Cataract surgery continues to be one of the highest volume and most profitable ophthalmic procedures performed in the ambulatory setting. But expanding your facility's eye surgery services by adding retina, cornea and glaucoma treatments can grow your revenues while it benefits your patients. We asked ophthalmology observers for their views on the business prospects and clinical considerations for the cases that have begun to gain ground in outpatient ORs.

Retina on the rise
"There's not much retina surgery being done outside of the hospital. ASC doctors could go after it, and should," says Lou Sheffler, MPS, chief operating officer of Somerset, N.J.-based American Surgisite Centers, which operates 8 eye surgery centers in New Jersey, New York, Pennsylvania and Massachusetts. "That's what we've been concentrating on expanding."

The time is right for retina, he says. A few years ago, the Outpatient Ophthalmic Surgery Society lobbied the Centers for Medicare and Medicaid Services for higher facility reimbursement rates in commonly performed retina procedures. It met with considerable success. In 2012, Medicare's national average for ASCs is $1,655 for CPT codes 67043 (vitrectomy) and 67036 (pars plana vitrectomy) as well as the retinal detachments detailed in 67107, 67108, 67112 and 67113.

Plus, technology advances in the leading vitrectomy machines — improvements such as easier setup and operation, faster vitrectomy cutters and more efficient aspiration — offer expert hands the potential to complete what was once invariably 2 hours of surgery in as little as 30 minutes.

In addition to being quickly and profitably done, building retina onto an existing cataract case load offers a "comfort level" for many of the participants, says Alex Stockdale, MBA, administrator for Campbell, Cunningham, Taylor & Haun, a Knoxville, Tenn., general ophthalmology practice. Specialists bring their procedures to a facility and staff they can trust to be efficient, he says. "You can take care of your patients in an environment where they feel comfortable." Even insurers "like one-stop shops."

There is a cost, of course, which demands planning. You'll need to invest in a vitrectomy machine; outfit your existing ophthalmic microscope with an image inverter, laser filter and other upgrades to accommodate retinal techniques; and purchase trays of specialized instruments. Total cost: about $250,000. Depending on the particular supplies used, per-case costs run about $400 to $600. "The break-even point is about 150 procedures a year," says Mr. Sheffler. "So you really need to know how many cases are coming. You can't just buy the equipment and hope people are going to show up."

Which raises another critical concern: Who'll perform retina cases in your ORs, and how long will they take? You may have identified a need for retina services and a substantial patient population in your community, but can you recruit surgeons with the skill and speed to deliver the cases' potential revenues? Your schedule might be able to routinely absorb 45-minute, maybe even 75-minute, retina cases and their associated costs. But an administrator and her budget are in for a rude awakening if a retina surgeon consistently occupies the OR for 2-hour cases.

While small-gauge instruments and techniques have accelerated retinal surgery and recovery, not every retina surgeon is equally adept with them. It's a common refrain among administrators considering the subspecialty, says Kevin Corcoran, COE, CPC, FNAO, president of the Corcoran Consulting Group in San Bernadino, Calif. "They say, 'We'd love to do retina, well and quickly. Let's find some retina surgeons who can fit this mold.' But that's the tricky part, they can be hard to find." They might not be amenable to retraining, either, or to employing regional anesthesia (which has a shorter effect but requires controlling an awake, aware patient) instead of general anesthesia (which carries longer recoveries and greater risks).

When approaching potential physician-recruits with the prospect of performing outpatient retina surgery, he says, be sure you make it clear that small-gauge techniques are a mandatory condition. Watch them in surgery at the hospital in order to judge their experience and efficiency. And, as a motivation from the physician's point of view, let them know that the possibility of becoming a shareholder in your center is the carrot to the stick of the small-gauge requirement.

DSEK decisions
When the endothelial cells of the cornea are damaged by trauma or disease, any possible repair requires replacement with donor tissue. This once meant grafting an entire cornea onto the patient's eye, but a surgery known as Descemet's Stripping Endothelial Keratoplasty (DSEK) — which replaces just the cornea's layer of endothelial cells — has made the process less invasive with a smaller incision, takes about 30 minutes for the experienced surgeon to perform and results in a quicker healing transplant for the patient.

"For the portion of the patient population that is needing a transplant, DSEK is a suitable option," says Steve Sheppard, CPA, COE, managing principal of the Medical Consulting Group in Springfield, Mo. But it can prove a lengthy procedure in comparison with a brisk cataract schedule, he adds.

Also, due diligence is required to ensure that the donor tissue doesn't sink your reimbursement, says Mr. Sheppard. Classified under the CPT codes for cornea transplant (65710 to 65716), DSEK earns a Medicare ASC national average reimbursement of $1,529.21. Medicare's rate does not include the cost of the donor graft, which averages about $2,500 to $3,500. Make sure to negotiate contracts with your non-Medicare payors that will reimburse you for the corneal tissue, and find out whether a tissue bank can provide you with the tissue at a rate that non-Medicare payors will cover. Without careful calculations, it's possible that DSEK procedures could wind up costing your facility money.

That's not the only decision you have to make with regards to the corneal tissue. You'll also need to determine whether it makes more practical and economic sense to buy it prepared for surgery, or for your surgeons to prepare it themselves on site. Buying the tissue prepared will add an upcharge to its cost, but if your surgeons want to prepare it, they'll need a microkeratome — a precision instrument that can dissect the cornea with an oscillating blade — which costs roughly $40,000 to $50,000. Mr. Sheppard notes that the surgeon will be reimbursed for the preparation, but the facility will not, nor will it be reimbursed for the use of the microkeratome.

Select medical device manufacturers have created hand-held instruments that assist in inserting and placing the prepared corneal tissue, but as with retina surgery, the skilled hands behind the instruments and procedures are the key to profitable procedures. Mr. Stockdale advises finding out whether your high-volume cataract surgeons are interested in performing cornea cases, while also seeking out and recruiting cornea surgeons who might also want to do cataracts.

Considering canaloplasty
As an alternative to trabeculectomy — a glaucoma treatment that removes a segment of ocular tissue to drain blocked fluid and reduce inner-eye pressure — canaloplasty hasn't yet displaced the standard remedy. But the procedure takes about the same amount of time to perform as the traditional filtration surgery, patients enjoy a shorter recovery and studies show less of a risk of post-op complications.

Canaloplasty entails the insertion of a miniature catheter tube or shunt from an affected eye's obstructed trabecular meshwork, allowing fluid drainage through the canal of Schlemm and reducing intraocular pressure. The procedure can be done in about 45 minutes, and several channeling devices have received or are presently awaiting FDA approval. "Glaucoma is a fertile area right now," says Mr. Sheppard. "And clinical results for canaloplasty have been encouraging." CPT codes 0191T and 0192T are presently set at a national average of $1,677.69, and since cataract surgery already makes an incision into the trabecular meshwork, canaloplasty can be conveniently performed in conjunction with it, he says.

There are, however, 2 fiscal issues to be aware of when considering adding canaloplasty to your schedule, says Mr. Sheppard. First, the implants used are relatively expensive, ranging in cost from $850 to $1,100. "Is your facility reimbursement going to be high enough to afford those shunts?" he asks. What's more, a surgeon may feel that implanting multiple shunts would deliver more effective outcomes. He recommends discussing with your commercial payors the possibility of a carveout for the cost of the devices.

Second, while canaloplasty makes an easy addition to cataract surgery — implanting a shunt only takes a few minutes at the end of the procedure — does it make economic sense? Reimbursement for a cataract case nationally averages at $963.62. But as the lesser-reimbursed of the 2 cases, it is considered the secondary procedure and is reimbursed at only 50%, or about $482. Given its case costs of about $200 or $300, it hasn't added a lot of revenue, and recall the amount that a shunt's cost has subtracted from the canaloplasty reimbursement (if your surgeon only used 1 of them). "You can do all of these things," says Mr. Sheppard, "but is it worth it to?"

Caveat on the cases
DSEK and canaloplasty are emerging fields, but limited. Don't crowd out your more profitable cases with the new ones you're chasing, says Mr. Stockdale, and avoid making it inconvenient for your busiest cataract surgery to secure his preferred blocks. The surest path to revenue may be expanding the volume of what you're already equipped for. "If it's profitability you're looking for, open extra hours or extra days and fill your unfilled time with more cataract cases," he says.