Two Approaches to Including VR Surgery in the ASC

A retina surgeon shares years of ASC experience, while a cataract surgeon explains how his ASC added vitreoretinal services.

By Victor Gonzalez, MD and Jay Pepose, MD, PhD

Victor Gonzalez, MD: My partners and I started our first ASC in 2001, based primarily on retina surgeries. Reimbursements weren’t very favorable at that time — a basic vitreoretinal procedure carried a $630 reimbursement — so we were very selective, referring all cases that required heavy liquids, silicone and the like to the hospital. With a balance of cash patients and patients from across the border in Mexico, we were able to make it work.

Over the years, reimbursements have more than doubled to over $1,500 and the number of covered procedures has improved significantly, enabling us to increase our vitreoretinal case volume in the ASC. We enjoy the setting, and our business approach has made our ASC profitable.

Why Retina Surgeons Choose ASCs

Several things attracted my partners and me to the surgical center setting. Compared to the hospital, there’s much less personnel turnover — no more teaching staff how to perform the procedure every time we go into surgery. That means less frustration for surgeons, better overall efficiency and faster turnover times. The increased efficiency in the OR allowed me to perform more cases in the same time, which meant I could either see more patients in the office or enjoy more free time.

The ASC also provides more access to cash-paying patients — not only people without insurance, but also patients who have Medicare with no secondary insurance. For these patients, 20% of the ASC bill is more affordable than 20% of the hospital bill, and that’s been important for patients in my region.

In our center, we streamlined the work by dividing procedures among six surgeons according to who worked most efficiently and had the best outcomes in different areas. Some doctors excelled at macular holes and epiretinal membranes, while others preferred the heavy-duty tractional cases and other complex problems. Our efficiency and outcomes have always been very good and I believe that success is a direct result of a careful division of labor.

We also appreciate the benefits to our patients. As I pointed out, the ASC is less expensive for them. Patients and their families also tell us they feel comfortable in the friendly, non-threatening ASC environment. I sincerely believe that performing these procedures over and over again with experienced doctors and staff reduces complications and improves patient safety.

Getting an ASC Started

If you’re starting a retina ASC from scratch, in addition to the cost of the facility itself, you’ll need to invest somewhere around $250,000-300,000 in equipment and supplies. If you already have an anterior segment ASC, that cost may be reduced because you’ll already have certain types of equipment, such as cryo units and microscopes.

I recommend starting a discussion with the doctors to see if you can arrive at a consensus about which equipment and supplies they’re most comfortable using. Any time you can use one device for both cataract and retina patients, you save money. For example, we perform endoscopic vitrectomy — an ability that distinguishes us and brings other retina specialists to the facility — and our glaucoma group uses the same device for endocyclophotocoagulation. Short term, a single device means you have only one capital investment. Long term, you not only limit yourself to one service contract, but you also free up valuable space in the OR, reduce turnover time and significantly decrease staff training costs.

For supplies, buying groups are important. You’ll be surprised at how much you’ll save buying simple items, such as sutures, through a buying group, compared to buying them on your own. And just as we did with equipment, we also planned to standardize the supplies, using the same cassette for anterior and posterior surgeries, for example. That means fewer packs sitting on the shelves.

In fact, because my partners and I didn’t want to have a great deal of supplies sitting on shelves, so we set up a good inventory control process. One of our staff members is responsible for ordering exactly what we need with just the right timing. This person also ensures that we have purchase contracts that make sense and that we don’t let them expire — an oversight that can significantly raise costs.

Good Business Sense

Whether you’re starting from scratch or adding a new procedure to your surgical center, I can’t over-emphasize the need for due diligence. After evaluating all the benefits, costs, and other factors, you have to ask, “Will we make money?”

Sit down with your partners, your accountant, your administrator, and your staff, understand the numbers, and be sure you can make them work. In addition to the equipment and supply costs, keep in mind that retina cases take longer than cataract cases. There is a higher cost per procedure, but reimbursement per procedure is higher if you have the right mix of cases (i.e., not a mix of cases averaging more than 45 minutes). Staff training is another investment, and you must follow surgical staffing requirements for your state.

Financial calculations reveal if you can be profitable, and they provide a good basis for negotiations. You can tell a device manufacturer, “I can’t make it on the price you’re asking” and possibly negotiate a better price.

The number of retina procedures performed at ASCs will increase, driven by improved reimbursement and benefits to both surgeons and patients. As our ASC has grown in its vitreoretinal services over the years, a sensible business approach, including the right mix of cases, has helped us to become successful.

Second Approach: Adding VR Surgery to a Cataract ASC

Jay Pepose, MD: When we decided to add vitreoretinal surgery to our cataract-based ASC, my partners and I knew we had several tasks in front of us. First, we had to recruit a retina surgeon who would help build the reputation of the ASC, increase profitability and be a good fit for our team. Next, we needed to consider the implications for the business and facility. We also had to train our staff. The integration was a smooth one and it was well worth the investment.

Recruiting a Retina Surgeon

My partners and I decided to recruit a retina surgeon to our practice as well as our ASC, although each place carries a slightly different list of criteria. For the ASC, we wanted a competent surgeon who would elevate the ASC’s reputation and have few patients returning for repeat surgeries. Efficiency is important as well. Surgeons don’t have to be the fastest, but they must be meticulous and methodical, working in a rhythm, not taking so long that hospitals have asked them not to come back.

To find out what characteristics surgeons show in the OR, I asked OR nurses for their experienced, up-close objective opinions. These discussions also helped me identify which surgeons work well with support staff, and that’s key because nobody wants conflicts that might lead to the loss of good staff members.

If you want the surgeon to work in your practice as well as your ASC, you have a few other things to consider. Obviously, you want the vitreoretinal surgeon to be competent and personable. You want him or her to share the core values of your practice, as it relates to delivering a high level of patient care and patient satisfaction. If you take part in clinical research, ideally so should the new surgeon.

It’s also important to find someone who is eager to meet other doctors and participate in activities that grow the practice, such as providing community education or networking with optometrists, ophthalmologists and other doctors, such as endocrinologists, to cultivate referrals.

Once you’ve identified the best candidates, be prepared to promote the benefits of accepting the position. Show them that by joining your successful practice and ASC, they’ll have the opportunity to treat retina needs for your existing patients and the opportunity to work with your referral network. And because many studies now require teams with both anterior and posterior segment surgeons in order to qualify, the partnership creates new opportunities for clinical research for both specialists.

Merging Specialties

As we recruited a retina specialist to our practice and ASC, we also prepared the business for change. One critical piece is the case mix. We don’t cherry-pick our cases, but we find that the ASC is best suited for cases that can be treated in an efficient way (for example, puckers, holes, peels and retinopathy in relatively controlled diabetic patients). Cases that may require general anesthesia are less cost effective, as are long cases requiring silicone or perfluorocarbon and extensive retinopathy in uncontrolled or undertreated diabetic patients. These types of patients, some of whom may present a higher risk when using anesthesia, are probably best managed in a hospital setting.

In addition, after focusing on reimbursement for the anterior segment, our administrator had to review our contracts and negotiate with certain carriers on reimbursement for retinal cases. Your practice may even have agreed to low reimbursements for vitreoretinal cases (some reimbursements are lower than Medicare), assuming that there would be no impact since these were not being performed anyway. Now there will be an impact, so you will need to renegotiate.

Scheduling is another consideration. We found that rather than having both specialties working concurrently, the best way was to dedicate a half-day block of time for vitreoretinal surgery. We scheduled it after the anterior segment surgery because it usually has a rapid turnover and ends at a predictable time. In comparison to anterior segment surgery, retina surgeries have fewer turnovers and use one OR.

Retina surgery also requires additional equipment in the OR. One value has been our premium combination vitreoretinal device, which can be used for both anterior and posterior cases. One device takes up less space than two, is more cost effective and reduces the need for two maintenance contracts. We use it for both specialties and our staff was already familiar with the basics of the system. This brought us to another important chapter in integration: transitioning our staff.

Transitioning Staff

The staff’s transition can make or break the integration process. First, schedule a training period during which the vitreoretinal equipment manufacturer trains the team. Like us, you may also consider hiring an outside proctor to spend several days training the staff and getting them into the flow while performing mock procedures. We encouraged our staff to ask questions and get practice with the new procedures, such as drawing up gas and handling buckles. This helped make everyone feel comfortable.

Both the manufacturer’s representative and the proctor were present for our retina surgeon’s first few days of surgery, which really helped to facilitate the transition.

Our staff saw the advantages for themselves as well as the practice. They grew professionally, gaining new competencies, and there’s added variety in their day.

Advantages for Patients

Adding vitreoretinal surgery to your ASC has tremendous value from your patients’ perspective. Patients can undergo diagnostic testing, such as fluorescein angiography, that you may not have been able to offer in the office. More remarkably, their view of the practice is enhanced when they see your ability to meet all of their needs.

Now, your vitreoretinal expert is able to add to patient education on retina conditions. And because many patients who need vitreoretinal surgery have undergone cataract surgery in the past, they can receive additional care in a familiar place, often with familiar staff. I’m always referring patients to the retina doctors, and retina is referring patients to me and my partners. These synergies make the facility friendlier to patients, differentiate us as a full-service practice and ASC, and ensure that our patients are very satisfied. ■