Doctor A spends $346.56 on supplies for his cataract cases, Doctor B $350.32 and Doctor C $314.32. Give or take a few, they all spend about 30 minutes in the OR per case. And they all use the same $116 cataract pack, $107 IOL and $72 phaco tip. So, how would you get Drs. A and B to act more like Dr. C? One strategy is to show the two outliers a list of supplies all three have in common along with a list of supplies that differ - one's choice in ointment, miotic or blade, for example. That might drive home the point that there's a way to save and, look, here's the proof. Is your facility already saving all that it can, or does your materials manager need to trim a few cents per case from the supply budget? Read on to find out.

What about you?
Chances are, you don't know down to the doctor or to the penny what you're spending on cataract supplies. But we found 18 surgery center administrators who case cost their cataract cases and asked them to give us a look at what they spend on everything from phaco tips to cataract packs, from viscoelastic to gloves.

On average, our panelists spend $250 on supplies per case and host 170 cataracts each month. The average OR time per case is 20 minutes. See "Case Costing Cataracts" on page 52 for a rundown of their average expenditures on basic supplies. As Sheila Rilee, MSM, BSN, RN, CNOR, director of the Riverside Surgery Center and Doctors Surgery Center in Newport News, Va., says, every little bit adds up - especially when you factor in that the proposed Medicare ASC payment system will reduce already limited reimbursements ($1,388 in the HOPD versus $973 in the ASC for CPT 66984) for the most frequently performed surgical procedure in the United States, meaning the cost of seemingly insignificant supplies are anything but immaterial. Here's what Ms. Rilee and others have to say about turning small buying strategy improvements into big supply savings.

Mass appeal
Take a look at your procedure packs, compare the contents to each surgeon's preference cards and attempt to standardize the included supplies. Ms. Rilee, whose Riverside Surgery Center hosts 12 ophthalmologists and two retinal surgeons, worked with the physicians, OR nurses and surgical techs to streamline the procedure pack supplies. "If the nurses preferred a certain type of 4x4, we were sure to include that in the pack," says Ms. Rilee.

She then negotiated a contract with a single cataract supply company and a group purchasing organization to supply the procedure packs, viscoelastics and equipment at a reduced price based on the high volume of cataracts (280 cases) her facility hosts each month. Ms. Rilee's facility is currently at the GPO's tier II pricing level, based mostly on surgical equipment and custom pack purchases. "If we can get the physicians to agree on an IOL and standardize our lens purchases, we'd obtain tier I pricing." That pricing level, she says, that would save her facility $30,000 each year.

Like any attempt at getting numerous physicians on a single page, standardizing lens purchases can be difficult, especially in the highly competitive IOL market. Lens company vendors are constantly courting physicians behind the scenes, says Mr. Rilee, and touting the unique benefits of their products, especially the specialty IOLs. With numerous and effective options available, you may find that your physicians are less likely to standardize their purchases.

Still, suggests Ms. Rilee, work to get your docs in agreement. She showed her physicians the benefits of agreeing on one lens. "Our doctors, like most doctors, like having the latest technology in the ORs," she says, referring to a $46,000 equipment upgrade her physicians recently requested. Agreeing on one lens and reaching the next level of GPO savings, she emphasized, would help get the surgical equipment they desired.

In addition to showing her docs the potential for $30,000 in supply savings, Ms. Rilee pressured her supply rep to lean on the physicians. The surgeons' reluctance to agree on an IOL brand had less to do with the products' performance and everything to do with the physicians' perceived lack of customer service by the company's rep. Ms. Rilee told the vendor that it was time to increase the number of visits to her physicians, reminding him that happy surgeons would generate more sales for the company and increased savings for the facility. "I have to say," says Ms. Rilee, "the rep really stepped up the quality of service and the physicians are starting to come around."

Linda Pavletich, RN, BSN, CASC, LHRM, administrator of the St. John's Surgery Center in Fort Myers, Fla., also works with her physicians to standardize the contents of the facility's procedure packs. She streamlines the packs to the bare minimum and purchases gloves separately so each physician can use the same pack without having to throw away gloves that don't fit. "We trialed different gloves through an independent vendor over a three-week period," she says. "Once everyone agreed on a brand, we were able to buy a variety of sizes in bulk and pull the gloves out of the procedure packs."

Bulk buying goes against par-level supply management and purchasing only what is needed in the short-term, but Ms. Pavletich says she knows how many supplies are used over six-month and 12-month periods, and plans her bulk purchases accordingly. "We're not running around looking for supplies or spending extra on last-minute shipments. We know we'll have what we need when we need it," she notes.

Significant savings can be found by asking physicians to consider less expensive brands of viscoelastic. Robin Williamson, RN, clinical director of Stony Point Surgery Center in Richmond, Va., says her physicians use brands that range from $25 to $85 per case. A surgeon who brings a high volume of cases to the facility uses the more expensive viscoelastic, offering some justification for the additional cost to Ms. Williamson. She still works to keep her physicians abreast of their per-case supply expenses, and the expenses of their colleagues, with the hope that old-fashioned peer pressure sparks a desire to use less expensive options.

Using a spreadsheet, she itemizes each physician's per-case supply expenses. Physicians are identified with numbers, so each doc knows his own expenses but is unaware of the identity of his colleagues. The de facto report card makes each physician accountable, if only to himself. He sees that others may be performing the same procedure for considerably less, and might look into ways to reduce his own supply expenses.

Power in numbers
Facilities performing cataracts often host a high number of procedures, relying on volume to offset low per-case reimbursements. Use a significant case volume to negotiate better deals with vendors, says Ms. Pavletich, who also recommends buying items in bulk, which results in rebates and even more savings. She works with nine ophthalmologists who bring 450 cataract cases to her facility each month. That adds up to significant amounts of lens purchases. Ms. Pavletich works with all the major players, bulk-buying lenses in sizes from 18 diopters to 25 diopters - the most frequently used sizes.

Specialty lenses are ordered on an as-needed basis, says Ms. Pavletich. "You can get anything shipped standard in two or three days without paying extra," she says. Surgeons fax special supply requests a week before the scheduled case. "It takes a high level of communication with your physicians to save on supplies, and ours realize that."

Ms. Williamson says her facility's stock ranges from a soon-to-be discontinued standard lens costing $60 to a $150 new technology IOL. Her typical standard implant lens costs about $130. The center's materials manager keeps up to six standard lenses of the popular diopters in-house, providing a backup to the primary lens for each case. The reserve of new technology IOLs is smaller, usually maintained at two lenses for each popular diopter. These specialty IOLs typically arrive with a backup lens; instead of returning the unused lens to the supplier, the materials manager adds it to the in-house stock.

In the OR, stay away from disposable cataract knives and invest instead in reusable blades, say our panel of experts. Ms. Rilee's physicians use diamond blades, which range from $38 to $4,000 each. The high end of that range is a hefty one-time fee, but it's money well spent, says Ms. Rilee, who has 12 diamond knives circulating through her facility. "Disposable blades can add $20 to $25 to the expense of each case," she notes, and touts the economic benefits of reusable knives - as long as staff and physicians are trained in the proper handling of these delicate instruments.

Ms. Rilee has vendors present quarterly in-services on proper handling techniques and her OR team examines blades under a microscope before each case, looking for chips or imperfections. She also asks that staff minimize the number of hands the blades pass through; if a physician brings in his own surgical tech, Ms. Rilee demands that someone from her staff hand the knives to the surgeon. She also insists that surgeons take ownership in the care and handling of the knives in the OR to help maintain the integrity of the blades.

Sending knives out for sharpening and standard upkeep is expected. Even the need for repairing broken blades is inevitable - Ms. Rilee estimates that she sends a single blade out for repair once a quarter. Still, she gives her staff plenty of incentive for keeping repair costs to a minimum. "They know that if we can keep our diamond repair costs under $4,000 over a six-month period, I'll take the entire OR team out for drinks and dinner," she says, admitting that dinner is truly on her. "No, I don't expense the meal."

Play the game
Ms. Williamson says her supply purchasing needs have changed over time, whittling down as physician techniques evolve to include smaller incisions, fewer blades and, in some cases, a sutureless conclusion. But in the end, she says, supply purchasing is a game requiring a delicate balance between physician satisfaction and fiscal responsibility. She relies on her surgical techs to make subtle suggestions to doctors when less expensive supply options are available.

"They don't use names, but they'll make recommendations," says Ms. Williamson. "Physicians want to be their own person, but they also want to be in the same arena as everyone else." Given the high number of cataracts performed at her facility, and with per-case reimbursement decreasing each year, Ms. Williamson emphasizes the need to keep costs under control to break even, or perhaps earn a profit.