VOLUME CONTROL The ASC of Western New York considered outsourcing its laser cataract service, but had enough cases to support investing in its own platform.

Does it make good business sense to add femtosecond laser-assisted cataract surgery? The answer isn't as clear-cut as the incision a bladeless, computer-controlled laser makes. Some surgeons are hesitant to invest in a six-figure femto laser because reimbursement from Medicare and private health insurance is paltry and the laser hasn't proven to deliver appreciably better results than traditional cataract surgery. Others, however, have found they can quickly pay off the machine they bought outright because their patients don't blink when they tell them it's a few hundred dollars extra per eye out of pocket for a laser-assisted procedure. Then there's the option of partnering with an outsourcing firm that will provide the laser on an as-needed basis, an option that might be best if you host a few cases each month. Before deciding what's best for your facility, consider the true costs of adding the technology, your surgical volume and the number of patients your eye docs can upgrade to laser-assisted surgery.

A numbers game
Patients view the femto laser as a sexy new technology that they want their physicians to use, even if laser-assisted cataract surgery hasn't yet proven to be more clinically effective than manual techniques, even though it is generally more predictable and precise.

"The marketing advantage is real — lasers do attract patients to a surgery center," says Kevin Corcoran, COE, CPC, CPMA, FNAO, president of the Corcoran Consulting Group in San Bernardino, Calif.

The capital investment for a laser is significant — between $300,000 and $600,000 — and you also have to consider the approximately $300 per-case patient interface fee, annual maintenance contacts that run between $25,000 and $50,000, and the staffing costs of the technician who runs the platform. Getting a return on the investment is dependent on having physician-owners recoup the purchase as part of the amount they charge patients out of pocket for premium IOLs and better refractive outcomes.

IN AND OUT Outsourcing companies set up a laser platform on the day of surgery and remove it when the cases conclude.

"Now the question becomes, can you make the business case in dollars and cents?" asks Mr. Corcoran. "You can if you host enough cases."

So how many patients would it take to make the total investment worthwhile?

"That's the sticky part," says Mr. Corcoran, who explains that not every patient thinks laser cataract surgery is a good idea, or wants or needs a premium IOL. "You can't possibly convert 100% of your cataract patients to the laser. That never happens. The difficulty lies in estimating the number of patients who will go for it."

It's a highly variable number, according to Mr. Corcoran, who says 10% to 25% of cataract patients typically opt for laser-assisted surgery.

Mr. Corcoran says you have to make an honest assessment of your cataract business after considering the cost of the technology, the number of patients who might opt for it and the potential revenue they'd bring in. Then you have to determine: Will enough current patients pay the extra out-of-pocket costs for the service and will it attract additional patients?

"It becomes a competitive issue within communities," says Mr. Corcoran. "If every eye center decides to get a laser to keep up with the competition, there is no advantage in terms of attracting additional case volume."

Surgeons, too, have to determine how much more their patients are willing to pay out of pocket for the technology. "They're already charging a substantial amount for implanting a premium IOL, and now they intend to increase that amount," he says. "It becomes a question of how much the market will bear."

High-volume investment
To buy outright or to outsource? JoAnn Vecchio, CCS, CPC-H, CMBS, administrator of the ASC of Western New York in Amherst, N.Y., researched laser platforms for 3 years to determine which offered the best fit at the best price for her multispecialty facility, where ophthalmic cases make up around half of the case volume.

Ms. Vecchio completed pro formas to assess if outsourcing a laser platform or buying one outright made the most sense. "There are great deals available for mobile units, and that's a perfect way to see if it's an economical option for your facility, or perhaps a way to get a program off the ground in order to someday purchase your own laser," she says.

Her facility hosts 5,000 cases a year, so she had the volume to justify investing in a femto laser. She pulled the trigger on a unit that costs around $600,000, but that doesn't mean the 16 ophthalmologists who have ownership stakes in the center were initially onboard with the decision. She felt plenty of pushback from hesitant surgeons who told her they achieved excellent outcomes by operating manually and they weren't convinced a laser would provide any clinical benefit. That was a problem, because Ms. Vecchio needed their support to make the laser work financially.

"The selling of the technology doesn't happen at the surgery center — we're the end point," says Ms. Vecchio. "Use of the laser is generated in the surgeons' offices when they talk to patients about laser-assisted surgery. The patient education piece is essential, so you must work with ophthalmologists who believe in the technology."

Ms. Vecchio realized the only way to get the word out about the center's new laser was through the physician-owners, so she scheduled a specialty meeting, during which she presented her case for adding the technology and had a representative from the laser manufacturer hit on the important selling points.

It must have worked. Ms. Vecchio ran the numbers to see how many cases the center had to perform to make the investment work. She determined that the facility's breakeven point was 19 cases per week. "We're now exceeding that in a day," she says. "Our center averages 52 laser-assisted cases each week because the surgeons really got onboard with the technology."

What about those naysaying surgeons? "They now perform the most laser procedures at the facility," laughs Ms. Vecchio.

The outsourcing option
Andrews Institute ASC in Gulf Breeze, Fla., is known for its world-class orthopedics program, but for 2 days each month the facility transforms into a low-volume cataract center. Terri Gatton, RN, CNOR, CASC, the facility's administrator, is hesitant to invest significant capital dollars in a specialty that doesn't bring in a lot of cases, so she came up with a creative way to add laser-assisted cataracts without a financial commitment.

She charges an ophthalmic physician-owner a reasonable fair market value for the space the laser platform takes up in the corner of an operating room. That's key to keeping the arrangement in accordance with the Stark law and equates to between $50 and $100 for each of the 2 days the surgeon operates during a typical month. The surgeon rents the laser platform from an outsourcing company, which, for a per-case fee that's dependent on case volume, provides a trained laser tech, surgical microscope, phacoemulsification machine and related handpieces, instrumentation and lens implants for each patient.

The outsourcing firm arrives at the Andrews Institute ASC the night before the surgeon's scheduled cases to set up the laser. Procedures begin at 6:30 a.m. the next morning and finish around 1 p.m., which is when the outsourcing company removes the laser from the OR.

"The surgeon rents the floor space, brings us 20 cataracts twice a month, and everybody's happy," says Ms. Gatton, who adds that the surgeon passes the cost of the laser through to patients, and the Andrews Institute ASC collects facility fees for cases it wouldn't otherwise host. Still, she says low-volume centers can't consider laser-assisted cataract surgery a true profit-generating service unless they bring in ancillary services with it or double their cataract volume with patients who want to be operated on with the latest technology. She suggests those facilities test the demand for the femto laser in their market, without committing significant capital dollars, by approaching an eye surgeon with the idea of renting the laser from an outsourcing company.

Mr. Corcoran says outsourcing laser cataracts is an attractive option for facilities without the case volume to support the purchase of a laser platform, but who want to say, Yeah, we offer that, too. "It requires a small financial commitment and lets you bring in the platform on a case-by-case basis instead of losing patients to a competing facility that has the technology," he explains.

From Ms. Gatton's administrator seat at an ortho-heavy center, the femto laser is a valuable marketing tool. Multi-specialty facilities that partner with an outsourcing firm can't ignore the potential downstream benefit of getting patients, any patients, into one of their ORs.

"If someone has a great experience and outcome after undergoing surgery in your center, they'll talk to other potential patients, and word will spread about the service you provide," says Ms. Gatton. "Good word of mouth will get additional patients through the door for other surgeries more effectively than any marketing campaign you can run." OSM