Having recently made the transition from hospital-based surgery to owning and operating my own ambulatory surgery center (ASC), my only regret is not making the change sooner. Any practice that has the right payer mix and surgery volume substantial enough to warrant opening an ASC has a lot to gain in economics and autonomy from this strategic move.

My practice has close to 200,000 active patients, and in April, we performed 266 procedures at our ASC, so adequate volume wasn't what kept me from opening a surgery center sooner. My personal commitment to supporting the work done at Catholic hospitals kept me in the hospital environment for most of my 20 years in practice, but the cost-cutting measures in Los Angeles hospitals and a change of ownership where I practiced led me to build my own ASC.

In this article, I'll recount some of my experiences while they're still fresh in my memory.

It took about 18 months to open my two-OR ASC from the time I gave the initial go-ahead on the project until the time it was fully up and running and I'd received my first reimbursement check.

The first step was hiring a medical architect to design the facility. We chose a top-notch firm with an excellent reputation, but I'd advise anyone considering opening an ASC to check references of even the country's leading architects and contractors. A firm may have designed and built numerous surgery centers around the country, but you need to make sure the people with whom you're working are familiar not only with federal regulations but also with state and local codes in your area -- and that they've successfully completed projects within budget.

The primary advice I'd offer anyone considering building a surgery center is to have the same company that does the architectural plan also be in charge of the contractor. The fewer parties involved in the process, the less likely those involved will fall prey to the 'blame game' if something goes wrong. Accountability increases exponentially when a single point person is ultimately responsible for the entire project.

Getting Certified

Once design decisions are reached, you'll need to secure licensure, certification or accreditation for your facility. The process is full of challenges, especially for the uninitiated. Hiring someone to lead you through the process is essential. This is a crucial choice because the person in this position can cost the project time and money in delays if he or she is inept. We encountered this problem with our first choice, but nipped the situation in the bud. We struck gold with our second choice, a consultant who had previously guided several other surgicenters through the maze of red tape required to legally open the doors for surgery.

To be reimbursed by the federal and state governments, you must apply for Medicare and Medicaid certifications. Be aware that Medicaid licensure laws vary from state to state. Also keep in mind that many third-party payers will require both Medicare and Medicaid accreditation during contract negotiations. Our consultant was instrumental in developing the various policy and procedure manuals required for these certifications.

A consultant also will guide you through the numerous inspections by city agencies that threaten to halt construction; and he or she will advise you when it's time to go to city officials to iron out discrepancies that might crop up. You'll need at least two separate inspections, one from the city and one from the Department of Health Services. Without their approval your project won't go anywhere.

Once the state approves the facility, you may apply for your Medicare license. Experience taught me that it could take up to 6 months or more before Medicare reimbursement materializes. It's not an exact science. It could take as long as a year to get a Medicaid number, which will further delay reimbursement.

Getting the state documentation you need to get paid by third-party managed care companies can be even more cumbersome. Be patient and have the capital to sustain your project for at least 6 months -- or more -- after you're approved for Medicare.

Before you can think about scheduling your first surgery, you must address your staffing needs. Our consultant helped hire and train our staff, including an excellent R.N. who acts as our administrator. The administrative R.N. was on board at least 6 months before the ASC opened. She made sure our manuals were in order and helped with pharmaceutical and instrument purchasing. Many other staffing needs are dictated by Medicare and state standards, which stipulate the number of R.N.s and technicians a surgery center must have, based on its capacity.

Ownership or Partnership? Buy or Rent?

There are three ways to branch out from the hospital environment to a surgery center. You can:

1. Join an existing partnership.

2. Start from scratch and open a center on your own.

3. Partner with a management company.

Your choice will depend on your surgery volume.

If it's financially feasible, I recommend buying the building that will house your surgery center. It's just a better investment for the long term. You can expect to pay about $140 per square foot, not including equipment, to build an ASC within an existing structure.

Attracting Patients and Surgeons

While some ophthalmic surgicenters diversify with participation from other specialties, we've opted to concentrate solely on ophthalmic surgery, at least for the time being.

We don't actively market our ASC to prospective patients. However, we do market our practice, which in turn draws patients to the ASC. We were pioneers in televised medical advertising, running TV commercials since 1984. I'm certain that marketing has helped us become the largest private ophthalmology practice in Los Angeles.

I will be marketing the surgicenter to surgeons -- preferably medium- to high-volume ophthalmologists who are good surgeons. Currently, we're near capacity, with surgery being performed in the facility 4 days a week.

When marketing to patients, our strategy is simply to explain that we use the newest equipment and technology that, in our opinion, is the best in the cataract surgery arena. For example, we were the first ASC on the West Coast to have the Infiniti phacoemulsification machine.

We refrain from discussing specific brands or technical details, however, and our patients are comfortable with that. They trust us to choose the best for them. We use mostly Alcon products, and I feel as strongly about using a primary supplier of surgical equipment and devices for our practice and ASC as I did about using a single point-person during the development of the surgery center.

From an administrative standpoint, I recommend working with a single supplier for surgical devices in an ASC environment. The process is much simpler when you can tell a company representative how many surgeries you expect to perform in a day and then have him provide the appropriate number of custom surgery packs to use in those surgeries. We use another supplier for pharmaceuticals and have a relationship with another surgical supplier, but we deal with Alcon primarily because I believe it offers the state of the art right now in both products and service.

Another reason I'm committed to using Alcon's products is because of the company's relentless commitment to funding medical education in developing countries. During the last 20 years, I've trained hundreds of ophthalmologists in Latin America in phaco courses and wet labs that were co-sponsored by this company. In many Latin American countries, these were the first phaco courses ever taught. During times of recession, many other companies withdrew their support, but this one always remained.

Choosing a primary supplier is among the many tough choices of operating an ASC, but the right decisions produce results that are worth the frustration and anxiety that may accompany them.

No Regrets

Despite all the challenges of building a new ASC -- and the limitations imposed by fixed reimbursement -- I still believe the sovereignty that accompanies ASC ownership is invaluable.

Dr. De La Peña is a professor of ophthalmology and medical director of the De La Peña Eye Clinic in Montebello, Calif.