As more surgery centers add ophthalmology and new ophthalmologic procedures to their services, it is important to consider some of the challenges unique to this specialty. Here are six challenges currently facing ophthalmology in ASCs and best practices for overcoming them.
1. Adding retina procedures can be expensive but profitable. Retina procedures require a significant initial investment for surgery centers that are interested in adding these surgeries to their services.
"A good retinal machine requires a significant capital investment," Jason Jones, MD, a physician at Jones Eye Clinic in Sioux City, Iowa, says. He also notes that the case load will be lower for retina procedures. "A center will do a few hundred of these procedures a year, not thousands, so it is important to weigh the costs while considering adding this procedure," he says.
Dr. Jones also notes that retina procedures use many products that are designed for single use. However, he says that this can be balanced by the greater efficiency that single-use products can have because time is not required for the cleaning and care that multi-use equipment needs.
Margaret Acker, CEO of the Blake Woods Medical Park Surgery Center in Jackson, Mich., agrees that the new equipment needed for retina procedures will mean a significant hit to a center's bottom line. As a result, it is important for centers to ensure that they have enough physicians who can fill the schedule and use the equipment for retina surgery.
Silicon oil and Perfluron used in retinal surgery can also be costly, but if surgeons are working effectively, Ms. Acker notes, supply costs can be easily maintained.
"You need to find your breakeven point — how many procedure need to be done in a year to justify the costs," Ms. Acker says. "Also, it is important to ask how many cases did your physicians do and how many would they bring to the surgery center."
Ms. Acker says that exact reimbursement for retina procedures depends on the payor, but her center usually receives around $1,500 per code and that her center generally uses multiple codes.
Ms. Acker notes that a good portion of patients who have retina procedures will probably need to have another procedure in the future. "If a surgery center does a good job of taking care of their patients, retina patients included, there is a good chance that if patients need to have another procedure a few years down the road, they will return to the center," she says.
2. Patient selection can require special considerations. While most ophthalmologic procedures don't require general anesthesia, there are still some risks certain patient populations can pose for surgery centers.
Ms. Acker notes that most retina patients are elderly and not in very good health. "Most of these patients are under local anesthesia or a periovular block, but it is important to have an anesthesiologist who is well-versed in taking care of elderly patients," she says.
Patients should be monitored closely and make sure that they have proper oxygen saturation during the procedure, according to Ms. Acker.
Dr. Jones says that because retina procedures require heavier sedation, longer postoperative care is also needed.
Ms. Acker mentions that in her surgery center, staff members make sure that elderly patients who come in for retina, cataract surgery and other procedures are awake and alert before discharge, which may also require a longer stay in the PACU, as their recovery times from anesthesia are slower than other patients. "They usually come out of the OR fairly aware," she says. Ms. Acker also notes that having proper arrangements for follow-up care, such as arranging for a ride to the physician's office for the next day, is also important.
Another patient population that can provide special concerns for ophthalmology in surgery centers is pediatrics. "You can't do ophthalmologic procedures on children without a general anesthetic," Dr. Jones says.
By the same token, Dr. Jones has also encountered mentally challenged patients, such as those with Down syndrome, who come in for ophthalmologic procedures. "Sometimes we need to give these patients general anesthesia, but it depends on the availability of general anesthesia at the surgery center and the affect it will have on the patient," he says.
3. Some cataract surgeries can run over the scheduled time. Cataract procedures can sometimes be cumbersome because if a newer lens, such as Toric intraocular lenses, is used, extra surgery time is required, says Ms. Acker. This extra time is needed because a surgeon needs to mark a patient's eye before positioning the lens. "Often, a surgeon doesn't know that they will have to use the new lenses until patient comes in," she says.
To resolve this issue, Ms. Acker's surgery center added five minutes to every cataract procedure. Additionally, in order to keep staffing cost down, many members of the staff agreed to work a little later, if need be, and the center was not required to make a hiring adjustment.
According to Dr. Jones, several other types of patients and procedures have special requirements when it comes to scheduling. As previously mentioned, surgery on pediatric patients, because they need general anesthesia, will require extra time. Dr. Jones also notes that some patients will have unusual anatomic needs that require specialized suture or implants that will also take more time.
"[A center] needs to strike an overall balance with the types of cases they take," says Dr. Jones.
Dr. Jones says that working with friendly owners and staff at surgery centers that allow surgeons adequate access to the center can help make scheduling go a little smoother.
4. Although ophthalmology remains stable, reimbursement issues can still raise concerns. Because most ophthalmology patients and procedures are covered by Medicare, surgery centers haven't seen the significant hit that other specialties have, according to Ms. Acker. However, she does note that there is a planned 2 percent decrease in payments for the 2010 Medicare payment schedule.
Ms. Acker says that her surgery center has not seen any significant drop-off in the payments from third-party payors, but as the unemployment rate increases, the increase in the number of patients on COBRA or government subsidies may affect payments.
Dr. Jones says that some procedures have had specific issues with reimbursement. For example, in corneal transplants, such as endothelial keratoplasty, payors have not been paying well for donor corneal tissues that are required in the procedure.
One way to account for these changes is to collect payments upfront, an approach taken by Ms. Acker's center. "By doing this, we haven't had any real issues with losing revenue," she says.
Dr. Jones mentions that ASCs treating some patients who require IOL exchanges may have difficulty getting reimbursed for implants that are better performing but cost more. In most cases, surgeons will use the implant that is covered, but for some patients, certain implants or devices are the only choice.
In some situations, a small percentage of patients who elect a premium lens require an IOL exchange, according to Dr. Jones. This can be problematic because insurance companies may be unwilling to pay for an additional procedure. "If the patient is unable to adapt to the premium lens despite efforts to help them adjust, then the indication for exchange could be considered a mechanical malfunction of the lens and it may be covered [by insurance]," Dr. Jones says. "If the lens is of the wrong power for optimal performance, then the exchange likely would be considered elective and not covered.
"The percentage of patients who require this is low," he says. "Then it becomes an issue of payment. We try to account for this issue ahead of time."
One such way is for the surgery center to receive reimbursements for what they can and collect additional fees from the patient. Another way is to have the patient pay up front via an "a la carte" fee for the implant and have the rest covered by insurance.
Ms. Acker suggests that surgery centers can prepare for changes in reimbursement by being frugal. "Watch your supply and staffing costs while safely taking care of your patients," she says.
One way in which Ms. Acker's surgery center has reduced costs is by standardizing the equipment all of the ophthalmologists use for surgery. "When you can use the same pack and equipment, it can save money," she says. "We also look at our packs from time to time, see what we aren't using and get rid of it."
5. Many patients are deferring surgery because of the economy. Dr. Jones says that some patients are choosing to put off surgery or are not seeing referring physicians for their regular eye exams. This means that some patients who may require surgery have not been seen by their regular physician and are not coming into the surgery center.
This trend may also account for the overall slowing of surgery cases that Dr. Jones has seen. However, he notes that by reviving an interest in eye surgery and raising the bar for care, surgery centers can make themselves a more inviting alternative to hospitals or in-office surgery. "The surgery center can be seen as a positive extension of the office visit," he says. "Patients are able to have an operating room and a certified staff, as opposed to the office, and there is no need to go into the hospital."
Dr. Jones also says that although his center hasn't seen much of a change, physicians in his region have seen an increase in the use of CareCredit and other healthcare financial services to help that patients pay for their surgeries. "There is less credit available," he says, "and this has often been the decision-maker for patients [as to whether or not they will have surgery.]"
6. The economy has had other effects. Aside from the increase in uninsured and government-subsidized patients and less patients coming in for surgery, other areas of ophthalmology have been affected during this tough economic time
Dr. Jones has seen, since Fall 2008, a decreasing trend in the number of patients selecting "premium" IOL implants, which would result in higher reimbursements for surgeons. However, this may be a temporary situation, and Dr. Jones says that he has started to see more patients opt for the "premium" lenses in recent months.
Physicians are encountering more savvy patients who ask for more information beyond cost in the current market. "Patients are more informed or want to be more informed, even if they get a routine lens," Dr. Jones says. "This can mean a bigger burden on the clinical end of operations to provide this information, but overall, it is very rewarding."
Certain regions and states in the United States have felt a bigger impact because of the economy. In Michigan, for example, Ms. Acker says that business tax has increased, and surgery centers have seen their expenses go up while their reimbursements have decreased. "We continue to take care of patients and make a living," she says. "Just keep watching staff costs and take proactive and frugal measures to preserve profits."
Contact Renée Tomcanin at renee@beckersasc.com.