RETINA IN THE ASC

Transferring Retina Procedures to an Ambulatory Surgery Center

Here's what you need to know to make this transition as smooth as possible.

By Margaret G. Acker, R.N., M.S.N.

► If you plan on performing retina procedures in an ambulatory surgery center (ASC), you're headed in the right direction. Retina procedures are a new addition to the ASC, and they're proving to be a very profitable investment. If you're already performing cataract procedures, the addition of retina will require new vitrectomy and cryotherapy equipment, an argon laser and hand instruments. Retina cases require longer procedures, staff training and entail higher costs per procedure.

However, despite the initial start-up costs, the return on your investment will prove to be satisfying. Before you move your retina cases to an ASC, here are some things you should know to ensure that you hit the ground running.

Expect Reimbursement

Margins used to be tight for retina procedures. If a surgeon used perfluorooctane (Perfluoron, Alcon Inc.), the center didn't make money because each vial cost $600, and it wasn't billable. Now surgeons have the opportunity to work as they wish and still make a profit. One way they're achieving this is through higher reimbursements. Reimbursement rates for ASCs are better than ever, and they'll continue to increase through 2011.

Today, ASCs receive 75% on ASC reimbursement rates and 25% on the outpatient prospective payment system (OPPS) rates given to hospital outpatient departments for surgical procedures. This means that reimbursements for many retina procedures have increased by about 50% to 60%. These percentages will rise by another 25% per year over the next 3 years, until ASCs are receiving 65% of hospital outpatient rates in 2011.

With surgical reimbursement rates on the rise, it makes sense to add more surgical procedures to the ASC. What's more, retinal disease is chronic, and people are living longer, so patients may need repeated procedures to maintain good vision for a lifetime.

Of course, to enjoy all of the economic benefits of performing retina procedures, you must place your ASC in a position to succeed.

Get Accredited

I recommend accreditation to every ASC because it means you're meeting standard of care requirements. The best surgeons want to work in accredited institutions, and the savviest patients want to be treated there.

What's more, accreditation isn't as optional as it used to be. Third-party payers are beginning to require accreditation as a pre-requisite before they enter into a relationship with you.

ASCs can be accredited through three accrediting bodies: The Joint Commission, the Accreditation Association for Ambulatory Healthcare (AAAHC) or the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Whichever one you choose, count on working through a process that's both demanding and forgiving. The accrediting body gives you a set of criteria you must meet, and you work to meet those criteria. When you're ready, you complete your application and begin a series of reviews.

Even if you're not ready for the review and you need to improve on a few areas, you'll be very pleased with the process. Accreditation gives you a reason to spend time taking inventory of your business and reviewing your processes. In the end, you'll have your self-assessment in writing, and every area of the ASC will meet current standards. You'll need to continue to meet those standards to maintain your accreditation.

Join and Learn

Thriving, accredited ASCs have an atmosphere of professionalism and encouragement that leads to continued learning. Doctors and administrators often join groups like the American Academy of Ophthalmology (AAO) and the Ambulatory Surgery Center Association (ASCA). Staff may belong to the American Society of Ophthalmic Registered Nurses (ASORN) or the Association of Perioperative Registered Nurses (AORN). These organizations have been infinitely valuable to me, often answering any question I've asked.

In our practice, if there's a professional organization that's associated with something we do, someone in our practice becomes a member. As a result, we learn the standards of practice and who the leaders are in our profession. In addition, we read about what people are doing, and we learn what does and doesn't work. In fact, I've found that all I have to do to be an expert in my profession is read. Many times, I've called the experts whose articles I've read, and they've returned my calls. And it doesn't end there.

The atmosphere of learning extends to clinical training as well. Surgeons want an OR staff that's well trained, especially for retina procedures. You can't expect nurses and technicians who've supported only cataract procedures to assist in a retina case. You don't want a staff that does retina procedures occasionally, either. You want a staff that performs them regularly. An experienced staff that knows retina helps you as a surgeon and serves as a strong selling point when you're looking to add surgeons to your staff.

One way to ensure your OR staff is qualified to help you perform retina procedures is through certification. Nurses and technicians can become board certified in ambulatory or ophthalmic surgery nursing, and they'll become invaluable to your practice. Fully trained staff members who need little guidance will ensure that all facets of your center — pre-op, OR and post-op — run smoothly. When your staff is solid, the whole surgical process is faster, more enjoyable and more successful.

Plan for Extra Time

Retina procedures often require more time than cataract cases. The time it takes for staff to prep the patient for surgery may be similar, but post-op time may require nurses to reposition patients for special procedures and administer medications. They may need to build in time for recovery from an anesthesia block. Remember that the surgical procedures typically are more time-consuming than other surgeries performed in an ASC setting.

Several other factors add time as well. As many practices are realizing, the shift to the hospital OPPS involves a learning curve for documentation and reimbursement procedures. The level of detail required is higher than we were accustomed to. For example, doctors and staff must clearly document imaging and drugs and emphasize them to coders and billers to ensure the practice gets paid. All of these things take time.

We schedule the most complicated retina cases early in the day, so we can maintain a more normal flow after the cases are complete. We have three surgery rooms and one retina room, and we do retina procedures 2 days per week. Throughout the day, one retina surgeon is in the surgery room while the other is admitting patients. We've weighed the merits of using disposable versus reusable implements and found that the more expensive disposables quickly paid for themselves when we factored in the time it takes for staff to sterilize reusable instruments.

Choose Cases Carefully

Another consideration is learning to choose your patients carefully. Certain retina patients are "right" for the ASC and some are not. Emergency cases belong in an emergency room, and the most complex retina procedures should be performed in the hospital setting.

In our practice, we choose cases we believe will take less than 60 minutes. That time assessment requires input from experienced staff and the surgeon. We also avoid scheduling cases that require perfluorooctane or silicone oil because of the time and expense involved.

Keep in mind that even under the new reimbursement system, we're not paid as much as a hospital to perform retina procedures. Surgeries that are predictably long or require expensive medications belong in the hospital setting.

Since perfluorooctane is $600 a vial and it's not billable, we keep it on hand in our ASC for emergency use. Surgeons don't use it for every procedure. Retina patients may require injections of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) or photodynamic therapy (PDT) with verteporfin (Visudyne, Novartis Ophthalmics), and we must ensure that we're getting reimbursed accurately and promptly.

Surgeon-friendly ASC

As a surgeon, you're the back-bone of the ASC. The best ASCs spend a great deal of time and money ensuring that the patient has excellent outcomes and a comfortable, confidence-inspiring experience. The best ASCs also spend time and money ensuring that surgeons are comfortable and have all the support they need to succeed.

I probably won't have to work too hard to convince you to buy the most exciting new toys for the ASC, but I'll go ahead and give you some justification anyway. You have to be fast, confident and comfortable, and that means having the equipment you prefer. It means having a well-trained staff that keeps the office running smoothly, the surgery moving quickly and the recovery process free of complications.

Eventually, you'll want to attract other surgeons to your ASC. Technology is important to surgeons. Just like you, a surgeon who's searching for an ASC wants to use high-quality devices. Perhaps the surgeon wants some flexibility as well, choosing 23- or 25-gauge needles, instead of 20-gauge, for example. The smaller-gauge needles cost more, but the end result is less time spent in surgery. Many surgeons prefer the 25-gauge needles because of the increased speed. The expense of offering several options pays for itself in time savings and surgeon satisfaction.

Always be sure to tell prospective surgeons what your facility has to offer.

Don't Rush

Before you can move your retina procedures successfully to an ASC, you need to buy new equipment, train your staff and prepare your practice for accreditation. So take a deep breath. Retinas aren't going anywhere. Take the time to do things right. Make your purchases carefully. Ensure that your staff's training suits your needs. Consider hiring key staff members who will take the lead in caring for retina patients and be resources for the rest of the staff.

And finally, before you begin performing retina procedures, spend a sufficient amount of time doing dry runs with staff and equipment. If possible, spend time observing a seasoned retina surgeon, and perform practice runs until your team is up to speed. When you have the necessary equipment and the best staff, the patients will come to you. Their outcomes will be positive and your practice will grow. nMD