Refractive Surgery: How You Can Get Involved

The laser refractive surgery market has taken off since the procedure was approved in 1995. Market Scope, a consulting firm that researches the US refractive surgical market, projects that 1,550,000 procedures will be performed in 2000, a growth of 61.5 percent from 1999. One out of every 280 people in the US has already had laser refractive surgery - and by the end of 2000, says Market Scope, one in every 150 Americans will have had the procedure.

And now laser surgery may become more affordable. Currently, procedure fees run from $1,500 to $2,500 per eye. But last month, both Visx and Summit, the two leading makers of excimer lasers, slashed their per-procedure royalty fees from $250 to $100. Another manufacturer, Nidek, charges no royalty at all, although it has a legal dispute going with the other companies. If providers pass these savings on to their patients, fees will drop and demand could increase.

If you currently host eye procedures, now may be the perfect time to start thinking about offering this service. You don't have to have a huge, posh facility and an unlimited budget - even if you add laser refractive surgery on a small scale, there is a reasonable chance to reap a modest annual profit (at least $60,000 annually, by our estimates). And, by becoming known as the place to do refractive surgery, you may increase the likelihood that surgeons will come to your facility to perform other refractive surgery procedures, especially the new implantable phakic IOLs, which should be FDA-approved within a couple of years.

We asked a number of experts how they would advise facility managers and owners who are thinking of adding refractive surgery to their centers. Here's what they had to say:

1. Gauge surgeon interest:
High-volume refractive surgeons will probably already have their own facilities. But you may have an excellent shot at attracting surgeons who have more moderate volume or who are just now thinking about getting into refractive surgery. Most individual surgeons do not have the volume to build a facility on their own; they need a central, neutral site to do the procedure. Chain laser centers such as TLC already offer centralized facilities, but depending on your market, you may be able to offer a number of advantages over these centers, including a more convenient location and more creative financial options whereby you and the surgeons can build equity and earn a profit.

Eric Donnenfeld, MD, a high-volume refractive surgeon on Long Island whose group just built a large ASC, says he will continue doing his cases at the local TLC. But he says the other physicians in his practice will be doing all their LASIK cases in the new ASC, and he says other physicians from outside the practice will also be doing LASIK there. "Our strategy is just to break even on LASIK facility fees in order to attract cataract cases," he says. "In the future, most ophthalmologists will offer LASIK in addition to cataract surgery. There is no point in going to two different facilities to do the cases." He adds that LASIK and cataracts are a near perfect fit, because cataracts are best done in the morning and LASIK is best done in the afternoon. "Cataract patients are NPO, so they'd like to get done as soon as possible. LASIK patients, on the other hand, like to have their surgery in the afternoon so that they only miss a half day of work."

2. Get the instrumentation.

If you have surgeon interest, you have several options for accessing the rather expensive equipment required to do Laser in-situ keratomileusis (LASIK), which is approved for patients with low or high myopia (up to 14 diopters). In this procedure, the surgeon uses a microkeratome to cut a thin, hinged layer or flap in the cornea, then lays the flap back and uses an excimer laser to remove a micro-thin layer of the cornea underneath. The flap is then put back in place and forms a natural bandage for the cornea, which heals without stitches.

A relatively risk-free way to get access to the two required items - an excimer laser and a microkeratome - is to lease them. Companies like St. Louis-based Laser Vision Centers, Inc. ((314) 434-6900; http://www.laservision.com) offer multiple choices for laser access: self-contained mobile refractive laser surgery centers, "roll-on-roll-off" lasers that can be installed temporarily in an OR, or fixed-site lasers. The company also provides a laser technician and a microkeratome technician. In the roll-on-roll-off and mobile scenarios, you guarantee the company that you will do a minimum of 10 cases every time the laser is delivered; you pay LVCI $700 per case, plus $150 per use for the microkeratomes. Other companies, such as EBW Laser ((888) 560-6364; http://www.ebwlaser. com), offer lease-to-own options for centers with higher volumes (30 to 50 cases a month).

Leasing mobile lasers is the route that the Wills Eye Surgical Network, based in Philadelphia, is taking while interest builds among its surgeons. The network currently consists of 10 multispecialty ASCs (services offered include orthopedics, ENT, hand surgery, pain management, and ophthalmic surgery), with five more in the works. Four of the ASCs currently offer refractive surgery using mobile lasers. According to Joe Bilson, president of the Wills Eye network, the goal is to have all centers offering refractive surgery within the next 18 months. "We are also looking to partner with physicians and allow them to be investors in this venture," he says.

Each of the centers that offer refractive surgery has a special mini-OR with air filtration, temperature and humidity control, and emergency power backup units to house the laser. Approximately 50 of the 300 ophthalmologists on staff are currently doing LASIK; Mr. Bilson estimates that number to increase to at least 150 before long. Each center currently does 10 cases a week. When the caseload hits 75 a month, says Mr. Bilson, they will think about purchasing a laser.

Once your facility is doing about 50 to 60 cases a month, it may make sense to bite the bullet and buy a laser. Expect to pay at least $400,000 to $560,000 (count on at least another $180,000 a year for maintenance) and $60,000 for a microkeratome (many experts recommend having at least two, so one is always available). You'll need at least two dedicated staff - a scrub nurse and a laser technician - to help you service the equipment and move patients through the process smoothly.

Karl Stonecipher, MD, who directs a laser center in Greensboro, NC, stresses that facilities that are just starting out in refractive surgery should start with a roll-on-roll-off model, then graduate to a lease-to-own option. "Don't make the mistake of jumping in too rapidly," he says.

3. Become a laser landlord.
Another option may be to rent space to a group of surgeons and let the surgeons purchase their own laser. You may be able to accommodate a group such as the one led by Richard Eiferman, MD, a Louisville, Ky., ophthalmologist who joined with 14 other surgeons to purchase a laser. Dr. Eiferman?? ?s group worked out a deal with the Louisville Suburban Medical Center (a flagship Humana/Columbia/HCA hospital), paying it approximately $600 a month to rent space for a laser suite. The hospital also provides staff, drugs, supplies, and administrative services. For its trouble, the hospital charges about $125 to $150 per case. The center does about 250 cases a month, which works out to nearly $380,000 per year in revenue for the hospital.

4. Look the part.
Most surgeons who do refractive surgery will do their own marketing, but you have to work with them to make sure patients have a good experience and refer your center to their friends. Remember that these patients expect to step into upscale waiting rooms and interact with customer-focused staff.

Wills Eye works to ensure that their refractive surgery patients have an optimal experience by keeping med-surg and refractive surgery cases separate. The med-surg cases are done between 7 am to 2:30 pm; all refractive surgery cases are scheduled for late afternoon. This allows the staff to focus on the refractive surgery patients and cuts down on the "medical feel" of the facility.

5. Plan for new procedures.
LASIK is by far the predominant procedure, but others may become popular in the future. Surgeons are now implanting Intacs corneal rings, two tiny plastic rings that reshape the cornea, for patients with low myopia. By next year, phakic IOLs - IOLs that either vault the normal crystalline lens or attach to the iris - may be approved for moderate to high myopia or hyperopia. This procedure is an intraocular one, and requires a sterile OR. If you're already doing cataract surgery, this may someday be a natural progression. If you do provide laser access, then you'll increase the chances that your center will become known as the place to do refractive surgery, which will make it more likely that surgeons will want to try these new procedures at your facility.

It's too early to say whether refractive surgery will truly develop into the "boom" procedure some predict. It's also too early to know how well traditional surgery facilities will fare against other kinds of providers. "Before you do anything, size up the market and see if there is a need," advises Robert Kershner, MD, an ophthalmologist with an ophthalmic ASC and a dedicated laser center in Tucson, Ariz. "This is a big moneymaking procedure, but there's a lot of expense involved." But if you are a bit of a gambler, jumping into refractive surgery may be a reasonable stratagem for the new millennium. The risks are relatively low and the potential rewards quite intriguing.

Who gets refractive surgery

Here's a quick look at the "average" refractive surgery patient1:
- Male or female, aged 32 to 45.
- Active lifestyle, although not necessarily athletic.
- The patient knows someone who's had refractive surgery.
- The patient already has a good bit of information about the procedure, and is trying to decide when and where to have refractive surgery.
- He or she is aware of the cost, and may have been saving to afford the procedure.
- He or she may need some assistance with financing, but also is likely to pay for refractive surgery with a credit card.
- The patient is concerned about how quickly he or she can return to a normal routine.