Options for the Lower-Volume Refractive Surgeon

Mobile lasers and open access offer cost-effective convenience

By Jerry Helzner, Senior Editor

For the refractive surgeon who does laser vision correction on anywhere from two to 40 eyes a month, purchase or lease of an excimer laser — and probably a femtosecond laser as well to meet increasing patient demands for a bladeless procedure — is not usually a cost-effective option. However, there are hundreds of ophthalmologists around the US who regularly perform high-quality laser vision correction on patients but find themselves in the “lower-volume” category. Fortunately, all of these doctors can use either a mobile laser service or, in more heavily populated areas, do their surgeries at an open-access center. This article will examine the attractiveness of both options.

Two Different Services

At first glance, one might think that so-called “roll-on, roll-off ” mobile laser services, a sector in which Sightpath Medical is the pre-eminent provider, are in direct competition with open-access centers. But though some refractive surgeons in urban and suburban areas may be able to choose between mobile and open access, the target markets for each option are essentially different.

A manufacturer-certified Sightpath technician sets up an IntraLase femtosecond laser at a practice that uses the company's mobile laser service.

“Our basic strength is with ophthalmologists in rural areas in which the population base to draw patients from is fewer than 150,000 people,” says Jim Feinstein, senior vice president of sales and marketing for both Sightpath Medical and its parent company, TLC Vision.

Sightpath has found a sweet spot in rural markets for two basic reasons. First, there is no competition from open access in these less-populated areas. Second, the demand for refractive surgery in most rural markets is usually not great enough to warrant the practice's purchase of a fixed laser installation.

However, for the ophthalmologist who is regularly performing laser vision correction on anywhere from eight to 30 eyes a month, a mobile laser arrangement provides an attractive solution. It offers a convenient and cost-effective way to both meet patients' needs and expand the scope of the practice. If procedure volume continues to increase, the practice can lease its refractive lasers from Sightpath so that procedures can be scheduled at any time.

“With the mobile lasers, we provide flexible scheduling,” says Mr. Feinstein. “The number of days the surgeon needs the laser(s) is dictated by procedure volume. We can schedule one day a month, back-to-back days or every other week.”

Mr. Feinstein says about 50% of the approximately 400 ophthalmologists in 46 states who use Sightpath's mobile laser services have both an excimer laser (either a VisX S4 or an Allegretto) and an IntraLase femtosecond laser delivered to their practices.

“The number of practices now using the IntraLase is definitely increasing,” notes Mr. Feinstein.

Each laser arrives at the practice in a specially designed protective carrier and with its own manufacturer-certified technician. On average, each laser is delivered to about 10 practices a month.

“Everything is covered under a single, per-procedure (per eye) fee for the use of each laser,” says Mr. Feinstein. “It's basically a turn-key package.”

However, there is one significant caveat regarding the mobile laser service.

“The practice must have the space and meet the environmental considerations to use a mobile laser,” says Mr. Feinstein. “Some practices that wanted to offer onsite refractive surgery have built out their facilities to accommodate the mobile lasers. This can cost approximately $10,000 to $15,000, depending on the practice, but many doctors consider it a positive enhancement to their practices — and appealing to patients — to be able to perform refractive surgery right in their own facility.”

Professional Support

Louis Probst, MD, of Chicago, who serves as medical director for TLC/Sightpath, is quite familiar with the company's mobile lasers. Despite being a high-volume surgeon, he also uses the mobile service.

“I perform the great majority of my refractive procedures at TLC centers in Illinois, Wisconsin and South Carolina, but I also have an office in Hilton Head, SC, where I have the mobile lasers delivered every two months. After working with fixed laser systems in the three TLC centers, I was pleasantly surprised at how precise and well-calibrated the mobile lasers are.”

Dr. Probst notes that ophthalmologists who use the company's mobile lasers are able to get regular advice and guidance from some of the nation's top refractive surgeons, including Drs. Richard Lindstrom, David Hardten, Eric Donnenfeld and Dr. Probst himself.

“The conference calls and guidance are all part of the package,” says Dr. Probst. “It helps these doctors to know that they are not working in isolation. They are part of a team with a support system.”

A Cooperative Effort in Open Access

Back in 1999, Edward Rashid, MD, and seven other San Antonio, Texas, ophthalmologists got together, formed an ownership group, and built the Alamo Laser Vision Center. The thought was that instead of each practice incurring the expense of buying its own laser(s), the ownership group would share the costs and be able to purchase the best technology available for performing LASIK and PRK. The group would also allow non-owners to use the center if these surgeons had adequate training and experience.

Dr. Edward Rashid at the Alamo Laser Eye Center he heads in San Antonio, Texas.

“The concept made a lot of sense to us,” says Dr. Rashid, who serves as president of the facility's board of directors and medical director of the laser center. “We wanted a standalone facility so that you didn't have to bring patients to another doctor's office. The arrangement has worked out very well for us, especially in terms of getting through this economic downturn.”

Dr. Rashid notes that the larger group of surgeons “has allowed our center to have IntraLase, AMO VisX and an Alcon Wavelight available.”

The laser center, which employs one part-time and two full-time technicians, has experienced procedure volumes varying from 70 to 200 cases a month, with individual surgeons performing anywhere from two to 60 procedures a month.

“The key to success is having the right surgeons who can be a bit flexible and work together for the common good,” says Dr. Rashid. “Not everyone can do that. But we have rarely lost a surgeon to another facility. Our techs are very experienced and they can make adjustments to fit each surgeon's needs.”

The Alamo Laser Center has done so well that other groups of surgeons have visited the facility, intending to use it as a model for their own open-access facility.

Three Centers in California

Jay Bansal, MD, who operates three open access refractive centers in the Northern California area, was a pioneer in performing LASIK in Northern California. He took part in clinical trials, did his fellowship in cornea and was among the first to offer LASIK as part of his regular practice in 1996.

“When I got my first VisX laser, I also offered to train other ophthalmologists who were interested in learning the procedure,” says Dr. Bansal. “Since they learned on my laser, after they achieved proficiency with the procedure I invited them to do their cases at my practice.”

Dr. Jay Bansal performs a refractive procedure at one of his three open access centers in Northern California.

Many of the refractive surgeons originally trained by Dr. Bansal have stayed with him and continue to use his three LaserVue open-access centers in Santa Rosa, San Francisco and Walnut Creek. Dr. Bansal's centers offer the VisX S4, the Allegretto and IntraLase lasers.

“Most of these doctors have been with us for 13 or 14 years,” he says. “When a new doctor asks to use the center, I make sure that he or she is qualified to perform these procedures. I check their credentials and personally observe the first few cases. I also provide additional training to those doctors who request or require it.”

Dr. Bansal says open access provides the most convenient arrangement for lower-volume refractive surgeons.

“They can do one or two cases a month at our centers — you wouldn't order a mobile laser for one case a month,” he notes. “The doctors come here and they work with the same staff and techs that they have been working with for years. They can schedule in blocks or even just call in the morning and say they would like to do a case over the lunch hour. Given the slow market for LASIK right now, scheduling convenient times is definitely not a problem.”

Ophthalmologists who practice in academic settings make up another target market for open access centers, as academic practices often do not include a laser suite for refractive procedures. Thus, these ophthalmologists take their refractive patients to a conveniently nearby open-access center. Most academic practices are in urban areas where open-access centers are generally available.

Dr. Bansal says he believes open access is the most cost-effective arrangement for lower-volume refractive surgeons.

“We have the most precise and advanced lasers, so the doctors get to work with the best technology available. We have only three basic fee structures — standard LASIK, custom LASIK and an additional fee for using IntraLase.”

When Surgeons Can Choose

Open-access arrangements can be made by surgeons at the 50+ TLC Laser Eye Centers. This allows lower-volume refractive surgeons located in urban or suburban areas near those centers to have an association with TLC/Sightpath either through mobile lasers or by using the fixed lasers at the company's centers. The cost to the surgeon is higher on a per-eye basis if procedures are performed at the TLC center, where incremental fees for use of the center, its staff and supplies are charged.

“We have had surgeons who started by using the centers and later switched to a mobile arrangement,” says Mr. Feinstein. “And we have also had surgeons who started with mobile and later switched to using the centers to do their surgeries. It comes down to what they find the most convenient and where they feel the most comfortable.”

Overall, Mr. Feinstein believes that most of the refractive surgeons who have arrangements with the company prefer the mobile lasers. “When a surgeon performs the procedure right at the practice, it's perceived as part of the practice, which most of our doctors look upon as a positive,” he says. “It adds an element of prestige and having ‘laser days’ creates enthusiasm within the practice staff.”

One More Category

In addition to lower-volume refractive surgeons, there exists a small number of strictly medical ophthalmologists who occasionally have a patient who would like laser vision correction. These “no-volume” doctors can actually participate in the care of refractive patients by referring them to a refractive surgeon in a co-management arrangement. In this way, the patient gets the refractive procedure and still has the security of knowing his or her regular ophthalmologist will be involved in postoperative care. OM