Hospitals an Increasing Presence in Ophthalmic ASCs

Surgeon and patient preferences drive change.

By Jerry Helzner, Senior Editor

The trend toward performing routine outpatient ophthalmic procedures such as cataract surgery in low-rise, patient-friendly standalone ambulatory surgery centers has been picking up momentum in recent years. The latest estimate by the Outpatient Ophthalmic Surgery Society (OOSS) indicates that approximately 75% to 80% of these procedures are now being done in the ASC environment.

The newer element in the equation is that more and more hospitals have been getting involved in ASC ownership, perhaps responding to that old adage “If you can't beat 'em, join 'em.”

From the pioneering and creative efforts in ASC ownership by the Wills Eye Health System that now serve as a model for other hospitals to follow, to more recent moves, such as Hartford Hospital's $28 million purchase earlier this year of Connecticut's largest ophthalmic ASC, there is ample evidence that hospitals have come to recognize that the ASC is a superior model for performing outpatient ophthalmic procedures.

Says Kent Jackson, PhD, vice president of member research and development for OOSS, “Ophthalmic-oriented ASCs have established themselves as the facility of choice for four of every five surgeons and patients by ensuring convenience, safety, efficiency and an exceptional level of care. The battle for customer preference was won several ago and the competitive focus is now shifting to optimizing ASC efficiency and utilization.”

Here, we will examine how some hospitals are moving to expand into ophthalmic ASCs and how surgeons who have performed outpatient procedures in both hospitals and ASCs compare the two environments.

The Wills Eye Model

To fully understand why hospitals are embracing the ambulatory surgical center model, one should first examine the experience of the Wills Eye Health System. Wills is an acknowledged innovator in hospital ownership of ophthalmic ASCs, and its initiatives in this area have been widely followed by other hospitals.

“We began moving to the ASC environment about 17 years ago,” says Joseph Bilson, executive director of Wills Eye. “We had a huge number of Wills alumni practicing in the tri-state area of Pennsylvania, New Jersey and Delaware and we wanted to stay close to our affiliated ophthalmologists.”

Mr. Bilson says the creation of a network of ophthalmic ASCs in the tri-state area offered Wills the opportunity to provide high-quality, cost-effective care in multiple convenient locations under the prestigious and highly respected Wills brand. The Wills Eye Hospital, which is located in downtown Philadelphia, would remain the foundation of the network, providing world-class expertise and state-of-the-art facilities for complicated cases, tertiary care and most retina patients.

“Initially, we studied the ASC marketplace, looked at the best existing facilities and decided to convert an existing building in Cherry Hill, New Jersey, that had been an insurance office into a two-OR ASC,” recalls Mr. Bilson. “We liked the Cherry Hill location because it was centrally located for many of our affiliated doctors.”

The success of the Cherry Hill facility led to Wills buying existing buildings in good locations such as northeast Philadelphia, Bucks County and Montgomery County and converting them to ASCs.

“Our first ASCs were 100% owned and operated by Wills, but about 10 years ago the market opened and it became easier for doctors to obtain an ownership stake in an ASC in Pennsylvania,” says Mr. Bilson.

Rather than lose key doctors who were high-volume users of its ASCs, Wills changed course and began to offer partnership arrangements, with Wills remaining the majority owner of all its branded ASCs. Today, the Wills ASC network encompasses nine facilities, with a primary emphasis on ophthalmic procedures and a few offering other specialties such as pain management, hand surgery and gastrointestinal procedures.

Qualifying to Use a Wills ASC

Because of the high confidence that patients in the tri-state area have in the Wills name and reputation, there are always surgeons eager to perform their ophthalmic procedures in a Wills-branded ASC.

“We are open to non-owners doing procedures in a Wills ASC, but they need to go through a robust credentialing process,” says Mr. Bilson. “It's stringent, very rigorous review conducted by doctors.”

Mr. Bilson says credentialing new surgeons to use Wills-branded ASCs is also based on the available space that each ASC has for additional procedures.

“A new surgeon can begin using a Wills ASC and eventually obtain an ownership stake, either from Wills itself or from a surgeon who is retiring,” Mr. Bilson explains. “I truly believe that surgeons want to be in our network more for the quality, convenience and patient-friendly environment of our ASCs than for any financial return they can earn.”

Wills Looks Ahead

Now that Wills has found a winning formula for ASC success, further expansion is in the works, whether it takes the form of ASC ownership, development, management, operation or any combination of those functions.

“Our plan is to add strategically,” says Mr. Bilson. “The ASC network helps us grow our tertiary business, as the network refers the more complicated cases and patients diagnosed with retina problems to our downtown facility.”

Geographic expansion is probably also on the agenda.

“We have considered going into new geographic areas,” says Mr. Bilson. “Look at all of the retirees from the tri-state area who are now living in Florida. The Wills name means a lot in Florida. That is one area we would strongly consider for future expansion.”

Why Surgeons Prefer ASCs

Ophthalmic surgeons who have had experience performing procedures in both hospital outpatient departments and in standalone ASCs tend to be almost unanimous in preferring the ASC environment.

Matthew Nutaitis, MD, is an ophthalmologist employed at the Storm Eye Center of the Medical University of South Carolina (MUSC) in Charleston. Dr. Nutaitis is in a good position to compare the two environments because he uses both routinely.

“At the hospital, we can perform procedures at our multispecialty Rutledge Tower surgery center, and since 2006 we also have the MUSC Storm Eye Ambulatory Procedure Center (APC), which is in a separate building five miles away,” says Dr. Nutaitis.

Dr. Nutaitis says the main advantages of the offsite APC are a stable, specialized staff and less downtime between cases. He notes that convenient parking for patients is available at both the APC and Rutledge Tower.

“The Rutledge Tower techs I work with are 85% to 90% specialized in eye procedures but there are some cross-trained techs who will rotate into other specialities,” says Dr. Nutaitis. “I would say that the APC is preferred by our doctors though it can mean some additional travel to use the offsite facility.”

Interestingly, some MUSC ophthalmic outpatients prefer to have their procedure performed in the hospital.

Hospitals, such as Hartford Hospital (left), have been transitioning their outpatient ophthalmic procedures to convenient, patient-friendly standalone ASCs. Hartford Hospital acquired this large ophthalmic ASC (right) in Newington, Conn., earlier this year. PHOTOS COURTESY OF HARTFORD HOSPITAL

“They may think that the hospital has more back-up for emergencies,” says Dr, Nutaitis.

The ability to do more cases in a highly efficient ASC may be important to a hospital-employed ophthalmologist whose compensation is based on a “salary/plus” formula that encompasses productivity. There appears to be a growing trend for more ophthalmologists to forgo the uncertainties of private practice and be directly employed by hospitals.

Dr. Nutaitis notes that the Storm Eye APC welcomes outside surgeons and will offer them block time if they successfully pass the credentialing process.

“Capital equipment for the APC is purchased through the hospital,” says Dr. Nutaitis. “The surgeons definitely have input into this process. We put in a request for a new microscope and received it as a need-based priority. Our retina equipment has also been upgraded and we receive money for special projects. Overall, we are definitely satisfied with the level of the equipment we have in the APC.”

Salim Butrus, MD, of the Eye Center on Capitol Hill, Washington, DC, is another surgeon who uses both an ASC and an in-hospital OR for his procedures.

“I began doing outpatient procedures in a hospital in 1992, but about a year and a half ago I acquired ownership shares in the Surgery Center of Southern Maryland in Clinton, Maryland.”

“One of the big advantages of the ASC is less down-time,” he says. “I can do two procedures an hour in the ASC, and I cannot match that in the hospital. Also, I can do YAGs very efficiently in the ASC. In the hospital, doing YAGs is a very complicated process. It means going to a different floor and finding a nurse.”

Dr. Butrus finds that cataract surgery patients overwhelmingly prefer the ASC environment.

“With the hospital, there is more paperwork, more bureaucracy, longer waits for patients because they have to go through admissions, more work-up and it's just a bigger building that the patients have to deal with,” he says. “For me and the patients, the ASC is better, less frustrating.”

Dr. Butrus does prefer using the in-hospital OR for more complicated cases such as corneal transplants and implantation of artificial corneas. “Plus, I like teaching at the hospital so I think it is important that I continue to do some of my cases there,” he concludes.

A Big Step for Hartford Hospital

When Hartford Hospital purchased full ownership of the Newington, Conn., ophthalmic ASC from Constitution Surgery Centers and its 30 ophthalmologist-owners earlier this year, Hartford Hospital administrators were candid in declaring that their goal was to follow the Wills Eye model. Their aim is to establish a regional center for eyecare excellence that will attract patients from throughout the state. They also cited the timing of the purchase, given that Connecticut is a state with an aging population demographic, a fact that will increase the number of cataract and other ophthalmic surgeries in the coming years.

Prior to the Newington acquisition, Hartford Hospital was not a major factor in outpatient ophthalmic procedures, with a core group of surgeons performing an estimated 800 eye procedures a year onsite as opposed to the approximately 11,000 procedures a year being performed at the Newington center.

Cheryl Ficara, vice president of patient care services at Hartford Hospital, says that the transition to full hospital ownership of the Newington facility has been going well, with many of the ophthalmologists who have used Newington in the past already affiliated with the hospital.

“We have credentialed all of the original owners (of Newington) and are open to new surgeons using the facility as well,” says Ms. Ficara. “The Hartford Hospital is now the sole owner of the facility but we have established a governing structure that includes both surgeons and the hospital.”

Ms. Ficara says the ophthalmologists who previously had ownership stakes in Newington will derive new advantages by being part of the hospital. These advantages will include using the hospital's supply management system and having access to the hospital's extensive medical resources and financial clout. In addition, retina specialists will soon be able to use the Newington facility to perform outpatient procedures.

“This facility provides the perfect environment for outpatient ophthalmic procedures,” asserts Ms. Ficara. “We have a stable, very focused staff in a setting that is comfortable for both patients and surgeons.”

Ms. Ficara says Hartford Hospital is open to adding additional ASCs in the region to its network. OM