If you get annoyed every time a surgeon wants to add a case to his already overbooked block, you're not alone. Add-ons can be incredibly inconvenient and disruptive, especially when they're cases that the surgeon's scheduler forgot to tell you about — not truly emergent ones like ruptured globes, detached retinas, testicular torsions and kidney stones.

But rather than abhor them, we adore add-ons at our 2 independent surgery centers in Richmond, Va. On the one hand, we get paid for performing surgeries, not for standing around. On the other, you can't put a price on the goodwill you'll bank with your surgeons — and your patients — when you accommodate them by gladly accepting add-ons (urgent and non-emergent). Maybe you'll view add-ons in a different light after reading our perspective.

Our duty and obligation

First and foremost, we see add-on cases as part of our commitment to surgeons and patients to provide surgical care when the need is critical, not just when it's convenient.

Many of our surgeons have left the hospitals and only operate at our centers. For example, our 4 retina surgeons operate at our ASC exclusively: 4 days a week — sometimes 5 if there's an add-on. Hospitals found it too expensive to maintain the equipment and the staff's competency in retina surgery. We feel obligated to accept their urgent cases whenever they arise — even on long weekends. A detached retina, ruptured globe or fractured orbit needs to be managed quickly, and the surgeons require OR staff who are comfortable with the procedure.

Besides ophthalmology, other specialties rely on us as well, such as urology. There's a limited amount of time to restore blood flow to a torsion testicle. A pediatric urologist can almost always get an urgent case on our schedule within an hour. We can quickly care for patients with kidney stones, either through surgery or lithotripsy. Finally, we are a primary site for infertility procedures. Sometimes, the infertility process results in a miscarriage, requiring an urgent D&C. If we're going to offer infertility and GYN services, we should be prepared to support our surgeon and patients in their times of need.

Build your reputation

Your surgeons and their schedulers will remember that you accepted their add-on cases without protest or complaint. You want them to think of your facility first for everything. Changing a surgeon's (and his scheduler's) habits is very hard. If they have had a longstanding relationship with another surgery center or hospital, getting them to bring their cases to you takes effort. Accepting an add-on case demonstrates your willingness to rise to the occasion and help them in a time of need.

Believe me, surgeons will notice. I can't tell you how many times I've heard surgeons complain about their urgent case being bumped to late in the evening by trauma cases or other cases perceived to be more critical. With few exceptions, we perform all our add-ons during daytime hours.

More surgeries = more success

Let's look at add-ons from a financial perspective. It's a simple equation: The more you can make your facility invaluable to your surgeons, the more financially successful you'll be.

At both of our facilities, we estimate that our fixed costs run $571.45 per case based on a volume of 14,423 cases. Every additional case decreases that fixed cost per case.

Add-ons help to cover your overhead. Some of your biggest ongoing expenses are the fixed costs associated with your facility, including staff, rent, repairs, maintenance, taxes, insurances and utilities, which you'll pay regardless of how many patients you operate on each day. We figured that our facilities' fixed costs are $185 per case.

There are other fixed costs. We offer employer-paid benefits to all of our full-time employees and we pay a proportionate share to part-time employees. Benefit costs don't fluctuate with the number of hours the employee works, making benefit expenses essentially fixed. There are also a number of employees, salaried and non-salaried, who are at your facility regardless of case volume. This includes the business office personnel, maintenance, administration, accounting and more. At our centers, staff costs and benefits account for $104.24 per case.

Finally, add-on cases are often profitable for us. Sure, there are a couple that we will lose money on when the fixed costs are included — but again, these costs are there regardless. For the purpose of this article, I analyzed 11 add-on cases that we hosted in the last 2 months. The average profit of 4 retina cases (one was performed on a Saturday) was $1,088.79. An infertility case netted us $1,361.18. Two adult urology cases resulted in a profit of $3,120. Of 3 reconstructive/plastic cases, one generated a profit of $132, the second lost $145 and the third created a profit of $1,500.

Accommodating add-ons

As you can see, it's clearly to your advantage to accommodate non-urgent cases when they arise. Rather than viewing add-on surgeries as a nuisance, think of them as a marketing tool, a commitment to your surgeons and patients, and a source of additional revenue. Any opportunity for you to help a surgeon is an opportunity for you to build a relationship and to be a vital part of the surgeon's "team." Do you want your surgeons to view your facility as their primary surgical site? Then gladly make room for add-ons. OSM