Deciding whether to participate in an ASC, or to build one's own surgery center, is a significant milestone in a retina surgeon's professional career. With the recent changes in reimbursement that make it more attractive to consider doing more retina procedures in the ASC setting, this is a decision that is surely weighing on many specialists' minds.

To follow is the first in a two-part series that is designed to help the retina specialist in the decision-making process. In the following article, Louis Sheffler, MPS, offers advice on where to start looking for resources, how to determine whether to join an existing ASC or consider building your own, and most important, he offers examples of successful models for ASC participation. The second article in this series will be more specific, discussing physical plant design and costs involved. -Pravin U. Dugel, MD

A revolution in cataract surgery was marked almost 30 years ago when President Jimmy Carter signed the Omnibus Reconciliation Act of 1980 into law, enabling doctors to open up their own ambulatory surgery centers (ASCs) and receive Medicare payments for the facility costs associated with the performance of certain outpatient surgical procedures. This change, along with the emergence of small-incision extracapsular phacoemulsification with peribulbar anesthesia techniques, created the perfect storm that drove the migration of cataract surgery from hospitals to ASCs. One surgeon who moved on this new opportunity was Richard Mackool, MD. Dr. Mackool built a new surgical environment in his office, using the latest equipment and uniquely specialized nursing staff to achieve superlative outcomes and new levels of patient satisfaction. Today, ASC-venue cataract surgery is the routine—not the exception.

Twenty-eight years later, this phenomenon is recurring in posterior segment surgery. In January 2008, a new reimbursement system tied to hospital rates kicked in, rendering ASC retina surgery economically feasible. That change, combined with the emergence of high-speed vitrectomy cutters and 23-gauge and 25-gauge surgery techniques, has forged a new, exciting opportunity that all retina surgeons should seriously consider.

This article is the first in a two-part series that will seek to create a critical path for retina surgeons to help them decide which direction is appropriate in starting an ASC project, by reviewing ASC venue choices, design considerations, and pro forma guidance.

ASC RESOURCES
Creating an ASC is complex. A facility requires a combination of some or all of the following: a State ASC license, a Medicare certification inspection, and accreditation status from JCAH or AAAHC. Funding requirements include monies for construction expenses, equipment, and startup working capital.

Years ago, surgeons had few resources or points of reference as they set out on this road. Today, any retina surgeon considering ASC involvement should take the first step of joining the Outpatient Ophthalmic Surgery Society (OOSS; www.ooss.org), an organization of ophthalmology ASC surgeon-owners. ASC ownership is not a prerequisite for membership; the organization assists new members in navigating the maze of requirements. More important, OOSS members have access to various experts and seminars that are vital in getting new projects off the ground.

ADDING RETINA TO AN EXISTING ASC
Joining an existing ASC is the easiest and fastest way to go if the right opportunity presents itself. It is sometimes difficult, however, to convince owners of existing profitable ASCs to invest in purchasing all the equipment necessary for a retina service. The cost involved in purchasing a posterior segment unit, an image inverter, cryotherapy unit, argon laser, and hand instruments can range from $110,000 to $150,000, depending on the requirements of the surgeon. ASC owners will be concerned about how many cases will be brought into the facility to justify this capital expense; after all, other subspecialties have lower set-up costs.

If the opportunity exists to work in a busy ophthalmic ASC, consider investing in a new retina program and providing the equipment to the ASC. One hundred-fifty thousand dollars of equipment financed over a period of 5 years at 8% comes to $3,000 per month. As an ASC owner, the retina surgeon will earn dividends from the ASC, plus they will gain referrals from the anterior segment surgeons who are already part of the facility. Alternatively, hiring an expert to help create a financial presentation for the ASC owners may convince ASC owners that investing in the equipment is a wise move. Consulting services should include reviewing the performance of the ASC and a review of the shareholder's agreement to affirm the proposed investment choice.

SCHEDULING BLOCK TIME
Another issue in joining an existing ASC is OR block time. Retina surgeons routinely receive less than optimal OR time following other surgeons in hospitals. One purpose of joining an ASC is to improve the quality of life for the surgeon by being more efficient with time, and, for that reason, an investing retina surgeon should clarify in advance just what OR block arrangements will be available to him or her. A proper retina block schedule should allow adequate time for retina elective cases followed by open OR time for emergency cases. Group retina practices often consider reserving time on Fridays. This choice would be good for practices that are open on Saturdays, so postoperatives can be seen. Friday is an excellent slot because emergency retina cases that need attending from the week's surgery at the ASC can be treated at the end of the week when all anterior segment surgery is complete, thereby maximizing time efficiency. Cataract surgeons working in ASCs generally prefer having required retina procedures done at the ASC over a having to inform the patient of a proposed hospital admission.

STARTING AN OPHTHALMIC ASC
In the absence of tenable opportunities with an existing ASC in a given community, the surgeon may choose to consider creating a new ASC with other ophthalmology practices. This is the option that Jay S. Duker, MD, Director of the New England Eye Center and Chairman of the Department of Ophthalmololgy at Tufts Medical Center and Tufts University School of Medicine chose when he started Surgisite Boston in Waltham, MA.

Dr. Duker spent 2 years contacting various practices in the Boston suburbs, aligning himself with Andrew Gillies, MD, an anterior segment surgeon with affiliations at other large area hospitals. Dr. Duker included the New England Eye Center as part of the project, so that all parties would benefit in the creation of this new ASC. Dr. Gillies became President of the new ASC organization, attracting more anterior segment doctors. The facility consists of four operating rooms to accommodate everyone on the medical staff. The initial medical staff of the ASC had 17 surgeons; it has since expanded to over 50. Included are seven posterior segment surgeons. Building from the ground up takes time, but can reap optimal results. Getting started involves finding out where eye surgeons in an area are performing their surgeries. Surgical equipment and implant sales representatives are usually good sources of such information. Once that assessment is made, the posterior segment surgeon will have to determine if it is worth the time and effort to try to organize an ophthalmic community ASC. If this is not in the cards, it will be time to consider building a stand-alone retina ASC.

STARTING A RETINA-SPECIFIC ASC
A stand-alone facility has particular advantages that cannot be reaped from the other ASC models. A surgeon may perform surgery whenever he desires. Such a facility is small, with generally only one OR that is connected to the surgeon's office. This drives down the cost of overhead, because employees can be shared with the practice.

Martin Uram, MD, took this route at his office in Little Silver, New Jersey. Dr. Uram chooses to perform surgery once a week at his facility. At times, if there is an emergency, he has the flexibility to open his facility on other days. He has one full time employee—the Nursing Supervisor. Her responsibilities in addition to running the OR on the surgery day, include administrative duties (eg, ordering supplies, creating surgical charts, and monitoring medical clearances to ensure that each day of surgery goes off without a hitch).

On the day of surgery, part-time staff comes in to assist with the procedures. Dr. Uram fills his day with patients, starting early in the morning, and finishing by mid-afternoon, having performed ten to 12 cases in 1 day. The double nursing teams, complete with two scrub techs and two circulating nurses who alternate, accomplish a rapid turnover. Multiple sets of instruments eliminate waiting time for the sterilizer, while eight employees cover the front office, preoperative and postoperative areas, and the OR. Dr. Uram could use less staff, but he believes that the personnel investment is wise in maximizing efficiency and providing superior care that his patients appreciate.

VOLUME MUST SUPPORT THE ASC
In considering whether to build a stand-alone facility, a surgeon must first determine if there is enough volume to support the ASC. Surgeons should thoroughly review the surgical volume history of the practice, including both incisional-type surgeries and retinal laser procedures, because they are now covered procedures under the new Medicare reimbursement rules. It is equally important to review the insurance carrier breakdown in the practice. Non-Medicare cases pay ASCs at varying rates, so this is critical information to have in order to determine if building a new ASC is a viable, sensible decision—one that could potentially lead to more productive surgeons and a more profitable practice.

The second part of this article will cover design considerations and break-even scenarios.

Louis Sheffler, MPS, is Chief Operating Officer of American SurgiSite Centers, based in Somerset, New Jersey. www.americansurgisite.com.

Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona and Founding Member of the Spectra Eye Institute in Sun City, AZ. He is a Retina Today Editorial Board member. He can be reached at pdugel@gmail.com.