Taking the Pulse of Your Ophthalmic ASC

Clinical and business benchmarks from the Outpatient Ophthalmic Surgery Society’s annual survey.

By Virginia Pickles, Contributing Editor

The news is good for ambulatory surgery centers specializing in ophthalmic procedures, says Kent Jackson, PhD, vice president of member research and development for the Outpatient Ophthalmic Surgery Society (OOSS). Dr. Jackson has been hunkered down, crunching the numbers from the fifth annual benchmarking survey, which reflects activity in the calendar year 2011. Although there were no dramatic changes compared with 2010, Dr. Jackson notes revenue and profitability increased, suggesting tighter management and improved productivity, while quality and safety were maintained at a high level. Here are some highlights from the latest report.

Efficiency and Productivity

In the 2012 survey, facilities reported average case times for cataract, retina, glaucoma and oculoplastic surgeries, breaking down total case times into pre-, intra- and postoperative times for each procedure (Table 1). Trend data are available for cataract cases only, as 2012 was the first year the survey included case times for the other procedures.

“We saw a downward trend in total average case time for cataract surgeries in 2011,” Dr. Jackson says. “The overall time of 86 minutes represents a decrease of 6 minutes, or 5%, compared with 2010. The reduction occurred primarily in preoperative time with a slight decrease in postoperative time. This suggests facilities have improved preoperative and pre-arrival patient preparations and recovery care, and it may be related to an increase in overall staffing also noted in the survey.”

According to Dr. Jackson, several OOSS Benchmarking Roundtable experts suggest reduced case times may be associated with implementation of EMR systems and enhanced patient screening and scheduling. For example, with EMR, pre-op and post-op orders, consent forms, post-op instructions, discharge summaries and operative reports are computer-charted and ready for all users to access at the same time, improving overall efficiency.

This improved efficiency may seem at odds with a 9% decrease in the average number of reported cases per day: 20 cases in 2011 versus 22 in 2010. Dr. Jackson suggests the difference may result from an increase in the number of more complex cases, including retina, glaucoma and oculoplastics, being performed in the reporting facilities.

Overall employee hours per case increased slightly from a median of 6.5 hours in 2010 to 7 hours in 2011, with clinical employee hours per case averaging 5 hours per case and business employee hours averaging 2 hours per case (Table 2).

Quality Measures

OOSS has been tracking incident measures for several years, aligning them with the same categories used by the ASC Quality Collaboration (www.ascquality.org) and, more recently, with mandated quality requirements for Medicare-certified ASCs.

Dr. Jackson notes a slight uptick in hospital transfers and postsurgical readmissions to the ASC in the 2012 survey. “Neither would appear significant,” he says. “Postsurgical readmissions are primarily the physician’s call and are related to surgical outcomes. Hospital transfers are typically unrelated to surgical issues and can be addressed by employing and adhering to patient selection criteria coupled with sound preoperative screening.” To put these and related data into context, 71% of facilities reported no postsurgical readmissions; 51% reported no transfers to a hospital from the ASC; and 95% of facilities reported no admissions to an emergency department within 72 hours of surgery (Table 3).

“We will be watching these measures closely with the 2013 survey of 2012 performance to see if any measurable trends are developing,” Dr. Jackson says. “It’s important to note that the rate of hospital transfers for all ASCs, as measured by the ASC Quality Collaboration, has been trending up. The rate for ophthalmic-driven benchmarking facilities is 0.63 per 1,000, which is about half the rate for all ASCs (1.19 per 1,000), as reported by the ASC Quality Collaboration.”

As for incidents of errors, inflammation and infection, the 2012 OOSS survey of 2011 results indicates no apparent change from data reported for 2010. “It’s notable that ASCs in general are reporting a downward trend in the aggregate of these measures, according to the ASC Quality Collaboration,” Dr. Jackson says. “While small, the aggregate across all ASCs is less than for ophthalmic ASCs, and this is associated with the wrong implant measurement for ophthalmic ASCs. All ASCs reported an aggregate measure of 0.045 per 1,000 for 2011, compared with an ophthalmic ASC aggregate measure of 0.12 per 1,000. The wrong implant measure is separated out in the OOSS benchmarking survey and in 2011 accounted for 0.08 per 1,000, or 67% of the aggregate.”

For the first time, facilities were asked about the incidence of toxic anterior segment syndrome (TASS), endophthalmitis and methicillin-resistant Staphylococcus aureus (MRSA) (these two infections were combined in one question) and torn capsule requiring vitrectomy. The survey found the following:

• 89% of facilities reported no cases of TASS, for a mean incidence rate of 0.16 per 1,000 cases

• 64% reported no cases of endophthalmitis or MRSA, for a mean incidence rate of 0.30 per 1,000 cases.

Dr. Jackson notes the aggregate of these two measures in 2010 was 0.36 per 1,000 cases, slightly less than the aggregate of 0.46 in 2011.

The mean incidence rate for torn capsule requiring vitrectomy was 3.97 per 1,000 cases; 27% of facilities reported no cases of torn capsule requiring vitrectomy. Dr. Jackson notes this measure was also new in the 2012 OOSS benchmarking survey and is related to a more detailed breakdown of cases into planned and unplanned anterior and posterior vitrectomies. “The 2012 survey was the first to break out vitrectomies in this manner,” he says. “The combined percentage of cataract cases with a vitrectomy is down from 3.9% in 2010 to 1.13% in 2011.”

Same-day cancellations were also addressed in the process measures section of the 2012 survey. “This measure was refined to substantially hone in on more specifics to aid facilities in evaluating and addressing cancellation concerns,” Dr. Jackson says. (We take a closer look at same-day cancellations on page 16.)

Business Benchmarks

“Revenues as measured by net collections increased in all areas this year — per case, per facility, per square foot and per full-time equivalent (FTE) employee — all boding well for income trends,” Dr. Jackson says. Specifically, the survey found the mean for all facilities as follows:

• $960 per total cases reported

• $686 per square foot

• $342,232 per total FTE employees (FTE=2,080 hours/year)

“When revenue per square foot increases, it signals increases in case volume, case mix and reimbursements and improved management of accounts receivable, all contributing to enhanced utilization of facility space,” Dr. Jackson explains. “It’s up to each facility to identify how these factors influence their results.”

Accounts receivable for 2011 were about the same as reported for 2010, with 69% of accounts receivable aging 0 to 60, days down slightly compared with data reported for 2010. Accounts receivable aging 61 to 120+ days, representing 31%, were up slightly compared with 2010 data.

Total surgical supply expenses in 2011 were about the same as expenses reported for 2010; however, cataract supply expenses as a percentage of ophthalmic surgical supply expenses increased by nearly 10%. “Interestingly, the relative expenses associated with standard and toric IOLs were down slightly from the prior year, while total expenses for premium IOLs were about the same, but unit costs were up slightly,” Dr. Jackson says. Specifically, average unit costs were $111 for a standard IOL, $488 for a toric IOL and $897 for a premium IOL.

Most expense measures were down, except for a notable increase in labor costs. Total costs, including supplies, labor, general and administrative, and occupancy costs per case were $673 in 2011 versus $752 in 2010. Total occupancy costs (rent, insurance, utilities, taxes, etc.) were about the same at $50 per square foot, while total labor costs per FTE employee rose from $61,000 in 2010 to $67,606 in 2011. “In cross-checking several data points, it appears facilities added staff and increased overall compensation for staff in 2011,” Dr. Jackson says. “We will be watching 2012 year-end results to see if this trend continues and how cost measures relate to revenue measures. It may be that facilities were anticipating a rise in case volume and invested in their staff accordingly. If so, other measures related to bottom-line performance suggest that investments in staff are paying off.”

“The combined percentage of cataract cases with a vitrectomy is down from 3.9% in 2010 to 1.13% in 2011.”

—Kent Jackson, PhD, vice president of member research and development at OOSS

Overall Financial Performance

Overall, the net income ratio for most facilities improved. Dr. Jackson attributed this improvement primarily to reduced general and administrative costs (down 3% from the prior year) and reduced occupancy costs in relationship to net collections. “This suggests a better utilization of overhead costs in light of some increased revenue,” he says. “We see modest evidence of an increase in overall case volume, with a modest change in case mix. In general, cases appear to be taking more time and attention and requiring more staff, while facilities are ably managing the bottom line (Table 4).”

The Benefits of Benchmarking

The 2012 OOSSMark Benchmarking Survey program represents the only comprehensive benchmarking program that focuses on the ophthalmic-driven ASC. It’s designed to enable the ophthalmic ASC industry to fairly compare the performance of facilities across a number of measures deemed useful for quality and performance improvement, and to address the recommendations of accrediting agencies and clinical and business experts. The program attracts more than 200 U.S. facilities. Participating facilities contribute data annually and provide ongoing input to refine and enhance the program. The 2013 survey, capturing year-end results for 2012, will launch in June. ◊