By E. Randy Craven, MD
The Lumenis Selecta Duet laser can make the shift an attractive option for your practice.
As ophthalmologists, we're familiar with the benefits that can be realized by performing procedures in an ambulatory surgery center (ASC) instead of a hospital or, in some cases, our offices. ASCs give us the opportunity to improve our patients' experiences and outcomes. They also provide additional benefits, such as increased efficiency in the procedures themselves and how we schedule those procedures. For example, we're generally able to schedule several procedures in a row in an ASC and perform them more efficiently with much less downtime in between.
ASCs usually have enough staff to assist with room turnover, and those staff costs are covered by the surgery center rather than the practice. Also, if a piece of equipment is needed, sometimes the surgery center can acquire it, which saves money for the practice.
In my practice, I've been reviewing the procedures I frequently perform to determine whether shifting them to an ASC would make sense for my patients and my practice finances. Recently, I analyzed how I could use the Lumenis Selecta Duet (Lumenis, Santa Clara, Calif.) most productively.
The Lumenis Selecta Duet is two lasers in one. With this one instrument, we can perform selective laser trabeculoplasty (SLT) for glaucoma patients and Nd:YAG capsulotomies for cataract patients. I was accustomed to performing YAG capsulotomies in an ASC, but the Duet led me to consider moving my SLT procedures to an ASC as well. My analysis showed it does indeed make sound clinical and financial sense. In this article, I share my analysis, which you can use to help determine if the same may be true for you.
Wise Clinical Choice
The advantages of SLT, which is indicated for IOP reduction in patients with openangle glaucoma, are well-documented.1 SLT selectively targets pigmented cells, leaving trabecular meshwork intact. It doesn't cause the coagulative damage associated with argon laser trabeculoplasty. Therefore, it's believed to improve aqueous outflow and regeneration of the meshwork. SLT is repeatable, and it can be used as primary, adjunctive or replacement therapy to decrease the need for topical medications. The clinical benefits of this treatment option are the same whether the procedure is performed in an office or an ASC.
The same can be said of YAG capsulotomy. Clinically, we can expect the same results in the office or an ASC. The Lumenis Selecta Duet in particular has very fine focusing capability and an excellent range of magnification. Its 8-micron spot size is ideal for capsulotomies. The laser features a highly accurate Super Gaussian beam profile, which causes photodisruption with low energy levels. This enhances the safety profile and lowers the risk of IOL pitting and other potential adverse effects.
Foundation for a Financial Analysis
To compare the financial ramifications of performing SLT and capsulotomy in an ASC versus in the office, we have to consider what type of practice and patients we have. If we have a referral-based practice, we may need the ability to provide sameday treatments in the office. Also, some patients may prefer to have procedures done in the office rather than at a different location. Both situations could limit how much we would utilize an ASC.
In this financial analysis, we make four assumptions. First, we assume SLT and capsulotomy procedures are performed in our practice. Second, we assume we own a stake in an ASC or have access to an ASC. Third, we assume the cost of support staff for an office or an ASC would be similar. In other words, we need a technician to assist us, regardless of whether we're performing the procedure in an ASC or an office, so the cost to hire a technician would be comparable. Our fourth and final assumption is that the laser is being financed, which means we're able to use the laser to perform procedures and generate revenue while we're paying for it. This avoids a large financial outlay up front and provides us with an opportunity to create a payment scenario in which the laser pays for itself over time.
Also, for the purposes of this analysis, we're using the estimated allowable amounts Medicare or our insurance carriers can reimburse us for performing SLT (code 65855) and capsulotomy (code 66821). For the analysis presented here, I used the published estimated payment a physician in my state can be expected to receive on average. Your payment amounts will be different depending on where you practice and your specific insurance carrier contracts.
First, let's look at how much we're paid in the office. Let's say we're paid $280 by Medicare but slightly more by commercial carriers, $301, for performing SLT in the office.
The rates paid for physician services are less when we perform SLT in an ASC; we receive $247 from Medicare and $265 from commercial carriers. Practice collections would be $33 to $36 lower for doing each procedure in an ASC. However, as you'll see below in Scenario 1, we can still come out ahead.
For YAG capsulotomies, the difference between physician payment amounts between the office and an ASC is much less, approximately $12 to $15 per case.
Of course, we must take into account the cost of the laser. If the purchase price is $75,000, financed with a 3-year loan at 7%, our monthly expenditure would be $2,316.
To examine various ASC ownership scenarios, we're going to assume we have an average busy ophthalmologist who performs approximately four SLTs and 1 YAG per week in the office. This will be the basis for the remainder of Scenario 1.
A typical breakdown for many of us is this − 75% percent of our patients are Medicare beneficiaries, 25% are covered by commercial insurance. Performing the SLT procedures in the office − 12 Medicare and four commercial per month − we would be paid $4,564 each month. Performing the YAG procedures in the office − three Medicare and one commercial per month − we would be paid $1,064 for the month. Our total monthly collections for in-office SLT and YAG would therefore be $5,628. After paying our $2,316 loan for the month, we would net $3,312.
If we perform our four SLTs and one YAG per week in an ASC we don't own, instead of the office, our monthly collections are somewhat less, $5,031 vs. $5,628. However, the laser payment isn't coming out of the practice finances, so our net is considerably more.
As the sole owner of an ASC, using the Lumenis Selecta Duet for SLTs and capsulotomies can be even more lucrative because there are two separate revenue streams. We would collect our physician payment of $5,031 for doing procedures in the ASC each month (as calculated above). In addition, as the ASC owner, we would receive related facility fees. Using the average fees a facility in my state can be expected to receive, Medicare would pay about $174 for each SLT, and commercial carriers would pay as much as $1,000. For each YAG capsulotomy, Medicare would pay about $292 in facility fees, and commercial carriers would pay as much as $1,200. As such, for our 12 Medicare and four commercial SLTs per month ($6,088) and our three Medicare and one commercial YAG per month ($2,076), we would receive a total of as much as $8,164 in facility fees. From that we would subtract our $2,316 monthly laser payment, which nets the ASC $5,848. To the ASC's net, we would add our physician payments of $5,031, for a total of $10,879 potentially available. The difference in collections to the 100% ASC owner versus in the office would be $7,567 ($10,879 less $3,312) or more available for the 100% ASC owner.
Even if we're one of 10 owners of an ASC, the numbers for using the Lumenis Selecta Duet in the facility remain favorable. We would earn $5,031 in physician fees for the procedures we perform. Also, based only on the procedures we personally perform, the ASC nets $5,848. As one of 10 owners, our ownership distribution probably decreases to 10%, or $584. The difference between the ASC versus the office for the provider in this scenario is $5,031 for doing the procedures in the ASC plus the $584 (10% return) less $3,312 (what you would have collected in office) or a total of $2,303 more for performing procedures in the ASC, assuming your ASC makes a profit and you receive some distributions based on that profit.
Furthermore, if only four of our ASC co-owners do the same SLT and YAG volume as we're doing, collections increase to 100% ownership levels. So, the owners can build upon one another's work in this scenario.
If your procedure volume is higher, the financial argument for using an ASC becomes even stronger. Doubling the volume of procedures performed in your practice will increase practice collections to $8,940 after deducting the laser payment. With no ownership in an ASC, it's $10,062, for a net of $1,122 more. This tells you that you need to perform more than the cumulative amount of 8 SLTs and 2 YAGS each week to make owning your own SLT/YAG − outside of an ASC − financially advantageous during the time you are financing it. If you're 100% owner of an ASC, the overall
increased cash flow available from physician fees and distributions increases to $15,308. This would be true in the 10% ownership model, as well, at $2,540 more. With more surgeons using the laser in the ASC, your returns would be even higher.
A Worthwhile Switch
Based on my financial analysis of the Lumenis Selecta Duet, I do all of my SLT procedures in the ASC instead of the office.
This change has worked for my patients, but it has also boosted my efficiency and my practice finances. Considering a similar change should be worthwhile for any practice that performs both YAG and SLT treatments, whether the physician owns or partially owns an ASC or not.
Dr. Craven, an associate clinical professor of ophthalmology at the University of Colorado School of Medicine, is a nationally recognized expert in glaucoma and its treatment. He practices at Specialty Eye Care in Parker, Colo.
- Kramer TR, Noecker RJ. Comparison of the morphologic changes after selective laser trabeculoplasty and argon laser trabeculoplasty in human eye bank eyes. Ophthalmology. 2001;108:773-779.