SUBSPECIALTY SERIES | PART 2

Are You Ready for Retina?

Straight talk from a retina specialist, who’s also an ASC owner

By Virginia Pickles, Contributing Editor

“Should I open up my surgery center to retina now?"

At least once a week, Pravin U. Dugel, MD, hears this question, in one form or another, from ophthalmologists looking to expand services in their ophthalmic ambulatory surgery centers. Like a Dutch uncle, he offers candid advice based on his own experiences as a retina surgeon — one of the first to operate in an outpatient setting — and as an owner of a multispecialty ophthalmic ASC since 2000.

“The interest in retina is understandable,” says Dr. Dugel. “Our field has changed immensely in the last few years. Surgeries that used to take 3 to 4 hours can now be completed in less than half the time, but require exponentially more technical skill. Not only have we reduced our OR times, but the way we operate has also changed. Just one example is that we tend to perform sutureless surgery, which was unheard of until recently. Another attractive aspect is that reimbursement for retina surgeries has historically increased, while in other subspecialties, such as cataract, it has decreased.”

Still, there is no simple answer to the question of whether or not to bring in retina, even if you’ve successfully integrated other ophthalmic subspecialties into your ASC. “You may have brought in cornea, glaucoma, or plastics, but retina is an entirely different animal, and the stakes are high,” Dr. Dugel says. “Not only will retina change the culture and strategy of a general ophthalmic surgery center, but relatively speaking, retina requires a massive capital outlay. If done correctly, integrating retina into your surgery center can be quite profitable; but, if done incorrectly, it can bankrupt your ASC.”

Dr. Dugel poses the following questions to help ASC owners decide whether retina is right for them.

Is the surgeon a good fit for your ASC?

This may seem like a basic question, particularly if you have brought in new surgeons in the past, but according to Dr. Dugel, covering all bases thoroughly is even more important when interviewing retina surgeons. Three factors in particular should be addressed. Is the surgeon …

…comfortable in the ASC setting? “In retina, the shift to operating in an ASC setting has been relatively recent in comparison to the other specialties,” Dr. Dugel says. “Many retina surgeons have been trained — and are still being trained — to operate in a hospital with the use of general anesthesia. Therefore, you need to be sure the surgeon is comfortable operating in an outpatient surgery center.”

And, according to Dr. Dugel, this isn’t necessarily a generational preference. “Some younger surgeons perform fantastic surgeries but feel comfortable only in a hospital setting,” he says.

…cost conscious? “Some surgeons don’t want to hear about costs at all,” Dr. Dugel says. “They feel those discussions detract from their role as a doctor. I won’t debate whether that attitude is right or wrong, but I advise you to avoid bringing those surgeons into your ASC. You need someone who will be cost aware, cost conscious, and always willing to discuss costs.

…adaptable? One of the advantages of ambulatory surgery centers over hospitals is their ability to quickly adapt to change. This is a desirable quality in a retina surgeon, as well, considering recent rapid advancements occurring in this subspecialty. As Dr. Dugel notes, “You definitely want a surgeon who’s willing to embrace new technology and change as technology evolves.”

Are you prepared for a dramatic cultural shift in your ASC?

There is often a sense of urgency surrounding retina cases that doesn’t exist with most general ophthalmology cases, such as cataract and glaucoma, according to Dr. Dugel. “Retina surgeries are generally more complicated,” he says. “Patients may be sicker and require more care, necessitating specialized nurses and circulators who are capable of delivering that care.”

An area likely to come under scrutiny with the introduction of a new subspecialty is staffing, and retina surgeons may have special requirements. “In any ASC, the largest expense by far is staff, accounting for as much as 75% of overhead,” Dr. Dugel notes. “This is another area where cost efficiency and sensitivity by the surgeon is essential. Some surgeons will demand twice the staff as others, and that can have a significant impact on the bottom line. Discussions of this nature need to occur prior to bringing in a new surgeon or surgeon group.”

Other “cultural shifts” to consider are emergency cases, late cases, and possible weekend cases. “The improper management of such cases can have a major impact on patient care, staff morale and retention, as well as surgeon relationships,” Dr. Dugel says.

Are you prepared to make a significant investment?

Integrating retina services could require an initial cash outlay as high as $1 million. “There’s a huge window of what it costs to take on retina surgery,” Dr. Dugel says. “Equipment costs can vary widely. The big-ticket items to consider are vitrectomy units, lasers, cryotherapy, and gas. Remember that redundant equipment is usually required in case of failure.”

The most expensive equipment isn’t necessarily the best nor is the cheapest necessarily the worst. Here again, a frank discussion between the ASC management and the incoming surgeon is needed to determine needs and preferences. Importantly, if the new retina surgeon has a relationship with any of the equipment companies, it may be possible to negotiate an all-inclusive agreement that will be cost-efficient.

“The biggest ongoing costs are disposables,” Dr. Dugel says. “The proper cost management strategy of the disposable expenses may determine the financial success or failure of the ASC. Usually, the disposable strategy involves a global package including all ophthalmic specialties, retina being the most expensive and influential.”

Can you stay true to your priorities?

Dr. Dugel cautions against focusing solely on the potential for higher reimbursement as a reason to integrate retina services. “The number 1 priority in any successful ASC has to be patient care, and number 2 is profitability,” he says. “That mindset should be shared by everybody from top to bottom in the ASC, including potential new retina surgeons. Certainly, an ASC is a for-profit venture, but you cannot reverse those priorities. Doing so is a surefire way to go out of business.”

Are you ready to go for it?

Dr. Dugel likens the question “Is it time to bring in retina?” to asking “Is it time to get married?”

“There’s no way to answer either question, unless you know the person, or, in the case of the ASC, unless you know the region,” he says. “Just like getting married, you’d better be sure you’re doing the right thing, because once you do it, you either can do really well or go down the tubes. It’s that kind of a decision.”

Although he may play devil’s advocate when advising ASC owners about the realities of bringing in retina services, Dr. Dugel is quick to acknowledge the upsides.

“Incorporating retina services into an ASC can be one of the best investments you will make,” he says. “As a retina surgeon, I mean that in terms of patient outcomes and patient benefit, which I firmly believe are much better because of the specialized care delivered in an ASC. When done properly, it can also be profitable.” ■

Pravin U. Dugel, MD, is managing partner of Retinal Consultants of Arizona and a founding member of Spectra Eye Institute, a multispecialty ophthalmic ASC in Sun City, Ariz. He is also clinical professor of the USC Eye Institute, Keck School of Medicine, Los Angeles.