Practice Management

The mobile solution to surgery

How the “RoRo” model benefits ophthalmology practices.

BY JIM THOMAS, EDITORIAL DIRECTOR

By providing mobile surgical solutions to clinics and ambulatory surgical centers (ASCs), vendors such as Sightpath Medical and ForTec Medical allow practices to offer state-of-the-art laser technology for cataract and refractive surgery without the capital expense of purchasing equipment. With the mobile, or “Roll-on, Roll-off” (RoRo) model, the vendor brings equipment and a trained technician to a surgical site as needed. The practice or ASC pays on a per-procedure basis.

Those interviewed for this article discuss the mobile model and offer tips to maximize the value of mobile services.

Financial considerations

One primary reason to consider mobile surgical equipment is if case volume is too low to justify the outright purchase of a laser. For example, in Maine, which has the highest median age of any state and many on a fixed income, there can be limited demand for elective procedures.

“If we had purchased a laser, it would be out of date by the time it was paid for,” says Mareshah Lynch, laser surgery coordinator at Eye Care of Maine.

Yet, with the mobile surgical option through Sightpath Medical, Eye Care of Maine can offer an Abbott Medical Optics (AMO) VISX Star S4 IR excimer laser (for LASIK and PRK), an AMO IntraLase FS laser (for LASIK blade-free flap procedures), and an Alcon LenSx femtosecond laser (for laser cataract surgery). Peter C. Kohler, MD, performs LASIK surgery on the fourth Friday of every month and laser-assisted cataract surgery on the second and fourth Mondays of each month.

Robert B. Miller, MD, of Advanced Valley Eye Associates in Davis, CA, explains that he performs LASIK and other elective refractive procedures “as an integral part of my comprehensive ophthalmology practice.” By using Sightpath, the practice can offer patients “the most advanced technology for these procedures.”

“Refractive surgery is a part of what comprehensive ophthalmologists do!” he says. “You just can’t say, ‘I’m not going to do that kind of surgery’ anymore. Our patients expect refractive excellence, and doing ‘standard cataract surgery only’ is no longer an option.”

Through Sightpath Medical, Dr. Miller schedules the LenSx for the local ASC, usually two to three days each month, for laser-assisted cataract surgery. He schedules blade-free LASIK (Star S4 IR and IntraLase FS) in his office one day each month.

For other practices, patient volume was less of a concern in deciding on a mobile model. NEOVision Group in Akron, OH, uses a femtosecond laser (Catalys, Abbott Medical Optics) provided by ForTec Medical. When the schedule is busy, Jeffrey T. Starkey, MD, will use the femtosecond laser at the ASC three days (14-16 cases per day) of the six days he performs cataract surgery each month. Lisa Sears, COT, surgical coordinator of all surgeries except LASIK, says the practice decided on the mobile model because of attractive costs and service provided by ForTec, including onsite technician support(discussed later).

While vendor contracts can specify a minimum number of procedures, revenue is generated with each procedure — the practice does not have to wait to achieve a break-even point as it would with purchased equipment. Also, the practice is spared the cost of equipment upgrades and annual maintenance agreements.

Tiered pricing

In addition, practices can often negotiate a “tiered” pricing structure, “which decreases the cost per case as the practice’s volume increases,” says John “Kelly” Clayton, administrator, Richens Eye Center, St. George, UT. Sharon Richens, MD, who co-owns the Coral Desert Surgical Center in St. George, uses Sightpath’s mobile solutions for laser-assisted cataract surgery (LenSx) three times a month, as well as LASIK (Star S4 IR, IntraLase FS, and Alcon’s WaveLight excimer laser).

Jacqueline Deneen Griffiths MD, medical director of NewView Eye Center, Reston, VA, takes advantage of tiered pricing benefits as one of a number of surgeons who use the Catalys femtosecond laser at an ASC in Reston, says Darren Jones, center director at NewView Eye Center. Under their agreement with ForTec Medical, each surgeon pays the same rate per procedure, and that rate is based on the total volume of all procedures per month. “It’s almost like being in a buying group,” says Mr. Jones. “The surgeons can take advantage of the purchase power of the whole group.”

The group considered purchasing a laser because they have the volume to support it, but the benefits of the roll-on model would relieve the group of concerns such as staffing technicians and administrative personnel, scheduling, and setting up payment models. “It made the decision very easy,” says Mr. Jones.

Equipment and expertise

In addition to supplying surgical instruments and many of the parts and tools necessary for adjustments and potential repairs, vendors also provide a qualified technician or engineer who travels with the equipment and sets up, calibrates, operates, repairs, and maintains the equipment. With this arrangement, “I don’t have to pay for the technician, training, or worry about keeping the technician busy when I am not using the equipment,” says Dr. Miller.

Because the engineer travels with the laser, he is much more experienced than a tech “employed by the practice who might use the laser once or twice a month,” says Sa-Tina Emery, surgical coordinator at Eye Care of Maine.

The day prior to surgery, the engineer arrives with the equipment, runs the calibration tests, and makes the adjustments necessary to operate the laser at “peak performance,” says Mr. Clayton.

With the qualified technician, “the doctor does not have to fly alone,” says Mr. Jones. The technician will even recommend a setting for the number of quadrants that the laser will do to sculpt the lens, depending on the grade of the cataract and other parameters, he says.

Managing repairs onsite

The engineers can minimize equipment break downs on surgery day, which “means a loss of revenue on that day and the potential loss of patients,” says Mr. Clayton.

Dr. Miller recalls once as he began a procedure, the “XY gantry” (side-to-side movement) of the laser failed to work. The technician calmly opened the cover of the laser, made an adjustment and said, “Proceed, doctor.” More definitive repairs were made later, but this prevented a minor technical failure from causing canceled cases.

The technicians are savvy, says Ms. Sears. “But, if there is an issue they cannot resolve, they have a direct line to an engineer. Managing maintenance, repairs, and associated costs is much easier when the vendor takes care of them.”

Efficient use

With the mobile platform, the lasers occupy space in the practice’s surgical facilities only on the days they are used, a benefit when space is expensive or limited. To improve efficiency, Mr. Clayton recommends scheduling the equipment on slower days.

In practices where laser cataract surgery is in high demand, efficient patient flow can become an issue. Ms. Sears recommends observing a surgeon “who is very active” with the laser procedure. Dr. Starkey starts with two procedures back-to-back and then will go back and forth between the laser, where he makes the incisions and softens the lens, and the surgery room, where he extracts the broken lens and implants the intraocular lens.

Mr. Jones says there are a number of scheduling methods that can be effective depending on the number of cases, staffing in the OR, and how the surgeons operate. “If not scheduled properly, it can create a bottleneck,” he says.

Flexible scheduling

Practices have found vendors can be flexible with scheduling. For example, under the practice’s contract, Eye Care of Maine can cancel the equipment delivery without penalty by providing five or more business days notice. This is an advantage for practices in states such as Maine where many severe winter storms are forecasted well in advance, says Ms. Emery.

When requested in advance, vendors will also agree to bring the equipment on extra days, say those interviewed. Mr. Clayton recommends that practice make certain ahead of time that the procedure numbers justify increasing the service dates.

Vendors often establish a minimum number of cases per visit, but again, they can be flexible. Dr. Miller negotiated a contract in which the minimum was set on a “per-calendar-quarter” basis. This arrangement helps minimize concerns over a lower volume day or a last-minute cancellation that would reduce the volume below the contracted case minimum.

Points to consider

Before committing to a purchase, lease, or mobile “RoRo” arrangement, those interviewed agree that practices should investigate their options carefully and receive estimates from different vendors. Because patient volume determines a cost-income break-even point for purchased equipment, Mr. Clayton urges practices to use conservative patient numbers. “I can’t overemphasize enough to be sure that each practice underestimate the volume they’ll do and use their statistical data from the last two years to assess that volume,” says Mr. Clayton.

Whether purchasing a laser or using the mobile platform, Mr. Jones recommends practices consider creating a “pseudo buying group” of doctors to use the laser. “Get a commitment from as many doctors as possible before you even start negotiating the terms of use, the rate, etc., because the more users you have that show good volume, the better terms and rates you can get,” he says. “Negotiate from a position of strength.”

In addition to assessing patient volumes, practices should expect the vendor to assist with patient demographics and perform a thorough site check to ensure the facilities can accommodate the mobile equipment, says Ms. Lynch.

A shift in marketing and education

Dr. Miller strongly emphasizes that a practice’s marketing philosophy and patient education messages must change to reflect the upgrade in surgical equipment and how it impacts patients. For example, he clearly explains to the patient that traditional cataract surgery is a Medicare-covered service.

“But, if the patient is interested in minimizing their dependence on glasses or contact lenses, the surgeon can offer laser cataract surgery or special implants, which are a type of refractive surgery, like LASIK. This is NOT covered by your insurance, but can be a life-changer for those who would like to be able to function without glasses,” says Dr. Miller.

Through ForTec, NEOVision provides cataract patients with consent forms and an iPad to view a video that compares the femtosecond laser to traditional surgery. “That is just an eye opener for the patient,” says Ms. Sears. The first portion of the video illustrates how cataracts develop and how surgeons traditionally perform the surgery. The second portion includes information on the Catalys. It explains how, vs. manual surgery, the laser can make a precise cut to remove the anterior capsule of the lens and “softly” break up the cataract. The difference is like “night and day for the patient,” says Ms. Sears.

Eye Care of Maine takes advantage of the vendor’s marketing materials, including brochures, fliers, and posters, says Ms. Emery. Sightpath customizes these to promote the practice, the specific doctor, and the procedure offering. The practice educates patients on the differences between traditional cataract surgery and laser cataract surgery, including payment. This was one of the biggest changes once Eye Care of Maine began to offer the laser cataract surgery: It requires the fee be paid in advance, as the practice would with any elective procedure.

Before patients come in for their cataract evaluation, Mr. Jones says that NewView Eye Center asks patients to visit their practice website where they can download forms and view a video that explains the risks and benefits of the Catalys laser to introduce them to the technology.

Ultimately, the office staff relays the most important non-verbal educational messages of all. “As with most new technology, when the surgeon believes in it, then the staff believe in it, and then the patients understand its value,” says Dr. Miller. OP