SPECIAL DELIVERY Outsourcing firms bring laser platforms right to your door and handle all the logistics of set up.

Femtosecond lasers have the potential to completely transform cataract surgery, but the platforms are expensive — costing upwards of $500,000, plus annual maintenance costs — and you need to attract plenty of patients who are willing to pony up for improved refractive outcomes in order to make that significant investment worth it. There is a way to see if laser cataracts will work at your facility with essentially no financial risk and no operational headaches. Outsourcing firms bring lasers right to your door and handle all the logistics of setup. All you have to do is schedule cases and count the profits.

Afraid of commitment
Ophthalmologist Paul Koch, MD, the founder of Koch Eye Associates in Warwick, R.I., was drawn to the reported benefits of laser cataract surgery back in 2013, but wasn't willing to invest in the hype. "We didn't know for sure what role femto lasers would play in cataract surgery, and almost every comment made about it was by someone with a direct tie to one of the manufacturers," he says. "So to purchase a unit at that time was quite a financial commitment, and one we weren't willing to make."

So he partnered with an outsourcing company instead. He pays a per-eye fee in exchange for complete set up and removal of the laser in one of his facility's ORs and a tech to help operate the laser. Basically, Dr. Koch is paying for a worry-free, no-hassle day of profitable surgery. "We have a situation now where we have a strong business relationship," he says. "They provide a service and at the end of the day, we make money, they make money and everyone's happy."

Ophthalmologist Jeffrey Starkey, MD, of NEOVision Group in Akron, Ohio, knew the femto laser made accurate cuts, but balked at the initial investment and $50,000 or so in annual maintenance costs to own a platform of his own, especially when he wasn't sure how the technology would pan out in his practice and for his patients. "Taking the risk out of the decision-making process was a wonderful thing," he says.

Dr. Starkey describes himself as the typical surgeon who decided to adopt a new technology and was blown away by how many patients know about it and are seeking out facilities that have it. He presents the option the same way during every cataract evaluation in his clinic, and says the rate of converting patients from manual procedures to laser surgery is about 45%, much higher than he anticipated.

The outsourcing company charges Dr. Starkey about $850 an eye, an amount that would decrease if he performed more cases (he says he's still working to convince other surgeons in the physician-owned eye-only surgery center to convert). "If we could somehow utilize the laser 2 days in a row, we'd make the per-click price even more favorable," he says.

Dr. Starkey says outsourcing the laser has significantly boosted his facility's bottom line, to the tune of nearly an additional $1,000 of revenue per eye after paying for the laser. "It's been a profitable venture," he says. "In my opinion, outsourcing is a no-brainer."

READY TO GO Trained technicians set up the platforms the night before surgery and are on hand to assist surgeons during procedures.

Seamless service
Getting the platform into and out of facilities is a seamless process. Dr. Koch gave his outsourcing crew — it's the same group each time — a key to the building so they can let themselves in the night before scheduled cases, set up the laser and calibrate its settings so it's ready to go first thing the next morning. "We have nothing to do but say hello to the rep," says Dr. Koch. "It's completely seamless."

Dr. Koch was the first to use the technology, but his partners decided to jump on board, so they scheduled the laser for the day after Dr. Koch's turn to get the most bang for their per-click-fee buck. The outsourcing firm brings the laser on 2 consecutive days, 3 times a month. Case volume varies by surgeon, but Dr. Koch says he can easily complete 5 to 6 patients an hour, or 20 to 30 cases a day.

The outsourcing firm that works with Dr. Koch demands a standard fee based on how many procedures he performs. "They must be guaranteed a certain amount of money to show up in the morning and a certain amount of money by the end of the day," he explains. "When your case volume increases, you qualify for volume discounts."

So when would it be profitable to invest in your own laser platform? How many cases would you need to perform? "We crossed that threshold a long time ago," says Dr. Koch, who concedes his center would be better off financially with its own laser. However, he points out, he'd then be responsible for managing the issues associated with keeping the laser up and running: space for the platform to sit, a full-time technician to help run it, maintenance fees and equipment upgrades.

"It's just easier for us to outsource and let the company worry about all those things," says Dr. Koch. "At the end of the day, you make the money, they make money and we have no headaches at all. It's a smooth-running system, one we're comfortable with and happy to continue."

Dr. Starkey accumulates patients interested in undergoing laser procedures and stacks the cases over 2 or 3 consecutive days each month. He performs about 15 eyes a day, or about 30 to 45 monthly.

His outsourcing firm also comes in the night before scheduled cases to set up the laser and ensure it's in good working order. Dr. Starkey says he's never had to cancel cases because of faulty equipment and touts the process as "turnkey" and "worry-free."

Dr. Starkey believes he could now afford to invest in his own laser, but the cataract cases wouldn't be as profitable as they are now — at least during the initial years of paying off the laser. Of course, after he owned the unit he'd earn more per case. Still, he hesitates to bite the bullet and make the purchase, saying, "It's working so well now and I have zero hassles, so I'm in no hurry to change that any time soon. I'm willing to make investments, but I sleep better at night this way."

Plus, what if the laser platform you invest in nears obsolescence by the time you own it outright? By partnering with outsourcing companies, you can be sure you'll always be working with the latest available technology.

CLINICAL NOTES
Less Agita With Laser Cataracts

PRECISE CUTS Femtosecond lasers are said to produce more predictable refractive outcomes.

Femtosecond lasers are generating plenty of buzz in ophthalmic circles thanks to the promise of improving the accuracy, precision and safety of cataract surgery. Results with the laser have been outstanding for ophthalmologist Paul Koch, MD, the founder of Koch Eye Associates, who partnered with an outsourcing company to bring the technology to his Warwick, R.I., facility.

The laser provides predictability in the size, shape and diameter of the capsulorhexis, leading to potentially better IOL placement for improved refractive outcomes. It also softens the diseased lens so less ultrasound energy is needed during phacoemulsification. Dr. Koch says the laser improves his ability to predict the effective position for the lens implant and lets him hit targeted refraction more than he used to with manual techniques. He says an eye done with the laser at day 1 post-op looks like a manual eye 1 week after surgery.

"But the big thing, and the thing that I think is underestimated the most," he says, "is less agita." For those of you without an Italian mother, that's slang for heartburn.

"Every time you sit down to operate, you hope the procedure goes well, but you're never 100% certain that it will," says Dr. Koch. "With the laser, my agita has plummeted, because so many steps have been done exactly and you know the cataract will fall apart easily. From the surgeon's point of view, it's a much calmer operation."

— Daniel Cook

Conventional approach
Cataract outsourcing isn't just for facilities interested in adding laser procedures. Plenty of centers still benefit by adding the pricey equipment needed for manual surgery, including operating microscopes, phacoemulsification machines, phaco handpieces, disposable supplies and an inventory of lenses.

Charles Strasser, RN, CASC, administrator of the Allied Physicians Surgery Center in South Bend, Ind., first partnered with an outsourcing firm back in 2003 to bring manual cataract cases to his ortho-heavy, 8-room surgery center, and now he's doing it again to add a femtosecond laser.

He thought about purchasing the needed equipment for manual cataracts when a lone ophthalmologist approached him about bringing cases to the center, but the return on investment was too far down the road based on the low number of cases they anticipated hosting.

The cataract volume grew enough at Allied Physicians Surgery Center to allow Mr. Strasser to invest in his own equipment, but he speaks highly of his partnership with the outsourcing company that let him get his eye service line off the ground and made the growth in procedure volume possible. Now he's outsourcing again as his facility attempts to break into the laser cataract market.

A busy eye-only center expected to host hundreds of cases a month would likely want to invest in its own equipment, but for centers like Mr. Strasser's that want to get a feel for the potential of cataracts before investing in equipment of their own or simply want to use the equipment and leave the upkeep to the experts, outsourcing makes perfect sense. "If you're looking at getting into a specialty," says Mr. Strasser, "but don't want to spend your capital dollars, outsourcing is the best option."