This article originally appeared in Outpatient Surgery Magazine, click here to view it on their site.
Sightpath customers Dr. Larry Patterson, Dr. Sandra Yeh and the staff from Mount Grant General Hospital are quoted in the article.

The Easy Way to Add Laser Cataracts

Cataract outsourcing companies will bring the femtosecond laser to you.

By Dan O’Conner, Editor-in-Chief

He was hooked the first time he played with a femtosecond laser. “I have to admit: It was very, very cool. Awfully impressive,” says ophthalmologist Larry E. Patterson, MD, the medical director for Eye Centers of Tennessee. Cold, hard economics quickly tempered his enthusiasm. “How could we possibly afford it?” he remembers thinking. “It looks interesting, but it seems terribly expensive and a lot of trouble. And is there any evidence that it’s worth it for patients?”

No matter how hard he crunched the numbers, no matter how many patients he thought he could convert to laser-assisted refractive surgery with the promise of blade-free precision, there was no way he could afford to buy a $500,000 laser and have the volume necessary to make a profit. “It wouldn’t work unless I had massive volume — at least 100 surgeries a month,” he says. “I didn’t think it would be a wise investment to buy one.”

But Dr. Patterson, a leader in the field of cataract and refractive surgery, didn’t give in. He did the next best thing to buying a femtosecond laser. He went the increasingly popular outsourcing route, leasing a femtosecond laser and all the people and supplies that come with it from a mobile cataract services company. A year ago this month Dr. Patterson performed the first mobile femto cataract case in the nation.

And now, a year later, without pushing it on patients but by simply letting them know that femto is an out-of-pocket option for them, Dr. Patterson says he’s converting about 25% of his cataract caseload to the laser treatment. “There’s something about the accuracy of the procedure,” he says. “The laser appeals to people.” Dr. Patterson’s monthly laser case volume has generally hovered in the 20s, with a low of 17 and a high of 34.

Given his laser volume, Dr. Patterson says he could “probably” afford to buy one now, but here’s why that’s not likely to happen. He figures it would take 18 to 24 cases a month to break even. That’s a lot of volume, a lot of extra time in the office and a lot of hand-holding, just to break even.

“You just did 25 cases and didn’t make a dime,” he says. “All you’ve done is pay off laser. That doesn’t make any sense.”

A true engineer

Besides the opportunity to have access to the latest and greatest cataract technology — without having to worry about insuring, maintaining or storing it — perhaps outsourcing’s greatest benefit is all that comes with the deal. Take, for prime example, the laser tech. “Every time that laser comes into your place, you have a technician coming with it — a true engineer with an enormous amount of training,” says Dr. Patterson. The tech brings the laser into the surgical center the night before to calibrate it. “Every time we use it, it’s fine-tuned for that moment,” he says. “If something goes wrong, he can take some panels off and fix it. We are getting a true engineer.”

Plus, he adds, his femto tech goes to several other ophthalmic surgical centers along his route, seeing what works and what doesn’t. “This is his job. It’s all he does,” says Dr. Patterson. The tech sees best practices and is willing to share tips, like how to prevent incisions from opening and how to save 10 seconds removing nuclear fragments. “I call it cross-pollination,” says Dr. Patterson. 

Another benefit to outsourcing is that you’re not in danger of buying a machine that looks like today’s top model but could be surpassed by the innovations of tomorrow. “Femtosecond laser surgery is brand-new,” says Dr. Patterson. “The worst can become the best. You don’t know what’s going to happen.” Dr. Patterson’s advice: Even if you can afford to buy a laser, rent one for a year so that you’re not locked in.

All-inclusive fee

Dr. Patterson’s mobile model lets him bypass the break-even level and puts him on the fast path to profitability. He pays the outsourcing company a per-click fee, which includes everything: the femtosecond laser, surgical supplies, a manufacturer-certified engineer, clinical support, an implementation guide and access to customizable practice marketing tools. He schedules all laser cataract cases on the same day.

Keep in mind that most outsourcing companies require a minimum number of cases. If you’re on the hook for 10 cases per visit per month and you’ve only booked 8 cases, you still pay for 10. Ophthalmologist Sandra Yeh, MD, of Springfield, Ill., who also outsources a femtosecond laser, got burned last month when several winter storms conspired to undercut her monthly quota. Her contract states that she pays her outsourcing company $8,500 per month, a figure based on her performing 10 $850 laser cataract procedures. She did only 2 in February, but still had to pay $8,500.

If Fayette County Hospital in Vandalia, Ill., has too few cataract patients, they reschedule the cases for next month, says Surgical Services Manager Melissa Williams, RN, BSN, CNOR.

As a rule of thumb, Dr. Patterson says outsourcing a femto laser will be profitable if your facility hosts at least 500 cataract cases a year and can convert 25% of those cases (125) to the femto. That would give you about 10 laser cases per month.

As an economic model, outsourcing eye surgery works because it lets surgical facilities pay only slightly higher variable costs without having to shoulder the brunt of the capital equipment outlay, says Matt Jensen, the director of Vance Thompson Vision in Sioux Falls, S.D. “If you’re doing 10 cataract cases a month across a few surgeons, it might be in your best interest to have someone bring in the capital equipment and run it for you for a flat fee,” says Mr. Jensen.

The quest of an outsourcing company is to develop a route of 15 or 20 surgical facilities in a given area where they can bring the phaco machine or femtosecond laser from site to site. He notes that outsourcing companies are creating “new audiences” for femtosecond lasers, giving access to a swath of surgical centers that otherwise would not have the volume or capital to afford a laser. “They’re bringing their laser to surgery centers that would have never thought of purchasing a femtosecond laser,” he says.

The next big thing

Cataract outsourcing was built on helping facilities offer their surgeons and their patients the ability to perform basic cataract procedures, facilities like St. Luke’s North Hospital in Kansas City, Mo. Not having to train staff or manage the phaco machines, microscopes and lens inventory is a huge relief to Debbie Nusbaum, RN, BS, MA, CNOR, the director of outpatient services. “It’s really pretty easy when they take care of everything,” she says. She especially doesn’t miss having to pay overnight shipping fees to get IOLs delivered to the hospital in time.

Tuesdays are cataract days at St. Luke’s, a single surgeon performing 25 to 30 8-minute cases between 2 ORs. After paying the outsourcing partner and staffing costs, each case generates around a $500 profit, says Ms. Nusbaum. Don’t overlook your own staffing needs. “Have enough PACU help,” she says. “You’ll need an RN transporter to take the patient from OR to PACU, because you’ll only need one CRNA to go from OR to OR.”

Partnering with an outsourcing company lets you and your eye surgeons trial different technology with no risk. In the past, the outsourcing business was driven by changes in technology and providing that updated unit or product from the same manufacturer. Now the focus has shifted to letting surgeons and facilities trial another phaco unit or another product, “the next big thing,” at a cost-effective price point. This shift has transformed outsourcing from a “roll on-roll off” industry to more of a true partner and a service provider.

Why outsource cataracts? Maybe you’re having a hard time getting the equipment clean and operating. Maybe you can’t afford the equipment and instruments. Maybe a surgeon doesn’t like your phaco machine and supplies. Or maybe your caseload is hard to predict.

Mount Grant General Hospital in Hawthorne, Nev., is 140 miles from the nearest city, Reno, that offers cataract surgery. Knowing that it was a hardship for Hawthorne’s older population to travel so far and spend the night for cataract surgery, about 15 years ago Mount Grant partnered with a mobile cataract service. An ophthalmologist sees patients every other month, says Janet Kollodge, RN, the director of nursing. “The doctor at first was reluctant, only because he didn’t think we had enough demand to make it worth our while. We were all wrong and the community is very appreciative,” she says. Her advice: Make sure that the company is able to give the doctor the equipment he needs and that it provides enough eye trays so that you keep immediate use sterilization to a minimum.

Outpatient Surgery Magazine, March 2014