpal tunnel syndrome and other common hand problems can reduce the need for revisions as well as the procedure's expense and recovery time, according to a study presented at the American Society of Plastic Surgeons' annual meeting in Baltimore last month.

"The ability [of a patient] to speak and move an appendage contradicts one's mental image of surgery," says presenter Donald Lalonde, MD, professor of surgery at Dalhousie University in St. John, New Brunswick, Canada. "However, having the patient awake and coherent provides better outcomes, and they are amazed that the procedure is pain-free."

The surgeons do not use a tourniquet for this technique in order to allow the patient's fingers a full range of motion. The surgeon can then ask the patient to make any necessary adjustments to their hands as well as their reconstructed tendons and bones before the skin is closed, which could potentially decrease the need for revision surgery for tendon transfers and repairs.

Dr. Lalonde says he's found that, as compared to traditional surgery, the wide-awake approach could reduce costs by 25 percent and reduce operating times without risking the patient's safety. And since only local anesthesia is used, there is no reason to worry about complications such as nausea and vomiting.

Before the procedure, Dr. Lalonde says, physical therapists can show patients the movements they'll need to make for the surgical procedure and for rehabilitation afterward. This lets the patients see how much movement they will regain when they are pain-free.

A California surgeon has developed an outpatient technique for removing branch varicose veins that employs a tiny lamp and, yes, a small crochet hook. Peter Lawrence, MD, chief of vascular surgery at UCLA's Geffen School of Medicine, has combined two vein-removal techniques - powered (lighted) phlebectomy and stab phlebectomy - with a common crochet hook that he has sharpened, enabling it to snag each vein and pull it out through a small incision. Dr. Lawrence says he learned the technique from a Brazilian colleague who taught him how to sharpen the arts-and-crafts implements.

Dr. Lawrence and his colleges describe the procedure - called light-assisted stab phlebectomy, or LASP - and the results of more than 250 patients who have had varicose veins so removed in the October issue of The American Surgeon.

Using LASP, in which the patient is sedated but conscious, UCLA surgeons have teased out veins as long as 31cm through a single 1mm incision. "It's like catching a fish," says Dr. Lawrence.

The technique, performed in a dark OR, results in fewer missed veins, reduced hematoma, less bruising and less pain, the authors say. Most patients go home the same day and recover with their feet elevated for 48 hours. "We believe that LASP will provide surgeons with an additional tool to be used to treat varicose veins," Dr. Lawrence says. "With more options, we can better target individual treatment."