Given retina surgery's reputation as a complex and costly undertaking, it's not surprising that most efficiency- and economy-minded ASCs yield the cases to hospital ORs. Those who have made outpatient vitrectomies work, however, say they're a profitable prospect for facilities looking to build on their cataract business. Here's what it takes to achieve same-day success with retina surgery.
The time is now
Vitreoretinal repairs can be added to the schedule at ophthalmic ASCs or even multi-specialty centers relatively easily, and a conjunction of changes in recent years has even cleared some previous barriers.
"Years ago, retina reimbursements were about the same as cataract reimbursements, but retina supplies were more expensive," says Glenn deBrueys, CEO of Somerset, N.J.-based American SurgiSite Centers, which operates 11 eye surgery centers in 5 states. "Now retina is 60% higher. Supplies are still more expensive, but the margin is a decent margin."
In addition, retina cases can be extremely time-consuming. Over the past 2 decades, though, technology's advances have picked up the pace. Smaller-gauge instrumentation has brought microincisional techniques, and their improved healing outcomes, to retina cases. Vitrectomy cutters capable of thousands of cuts per minute boost efficiency and accuracy. While the end results don't match cataract case speeds, they've drawn the attention of ambulatory surgeons and administrators. "Retina surgery time has significantly diminished," says Mr. deBrueys. As an example, he cites pars plana vitrectomy, which takes 30 or 35 minutes today compared to 75 minutes 25 years ago.
These changes have leveled the playing field for retina in outpatient settings, but cost-benefit analysis is still necessary to select the most promising procedures, says Caroline Ivanovski-Hauser, CASC, administrator of the Bergen-Passaic Cataract Surgery and Laser Center in Fair Lawn, N.J. "Almost all retina cases lend themselves to the same-day setting, except those cases that use very expensive implants and supplies," she says.
Using perfluorocarbon liquid or silicone oil, for instance, will add several hundred dollars to a case's expenses, which could easily swamp the $1,800 to $2,000 Medicare is reimbursing a facility for the case. "Our physicians tend to bring us reasonable cases we can earn a profit on," says Mr. deBrueys.
Before your facility can profit from retina, you'll have to foot the initial capital investment in equipment, instruments and supplies. Glenn deBrueys, CEO of Somerset, N.J.-based American SurgiSite Centers, estimates the total cost of adding a retina service line at about $100,000 to $130,000.
The major purchase in this investment is a vitrectomy machine, which will cost at least $60,000, although the availability of previously owned and refurbished equipment can offer price variability. Lease arrangements are another option, especially during the startup stages. "Roll-on, roll-off is how you do it until you know you have sufficient volume," says Caroline Ivanovski-Hauser, CASC, administrator of the Bergen-Passaic Cataract Surgery and Laser Center in Fair Lawn, N.J.
Some phacoemulsification machines can be upgraded with a vitrectomy module for a fraction of the cost of a standalone vitrectomy machine. If your phaco is getting on in years, though, you might consider the technology that integrates both anterior and posterior capabilities into a single unit. "If your surgeons can agree on one manufacturer or the other, this can be an economical choice," says Shawn Herman, RN, BSN, clinical director of the Eye Center of Columbus in Ohio. Not only does combination equipment expand the number of ORs, and schedule slots, in which retina cases can be performed, it also standardizes and reduces your supply inventory, he notes.
The operating microscope that your surgeons use for cataracts can also serve retina cases, but it will require the attachment of wide-angle viewing and inverter accessories, which enable views of the posterior segment, as well as a filter for protection during argon laser use. These accessories will cost about $35,000, and the argon laser about $30,000, depending on whether it is new or refurbished. A tray of retina instruments can range from $5,000 to $15,000, and the procedure pack of disposable supplies about $200.
To succeed in an ASC, retina surgery depends on physicians who not only know the techniques, but also keep an eye on the clock and the budget.
Manufacturers' reps are good sources of information on the retina surgeons you're considering inviting into your ORs, says Mr. deBrueys. "They know whether they're relatively fast, whether they use a smaller armamentarium, are they cognizant of time, are they patient with staff. Reps will tell you everything you want or need to know about docs."
The support of a trained surgical team who know the surgeon and the routine can help to smooth the process. "When our docs came over from the hospital, they were astounded at how much our staff was acclimated to their cases, and how much easier that made them," says Ms. Ivanovski-Hauser.
Your slate of retina services shouldn't come at the expense of your consistent, predictable cataract schedule. "You can do 6 cataracts in the time it takes to do 1 retina," says Ms. Ivanovski-Hauser, and while a retina case can net you as much as $1,000, the cataracts deliver a $250 profit multiple times.
Mr. deBrueys further points out that a high-volume retina surgeon might bring in 200 cases a year, but cataract surgeons can reliably perform 500 to 1,000. "My No. 1 thing when meeting with a retina surgeon is to find out if they have flexibility on when they'd like to bring cases to the center," he says. "Are they willing to follow in the afternoon? If they want every Tuesday at 7 a.m., that's prime time for cataract surgery."
While cataract patients are nearly always Medicare patients, retina patients aren't. So negotiating contracts with private payers is critical to making your cases pay, says Mary Meier, BS, CPC, administrator of the Eye Center of Columbus in Ohio.
"We look at our top procedures case costs, overhead, staff and make sure even our highest-cost cases can be reimbursed at a profit. If we can show them how much less expensive, more efficient and safer it is than at a hospital, private payers love that," she says.