Unlike cataracts, retina procedures are not ideally suited for the ASC: They can be unpredictable, time-consuming and expensive in terms of supplies and equipment. But the Medicare ASC payment system’s increased reimbursement for these cases makes them an intriguing possibility at the very least. Here’s what you need to know to add retina as a profit line in your surgery center.
Explore costs
The minimum you can expect to spend on retina equipment is $125,000, according to Scott Baratta of Ascent Health Care Advisors in a presentation at ASCs 2008 in San Antonio in May. He breaks down the capital costs like this:
• $50,000 for the average refurbished posterior segment vitrectomy machine, including light source;
• $25,000 for the necessary microscope modification (for faster turnover, you may want to do this to two microscopes);
• $25,000 for the laser;
• $5,000 for filters;
• $10,000 for surgical instruments; and
• $10,000 for a cryo unit.
“You can easily be at $240,000 on capital costs [for retina] without blinking an eye,” says Steven R. Blom, RN, MAHSM, CASC, administrator of the Specialty Surgery Center in San Antonio, Texas. To test out a retina program, “we’re renting some of the equipment for a while. If it doesn’t work out, then the cataract surgeons will have a fancy microscope.”
Further, says Mr. Blom, supply costs are “terribly high — retina uses more expensive supplies. If you’re not careful, you can easily be at supply costs of $750 or $800 and only $1,200 reimbursement. When you add in overhead and other costs, it might not be profitable.”
Disposable packs containing laser probes, gas and oil will run you at least $320 to $650 per case, says Mr. Baratta.
Look at reimbursements
The reimbursement for five retina codes will increase substantially by 2011, says Don Cook, the founder of Pacific Surgical Partners, based in southern California:
1. 67107 scleral buckling dissection (up 50 percent),
2. 67108 scleral buckling w. vitrectomy (up 24 percent),
3. 67110 injection of air or other gases (previously unlisted),
4. 67112 complex procedure (up 24 percent) and
5. 67113 repair complex retinal detachment (previously unlisted).
“And modifiers will let us get some extra reimbursement, more than covering the cost of doing these procedures,” says Mr. Cook. “Most retina procedures are more complicated, yes. But I look at it in terms of reimbursement per surgery center resource. And the gross margin on the cases is comparable to cataract in terms of price per unit of time.”
Recruit surgeons
“It’s very important to seek active, efficient surgeons,” says Brent Lambert, MD, FACS, founder and director of business development for ASCOA. “We don’t do retina in most of our eye centers currently, but by 2011, will be doing it because the reimbursement will be such that we can make money.”
Dr. Lambert recommends asking your eye surgeon partners who the most efficient retina surgeon in the community is.
“Sometimes we get more than one name, but usually there’s agreement on two or three extremely efficient surgeons,” he says. “We go to them and tell them that our surgeons are saying they are excellent, and ask if they would like to join us to at least try using our ASC for retina for a while. If we ask, ‘How long does it take you to perform membrane stripping?’ and the surgeon says 30 minutes, we bring them on now. If they say an hour, we tell them we’re ramping up, and that we’d love to talk to them again in January.”
Put it into practice
Once you’ve got your efficient surgeons, it’s time to actually give it a go in the ASC and see how the retina program would actually work.
“You want to have the same types of cases bunched up in one day or one block, so you’re not flipping the room for different types of cases,” says Mr. Cook. “The volume looks as if it’s out there, so we have high hopes we can do that. Especially because profitability of retina is dependent on efficiency of the cases, you have to push to collect the cases in the most efficient scheduling categories so you can provide the right staff, right instruments and fast turnover.”
Because cataracts are the bread and butter of ophthalmology, and it’s necessary to keep those going at a rapid-fire pace, you don’t want to stop one guy from working two rooms and slow him down in order to bring in a retina case. But that’s one of the challenges provided by retina: Cases are often emergent in nature.
“Typically, the center is busy with ENT cases in the mornings and cataracts in the afternoon,” says Mr. Blom. “You have to be careful with longer cases or you could end up sitting there doing retina cases at 6, 7, 8 at night, running staff on OT and losing money.”
Mr. Blom’s center has five ORs. Four of the five are used daily and are near capacity five days a week; the fifth was running at about 20 percent capacity, so it “made sense to invite four retina surgeons to the ASC Monday through Thursday and let them utilize the available time to test the potential profitability.”
However, he was up front with the surgeons about limitations to ensure his center doesn’t run into a money-losing situation, such as the one described above.
“There are no on-call teams and the center isn’t open on weekends,” says Mr. Blom. “If they have a case at 3 p.m. or 4 p.m., we’ll tack it on. If they have an ’emergent’ situation in the office, we have a loose agreement with the cataract surgeons, who are often their referral sources, to use one of the two ORs they may be working out of. But they can’t call me at 8 p.m. and tell me I have to open the center up. There are some retina physicians who aren’t willing to work here because of this arrangement. That’s fine. But some physicians say they don’t really do that much emergency work, so they’re happy to bring their non-emergent cases to the ASC.”
Contact Stephanie Wasek at stephanie@beckersasc.com.
