Many ophthalmologists today are preoccupied with speed. But I believe that you can be an average volume surgeon and still be profitable. The key is to combine efficiencies of time and motion with cost-efficiency. To accomplish this, you must constantly reevaluate each step of your surgical procedure and know the cost of doing business.

Here, I'll demonstrate how I've applied this philosophy in my practice and offer advice on how you can increase efficiency in yours.

Every practice should have a method in place for getting information and responding to information. In my practice, each section of the office and the ambulatory surgery center (ASC) has its own operating statement showing revenues and expenses. I review these statements monthly and look for trends. For example, if there's an unusually high trend in repair costs, I'll look into whether there's a problem with equipment or care of instruments.

We also periodically reevaluate supply costs. Every time I've asked my staff to do a price comparison, we've been able to make improvements. For instance, when we looked at our expenses for cataract packs, we found that much of what goes into the packs is no longer needed because of our improved efficiency. So, we were able to reduce the number of supplies that go into the packs and negotiate a better price from our suppliers.

We also did a study comparing the acquisition and repair costs of diamond and single-use metal blades, and we found that using diamond blades would save us more than $90,000 over a period of 5 years.

If something can make you more cost-efficient, it's worth investing the money in it. For example, using our monthly income statements, we did a cost analysis and found that our cost per case for the phaco unit was increasing. This was happening for two reasons: our average phacoemulsification set cost per case was increasing, and our annual repair cost for each phaco unit was increasing. Replacing the older units with new phaco units not only reduced our cost per case, it also improved my time per case.

Becoming more efficient often means embracing the latest technology, but with declining reimbursements you still have to recognize how to be cost-effective. Some of the new technology lenses that we use have a higher cost, but aren't reimbursed any higher. Instead of using them 100% of the time, I try to carefully select the patient who would most benefit from the new technology lens.

The use of an array of lenses from different vendors allows me to keep the average cost per lens to an acceptable level. A recent study by the Accreditation Association for Ambulatory Health Care (AAAHC) listed the average IOL cost per cataract surgery at $85. Even using the new technology lenses in approximately one-third of our cases, we're able to keep our average cost of IOLs at around $93.

I transitioned from scleral tunnel to temporal clear corneal surgery shortly after we moved into our surgical center. This improved our efficiency in a number of different ways. First of all, the procedure is much more time efficient because there are fewer steps in clear corneal surgery.

Secondly, we save on materials with clear cornea surgery because sutures aren't routinely used. With our own ASC, we find that, without feeling rushed, we can easily perform at least 4 cases per hour over the course of the day. In terms of efficiency, the time to measure a case is from incision to incision. The surgeon may be doing a 9 minute case, but if his turnaround is 20 to 30 minutes, it's not a cost-effective situation for the ASC.

Additional factors that improve efficiency and patient satisfaction in our ASC include:

• Using a topical anesthetic with light IV sedation.
This minimizes patient recovery time. For example, the May 1999 AAAHC Performance Measure Initiative for Cataract Extraction with Lens Insertion reported a mean facility time of 137 minutes for their surveyed facility. Ours averages 87 minutes from the time the patient walks in until the time he walks out. I believe that topical anesthesia with light IV sedation is an important factor in this.
There has been concern that IV's aren't necessary and are an extra expense, but I disagree. Almost all of our patients receive mild sedation, usually Versed (Midazolam), in the preoperative area. I believe that a relaxed patient allows everyone to be much more efficient, making IV access cost-effective. We initially used IV infusions at a cost of just over $4, but now our patients receive a saline lock at $0.38. If we compare the costs of a saline lock and the option to give additional medication as necessary over the course of a day, compared to our cost per minute to operate an OR with more than $25 per minute in overhead and personnel, the time savings that an IV offers is extremely cost-effective.
I also find that using topical and intraocular anesthesia is very cost-efficient. Preservative-free intraocular Lidocaine costs about $0.17 per case, but again, it reduces the need for systemic pain medication such as Fentanyl (Sublimaze).
• Sharing employees with the clinic and ASC.
In most of our cases, the patient assessment is completed prior to the patient's arrival in the ASC. This is often done by the same person who will work with the patient in the pre-op area of the ASC. This means that the nursing staff is already familiar with the patient when he or she arrives in the facility, which allows them to proceed in a more efficient manner. Patients also appreciate seeing a familiar face when they show up for surgery.
• Using foldable IOLs.
These are more expensive but they more than make up for their higher acquisition cost in time efficiency.
Phacoemulsification with a small incision foldable intraocular lens is a more efficient procedure. It requires fewer steps and eliminates the extra time and instrumentation needed to enlarge the incision for a polymethyl methacrylate (PMMA) implant. We further improve efficiency by trying to keep each step of the procedure consistent from patient to patient.

According to the AAAHC cataract study in May 1999, there is no meaningful statistical correlation between the volume of cases performed and supply cost or procedure time. This means that you don't need large volumes to be efficient, you only need to adopt best practices.

You can learn about best practices through benchmarking data and by comparing yourself to other surgeons. Find out what makes them more efficient in terms of technique, instrumentation and cost.

Every time we look at costs or visit another surgeon's practice we learn something that can improve our situation. When we compared our facility's salary overhead and supplies to a multi-ASC expense ratio, for example, we found that our overhead was higher because our ASC is only open 2 days per week and the benchmark was open 5 days per week. But our salary ratio was lower because we share staff with our eye clinic. In analyzing this data, we determined that we'd be able to increase utilization and be cost-effective because we already have a fixed overhead. Any increased revenue associated with more cases would go against the fixed overhead.

If you operate in a hospital, bear in mind that hospitals are also threatened with declining reimbursements, and are more inclined to work with you to become more efficient by introducing time savings on the procedure, as well as by encouraging efficiencies on the part of the hospital staff.

If you have the opportunity to be part of an ASC, by all means consider it. The opening of my surgery center not only made me more aware of the need to look at cost-efficiency, it gave me the means to do it. It also gave me the opportunity to more than double my case load, yet actually spend less time in the operating room.

If an ASC isn't feasible, you may need to look critically at your efficiency in your hospital. If it's taking you more than an hour to complete one case, you may need to consider referring surgery out. With the newly increased reimbursements for office visits and procedures, you may find that this is actually more profitable for you.

Of course, if reimbursements continue to decline, we'll all be out of business. But for now, you hold the key to your success. If you're willing to spend the time to review the critical aspects of cataract surgery from a surgical and economical standpoint, you can be economically viable.