OASC | RETINA

Retina Surgery

Finding the right fit for your ASC.

By James Knaub, Contributing Editor

Should you bring a retina surgeon into your ASC?

If you’re a vitreoretinal subspecialist, should you move your surgery to an ASC?

Experts on both the facility and the surgeon side agree that technology and technique have evolved to where it’s feasible to provide quality, efficient retina surgery in an ASC.

“Vitreoretinal surgery has a long history of being a hospital-based, and often an inpatient, procedure. But technology and training have changed and moving retinal surgery to the ASC is a natural evolution, not a radical shift,” says Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona, Clinical Professor of USC Eye Institute and a founding partner of Spectra Eye Institute. Dr. Dugel, who has performed most of his retina surgery in ASCs since the 1990s and is co-owner of his own facility, believes ASC operators and retina specialists should explore working together — but doing so is not a foregone conclusion. He believes operating in a well run ASC offers advantages in quality, cost and patient experience, but warns that the wrong ASC relationship can threaten the referrals that are the lifeblood of a retina practice. For example, a retina surgeon who joins a primarily general ophthalmologist-owned ASC may risk losing referrals from the center’s general ophthalmology competitors.

“In a consulting practice, it’s always important to keep in mind that referrals are your first priority,” Dr. Dugel says. (See The Retina Surgeon’s Perspective.)

While the retina surgeon must carefully assess referral relationships before joining an ASC, the facility’s chief concerns are the economics of adding retina surgery and finding an efficient, compatible surgeon. From the economic perspective, adding retina surgery starts with the idea that most ASCs are significantly underutilized, says Stephen C. Sheppard, CPA, COE, the managing principal of Medical Consulting Group. When you consider the time physicians are out of the office for vacation and conferences, plus the cases that could be added through improved efficiency, Mr. Sheppard says most ASCs have the capacity to add a significant number of cases.

“It’s rare to find an ASC with a utilization rate above 55% or 60%,” Mr. Sheppard says. “Most have much more available capacity than they think they have.” Filling one-half of that typically available capacity could translate to a 50% boost in volume or revenue, depending on a facility’s case and payor mix.

While posterior segment procedures generally require more time, their facility fee reimbursement is higher. Mr. Sheppard says the national average facility fee that covers about 80% of the common retina CPT codes is $1,680, compared to $945 for cataract surgery. That means two retina procedures can generate the same facility fee reimbursement as 3.5 cataract cases. Retina patients also tend to be younger than cataract patients and more likely to have commercial insurance that reimburses better than Medicare, according to Mr. Sheppard. Those factors need to be considered in business plan revenue projections.

Offering retina surgery also adds significant costs. Mr. Sheppard says it can easily cost $200,000 to $300,000 to add the service to an ASC — including a vitrector with a 532 nm laser, instruments, surgical trays, cryo equipment and an operating microscope with an indirect view system and image capture. He notes that if an ASC already owns upgradeable surgical microscopes, it may be able to reduce that cost by $70,000 to $90,000 by only adding an image capture system rather than purchasing a new microscope.

Start-up costs are also affected by whether the ASC already has a Class C operating room and whether or not it will provide general anesthesia. Mr. Sheppard says that bringing in a retina surgeon who will utilize general anesthesia helps an ASC support its anesthesia staff.

Consumable supplies are another considerable cost consideration Mr. Sheppard says vitrectomy case packs typically cost $325 to $600 per case and silicone oil and perflurocarbon liquid are in that same price range. Finding an efficient surgeon who stays current on technique is important to the ASC because he or she will tend to use silicone oil and perflurocarbon liquid in fewer cases.

“Efficient surgeons should be using silicone oil and perflurocarbon in 5% to 15% of cases,” Mr. Sheppard says. “If they’re using them in 50% of cases, they probably shouldn’t be operating in your ASC.”

He says finding an efficient, compatible surgeon is the best indicator for success in an ASC arrangement. He notes that surgeon efficiency is more important in an ASC because it receives only about 56% of the facility fee that hospitals receive per procedure for a Medicare case. The difference between 60 minutes per case and 2 hours per case is significant over time.

Dr. Dugel agrees with the need for efficiency. “Both the surgeon and the ASC have to be totally committed to efficient, quality care,” he says. Efficiency is more important than high volume. You don’t need to perform 15 or 20 cases a week for a move to an ASC to make sense; Dr. Dugel says five or six cases handled efficiently can work.

Dr. Dugel operates in his ophthalmology-only ASC, which also performs cataract, glaucoma and oculoplastic procedures. The center doesn’t offer general anesthesia, but he says the ASC can still handle 100% of his adult retina cases.

Patients also benefit economically having their surgery done in an ASC. As the Affordable Care Act and other healthcare reform increases deductibles and copays, out-of-pocket costs are less than in a hospital because of the ASC’s lower facility fees. Mr. Sheppard says those lower costs attract increasingly cost-conscious patients, who also tend to prefer the ASC environment over the hospital experience.

Moving retina surgery to an ASC is not just an economic decision. Like their anterior segment colleagues, retina surgeons are likely to prefer the ASC operating experience. Mr. Sheppard points out that ASCs operating schedules are more predictable and cases don’t get bumped by trauma cases as often happens in a hospital.

“A specialized ASC offers a consistent, team-oriented environment that supports quality,” Mr. Sheppard says. “Surgeons work with the same team every week. In larger hospitals, that’s not necessarily the case. The ASC gives surgeons the opportunity to provide the kind of care they want for their patients.” ■