In Addition …

Oculoplastics in the OASC

According to the Ophthalmic Outpatient Surgery Society (OOSS), the number of oculoplastic procedures performed in an ASC increased from 5% of overall cases in 2009 to 7% in 2010. During the same timeframe, cataract procedures decreased from 61% of the case mix in 2009 to 55% in 2010. Yet overall ophthalmic ASC net revenue remained relatively flat from 2009 to 2010, according to VMG Health, a healthcare analytics company.

Cataract reimbursements continue to decline, and ASCs may consider expanding into other specialties or subspecialties, with retina and plastics the most likely, say ASC owners. Unlike retina, oculoplastics is divided into medically necessary procedures and aesthetic procedures, such as skin resurfacing or cosmetic blepharoplasty. For some owners, that makes plastics a logical add-on choice. A recent report by the American Academy of Ophthalmology¹ suggests that upper blepharoplasty and blepharoptosis repair substantially improve vision and should be reimbursed by third-party payors; those procedures should continue to be performed in an ASC.

Opportunity for Growth

With hospitals “truly discouraging ophthalmic surgeons by giving them poor surgical times and staff who are not familiar with ophthalmology,” more and more surgeons will continue to move to ASCs, says Robert B. Nelson, PA-C, executive director at Island Eye Surgicenter (IES, Carle Place, N.Y.), and OOSS board member. IES has 35 attending surgeons, 14 of whom are physician-owners, Mr. Nelson says.

“While two of our surgeons are exclusively oculoplastics specialists, several of our other surgeons also perform minor plastics procedures,” he says. Of IES's eight founding partners, six were affiliated with Ophthalmic Consultants of Long Island (OCLI), and the ASC grew out of a need for an ophthalmic-specific outpatient facility. In 2012, OCLI anticipates “implementing a more focused business plan around aesthetics and would like to grow the cosmetic area of our business to between 30% and 50% of our oculoplastics revenue mix,” added Tom Burke, chief executive officer, OCLI.

State regulations vary but in Pennsylvania, ASCs housing one specialty only (such as ophthalmology) do not need additional certification to bring on subspecialists, explains Scott M. Goldstein, MD, Tri-County Eye (Philadelphia). “Another huge advantage to bringing in plastics is that our instruments are pretty inexpensive when compared to a refractive surgery laser,” Dr. Goldstein says. “I have three trays, and some are small, with just scalpels, scissors, forceps and a few other instruments for straightforward surgery. Another tray will have specialized instruments for lacrimal surgery, but all in all, the overhead costs for oculoplastics are not high.”

Do Your Homework

Before rushing ahead to recruit plastics specialists, current ASC owners should evaluate the challenges as well, advises William Trattler, MD, Center for Excellence in Eye Care (Miami, Fla.). Medical procedures must be performed in an ASC or hospital setting, but blepharoplasty or Botox (Allergan) treatments can be performed in either. “In some cases, it's less expensive for the patient to have the procedure done in an office instead of the ASC,” he says.

Scott Goldstein, MD, preps before surgery at Tri-County Eye outside of Philadelphia.

Postop cataract follow-up is typically day 1, so few cataract surgeons want Friday OR time, says Lou Sheffler, chief operating officer of American SurgiSite Centers. But “the surgeon needs three days for the skin to heal after oculoplastic surgery. It's a much more effective use of the OR since oculoplastics can be done later in the week.”

Mr. Sheffler says losing the New Technology IOL reimbursement of $50 for each qualifying cataract case was a big hit to revenue. He says revenue can be more easily recovered by adding a subspecialty such as oculoplastics, than by increasing the number of cataract surgeries.

Careful vetting of the oculoplastic surgeon is necessary, however, says Carlos Buznego, MD, Center for Excellence in Eye Care.

“There's a general trend in all plastics to perform more of the work in the office and reserve the more complicated cases for the ASC,” Dr. Buznego adds.

For Frank Baloh, MD, medical director, Valley Eye Surgical Center (Bethlehem, Pa.), the “numbers that come out of our center in terms of revenue per case are significantly higher than in other ASCs, and I attribute that to the plastics component.” Dr. Baloh, an oculoplastic surgeon himself says, “What an ASC earns per case for plastics is much higher than what the center earns per cataract case.” So, centers that may add plastics should consider the potential revenue stream independent of the number of cases performed. For instance, an uncomplicated blepharoplasty may cost the center $40, compared to an uncomplicated cataract surgery, which could cost up to $230 per case.

Financial Considerations

New York State has one of the most restrictive malpractice limitations in the country, and that affects the types of surgery plastics specialists can perform, Mr. Nelson explains. IES's oculoplastic specialists are limited to just oculoplastics. In other states, those same surgeons may perform breast augmentation or facelift surgery in addition to oculoplastics. Conversely, however, a surgeon with training in the broader category of plastics may also undertake orbital and globe surgery in New York, Mr. Nelson says.

Injectables such as Botox and fillers are usually given in the office but can be combined with cases in the ASC if the patient and/or oculoplastic specialist prefers. Some surgeons have noted an increase in the number of patients opting to add cosmetic services to their functional surgery.

Dr. Goldstein's patient base is comprised of about 80% functional disease, with the remainder being cosmetic or combined functional/cosmetic, he says. Because Pennsylvania doesn't have the same limits on surgeons as New York, Dr. Goldstein could spend up to 3 hours on a facelift, but “from the ASC perspective, it's much more profitable to put a cataract surgeon in that same room for 3 hours doing ten cataracts in the same time.”

For centers considering adding a plastics specialist, Mr. Nelson recommends “pre-stocking” the ASC with preferred supplies, instruments and staff who are familiar with the intricacies of orbital surgery. For plastics surgeons, ASCs may need to upgrade their surgical lighting. “When you're considering bringing on a plastics specialist, it's easy enough to put the instrument trays together,” he says. “What they really want are quality instruments and good lighting. But if that surgeon is demanding a CO₂ laser, a Fraxel laser and an intense pulsed light laser right off the bat, it may not make as much financial sense for the ASC until you know the surgeon is committed to doing those types of procedures at your ASC and that he's got the patient depth to support those expenses.”

ASCs should also ensure negotiations with insurance carriers discuss implants and tissue reimbursement at invoice or at invoice plus, says Nelson.

Adding to the financial consideration are the various fees ASCs charge for cosmetic cases. In an attempt to minimize patient costs, surgeons may negotiate special rates for OR fees, leaving the more straightforward cases to be performed in the office. Conversely, the ASC benefits from higher OR rates and additional cases. For non-physician-owners, that may impact the decision on where the procedure is being performed, Dr. Buznego says. But owners can control expansion costs by adding oculoplastics, which has a much lower overhead and a good reimbursement rate, Dr. Goldstein adds.

Most of the startup equipment needed to bring an oculoplastic specialist on board is portable and involves a minimal amount of time to properly prepare the OR, Mr. Sheffler says.

“The investment to bring on a retina specialist is much more expensive — about $250,000; for oculoplastics specialists who need a facial laser, it's about $100,000,” he states.

Dr. Baloh mostly performs functional surgery, and the initial outlay for the surgical/reconstructive component can be as little as $5,000-$10,000 for proper instruments.

“Our instruments are much less expensive than what cataract surgeons use — we've got scissors, knives, cautery units — so again, overhead isn't very expensive for an ASC,” he says. Although some cosmetic-only plastic surgeons opt for a spa-like environment, Dr. Baloh believes most patients have an expectation of what a surgical center should look like and upscale chairs or couches in the waiting area aren't necessary. However, if an ASC has a resurfacing laser and finds increasing cosmetic-only patients, it may want to consider setting aside an area solely for cosmetic patients, Dr. Baloh says.

Efficient cataract surgeons can run “a tight ship with good profit margins, but the future is unknown with reimbursement issues,” Dr. Buznego says. ASC physician-owners should scrutinize the finances before expanding, regardless of whether they decide to add surgeons or subspecialties.

Efficiencies of Scale

When Dr. Baloh moved from the hospital setting to his ASC, turnover times were substantially reduced: “The staff knows exactly what I need, and the equipment is right there. Turnover times are ridiculously fast — 7 to 8 minutes between cases,” he notes. In a hospital setting, he was able to perform about five surgeries per day; in the ASC, he's performing closer to 10.

Dr. Goldstein's ASC has two ORs, one reserved for cataract and the other for plastics. The average turnover time in between plastics cases is about 10 minutes (compared to about 45 minutes in a hospital setting).

Technology and patient volume will impact staffing as well, Mr. Burke says. “Other staffing decisions, such as hiring a front desk team member, should come from managers seeking to anticipate and improve customer service.”

Dr. Baloh believes that having staff that is dedicated to ophthalmology is what helps his three-room ASC operate efficiently.

“I've become more efficient because of the ASC's inherent efficiencies,” he says. “Our staff is dedicated to ophthalmology — they're not performing a colonoscopy in between two blepharoplasties.” At his three-room ASC, that economy of scale has allowed him to open up another day to see patients instead of scheduling OR time.

Marketing Strategies

Dr. Buznego says his ASC doesn't need much oculoplastic marketing, because it works off referrals or gains patients newly implanted with presbyopia-correcting IOLs who notice their droopy eyelids and self-refer to an oculoplastic specialist. In the Miami area, most ASCs don't want a plastic surgeon on staff, as most straightforward cases are performed in the office and play ASC facility fees off one another, he says. Surgeon loyalty for non-owners can be non-existent, so it “doesn't make a lot of sense to actively market.”

Marketing needs to fall into two separate camps, Dr. Goldstein says: the surgeon-recruiter and the ASC-recruiter.

“Patients don't really care where the location is — they're going to go where their surgeon is based,” he says. The physician is the key marketing tool. “It's all about your reputation. Happy patients will beget more patients,” Dr. Goldstein says. He “markets” by spending additional chair time with patients and being as helpful to colleagues as possible.

“Social media can be helpful, but only if you spend a significant amount of time and money on it, and it's not a great return on investment. Once a potential patient has gone to the Internet, there's so much competing information that it doesn't make much sense, from my perspective, to spend a lot of money or time in that arena. About 98% of our referrals are word of mouth and other physicians,” says Dr. Goldstein.

Mr. Burke agrees, noting, “word of mouth continues to be the biggest source of new patient referrals. Satisfied customers bring more customers/patients. Other marketing opportunities we've employed include local print ads, public relations opportunities surrounding charity care, medical screening volunteer work and advertising new devices or treatment modalities.” Among the ways OCLI achieves its growth are by increasing new patient volume for the physicians; increasing retention of current cosmetic patients; improving repeat and cross-promotional opportunities for existing patients, and leveraging existing internal and external referral sources, he notes.

“We've had successful marketing campaigns that included expanding our presence in social media, cultivating refractive patients for cross-selling, improving phone triage of potential patients and cultivating relationships with high-end spas, aestheticians, salons and health clubs,” he says.

Once the cosmetic side of the business comprises about 50% of the plastics procedures, Mr. Burke says the group would consider segregating an area to create a “softer feel.” The truly cosmetic patient needs to be treated differently from the functional surgeries, he says.

“Our plastics specialists spend more time on these cases, there's more handholding, the patient is spending more out-of-pocket money, and there's a greater discussion about what the possibilities can entail,” he says. He predicts the group will reach a 50% cosmetic volume over the next 4 years or so, mainly because the surgeons are so heavily involved on the functional side.

At Dr. Trattler's ASC, marketing focuses on the facility rather than particular surgeons, as surgeons may use a few different ASCs, negating the benefit of promoting a single surgeon over an overall specialty.

“It's easy for me to sell what I do,” Dr. Baloh says, who emphasizes that “I want to sell my niche. I don't do breast implants and tummy tucks; I do eyelids all the time. I think patients like specialists. Adding a busy plastics specialist can increase the revenue per case for an ophthalmic ASC.” ◊

Reference:

1. Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011; 118:2510-2517.