11 Ways to Improve Efficiency, Quality and Profitability in Ophthalmology

As Medicare incentivizes ophthalmalogists to perform more procedures outside of hospitals, ASCs are luring more of them to do not only the traditional cataract surgeries, but also corneal transplants and retina surgeries.

Some ASCs are scrambling to recruit retinal surgeons to capitalize on the expected growth of retinal outpatient surgeries.

Ophthalmologists and ASC administrators say that with the right process, equipment and experienced eye team, surgeons using two operating rooms are capable of doing five to six cataract procedures an hour.

"We have surgeons who can perform cataract procedures without complications within 10-15 minutes," says Ellen Johnson, vice president and chief operating officer for Facility Development & Management, which provides consultative, developmental and managerial services for ASCs. "Patients are leaving after surgery and nurses, anesthesiologists and technicians are bringing in trays for the next procedure. From cut to cut it can take between 8-10 minutes."

Ms. Johnson says, "The name of game is to move things efficiently. One reason ophthalmologists perform procedures in ASCs is they don’t want to go to hospitals and wait around for ORs to open up. Pain management and ophthalmology are practically instantaneous turnarounds, with limited cleanup and prep compared to orthopedic or other procedures. Physicians like them because they can do a tremendous amount of cases and still be out the door at a reasonable time of day. Patients love it because the recovery is pretty quick. They’re not hanging around forever in recovery rooms and it’s usually not done under general anesthetic."

Here are 11 best practices to improve ophthalmology services in ASCs.

1. Standardize surgical products. George Violin, MD, board-certified ophthalmologist and a co-founder and owner of Ambulatory Surgery Centers of America, an ASC management and development firm that owns interests in 34 ASCs, says ASCs can save money by sharing information between surgeons and minimizing idiosyncratic equipment.

"The bulk of ASC ophthalmology services are cataract removal and lens implantation," says Dr. Violin. "If you can convince every surgeon to use the same knife, the same pre-packs of surgical instruments and cataract kits, then you don’t have to stock 10 different kinds of lid speculums and other tools. You achieve uniformity of disposable items and kits and avoid multiple iterations and variations of the same thing. And you save a lot of money."

Dr. Violin also advises minimizing inventory of all supplies to reduce overhead costs. One way is to hold an annual "Dutch auction" to select the lens used by that ASC for the year.

"The lowest priced lens wins the auction and all surgeons must commit to use a common lens," he says.

Also try to minimize the total number of vendors as uniformity results in greater volume purchasing power and lower costs.

"Standardization is the best thing," agrees Ms. Johnson. "The more preferences, the higher the costs. If you can get the docs to agree on custom packs, you can negotiate better pricing deals with vendors."

She also recommends keeping irregularly used kits out of the OR unless they’re requested.

"Don’t bring it out unless they need it and don’t open it until it’s requested," Ms. Johnson explains, saying that helps protect the integrity of the custom pack, which includes eye drops, surgical drapes and sometimes gloves.

"Another trick is you don’t want to buy implants up front, but on consignment," she adds, explaining that lenses, screws and other implants are costly to purchase up front and could sit on shelves for a long time. "If you have a consignment arrangement with a vendor, then the required items are on your shelf and you notify the company when you use them and only pay then."

She also suggests trying a new product first to be sure it’s needed and pays to have it, rather than purchasing it upfront and waiting.

Ms. Johnson says she cultivates relationships with various vendors when her firm develops centers to price OR tables and lights and has inked national contracts with some firms. The ASCs her company manages contract with group purchasing organizations. "But sometimes I get an even better preferred rate because we have more than one center. This helps also when we bring on a new center because we can access better prices for them."

2. Give only the most efficient surgeons two operating rooms. "You probably should not have surgeons who can do less than three cases per hour," says Dr. Violin. "We use two operating rooms in tandem and the surgeon goes room to room between procedures using two identically equipped and staffed rooms. You give those rooms to doctors who can do five to six cases an hour. Give the most efficient surgeons the chance to use two ORs and those who can’t perform that many should only use one room."

Even efficient operations improve through advanced planning, says Rajiv Chopra, principal and chief financial officer with The C/N Group, an ASC and imaging center development and management company. "Pulling supply trays in advance, documenting lens requests, communicating with the surgeon’s office all have positive impacts on readiness, efficiency, inventory needs, turnover time and quality and risk management."

3. Make sure all paperwork is done before the day of surgery, including the selection of the lenses. "That way the surgeon is not looking for lenses between cases," Dr. Violin says. "The surgeon should validate the lens before the procedure, examine the patient chart and the lens picked and confirm that it’s the correct lens," he says, explaining the practice not only improves quality, but reduces potential legal risks. "One of the most common causes of intraocular lens litigation is implanting the wrong power lens."

4. Schedule wisely. The ASC should use per diem employees whenever possible. When the center is not busy, it should be closed. "If there is not enough business to make a day profitable, the center should be closed to keep a handle on costs," Dr. Violin says.

5. Require justification for expensive extra supplies. If a surgeon needs such costly extras, he must justify their specific use, says Dr. Violin. "It’s a constant war between vendors and surgery centers to keep profit margins reasonable. And the ASC should be a profit center, not simply a facility for the surgeon’s convenience."

6. Know the Medicare reimbursements for your region. Ms. Johnson says every U.S. region differs in Medicare reimbursement. "[ASCs] need to that and know what their costs are," Ms. Johnson says. "This is global. They can’t go to the table with insurers and negotiate intelligently otherwise. With ophthalmology, ASCs have to remember to be sure their contracts cover lenses separately. Some companies will not reimburse 100 percent for the new super lenses. They should never negotiate a contract with a commercial insurer for less than what Medicare pays. I wouldn’t give a flat rate without including the price of lenses. Why should they eat that $150? If you forget to include lenses it can cost you a lot. If you don’t get it from the insurer, then you have to tell patients they’ll be charged extra."

She says the contracts for her firm’s ASCs are all downloadable, so when someone asks about a product or procedure and aren’t clear about it, they can verify almost immediately.

"We can track each insurer’s payment times and if they aren’t within the 30-day frame, we can get on the phone with them," Ms. Johnson says. "Insurers are always challenging us with out-of-network arrangements. Sometimes they send checks to the patients without telling us. We try to let the patients know that. Insurers can be quite capricious."

Mr. Chopra says one key to collecting every cent is to know what each payor requires under contracts.

"Some payor contracts allow reimbursement for implants, but you have to make sure there is a nurse in the room when the surgery is performed to document everything," he says. "Then that goes to billing and collections. You want to ensure that if medical supplies and implants are reimbursed under contract, that you have documented and not billed for them. If you don’t bill for them, you won’t be paid."

7. Drive growth in volume by expanding scope of ophthalmology procedures. "Cataracts comprise the bulk of most ASC ophthalmology procedures, but centers should consider moving beyond cataracts to include corneal transplants and retina work," says Mr. Chopra. "Corneal transplants are more complex, but yield higher reimbursements and volumes."

Michael Sayegh, MD, ophthalmologist and co-owner of the Eastern Orange Ambulatory Surgery Center in Cornwall, N.Y., points out that Medicare is now allowing more retinal procedures to be performed in ASCs.

"This is one area that will grow a lot and we’ll soon see ASCs recruiting retinal surgeons," Dr. Sayegh says. "Reimbursement looks promising."

8. Hire, train and retain a team dedicated to ophthalmology. Having a trained and dedicated staff that works exclusively in ophthalmology improves efficiency, quality and profitability, says Mr. Chopra. "It also makes it easier to recruit and keep physicians."

Ms. Johnson concurs. "Dedicated teams always work the best. When a surgeon works with the same team, it improves efficiency. That’s not to say if the ASC only has ophthalmology one day a week that the staff can’t work with other specialties. But if the eye surgeon works with the same team of experienced staff, it helps their confidence level and efficiency. Even if those are per diem nurses and techs, from the doctor’s point of view, he has his team, rather than a different person each week that he has to break in to adapt to his work style. And the team learns how a doctor works and what to anticipate and that doctor’s preferences and helps to move cases along. Many doctors have idiosyncrasies," she says. "You may have to have backup during vacations and rotate people"

Dr. Violin also supports ASCs creating dedicated ophthalmology teams. "If you can, have a design set of nurses that do ophthalmology only. It builds excellence in the nursing staff."

9. Surgeons must become active partners in improving efficiency. It behooves surgeons to become part of the same team working to improve quality and efficiency, says Dr. Sayegh.

"The team shouldn’t just be working around the surgeon," he says. "I’ve met surgeons who think the ASC will make him efficient, that he doesn’t have to do anything and it will be a turnkey operation. But the surgeon needs to be involved or any attempts to improve efficiency will fail and the entire ASC will adopt his approach and efficiency will drop. If the captain of the ship isn’t efficient, no one else will be either."

10. Schedule patients quickly. "People don’t like to wait for surgery to begin with, but with ophthalmology services, when patients finally decide, they want it quickly," says Ms. Johnson. "By the time you need cataract surgery, your vision is already clouded and you don’t want to wait another 6-8 weeks. We like to schedule our patients as quickly as possible and they appreciate it."

11. Pre-screen patients. "We’re seeing more and older patients with the aging of America," Mr. Chopra says. "Our patients are much older on average than we saw three to five years ago. That creates a greater challenge in caring for that patient. We’re pre-screen before we schedule them for surgery. Someone who is 80 could have an irregular heart beat and might not be able to tolerate anesthesia. Because of this demographic shift some of our patients are at higher risk and we need to plan and adapt to that."

Contact Mark Taylor at mark@beckersasc.com.

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