Soon after we opened our ASC in 1999, the hospital I operated at cut my OR time by two-thirds. I had two choices: Perform routine retinal cases at the hospital in the evenings or on weekends; or move my retina cases out of the hospital and into my ASC. After careful consideration, I chose the latter and haven't looked back since.

My partners and I hadn't been looking to add vitreoretinal surgeries to our ASC; it happened out of necessity. Now, three years later, I am performing 80 percent of my retinal cases in the ASC - and turning a profit in our physician-owned, single-specialty eye center. Here's how we added retina to our facility, and how you can, too - especially if you're looking for a simple and sensible way to fill under-utilized OR time.

Getting equipped
Before we decided to move my retinal cases to our ASC, I needed to know the cost of the equipment needed to perform the surgeries. I made a list of the things I would need to undertake easy retinal cases. To my delight, we already had a lot of the equipment in our ASC or in the office.

• Our OR microscope was acceptable for anterior segment work as well as for posterior segment operations.
• We retrofitted our existing clinic laser to perform indirect pan retinal photocoagulation (PRP) and endophotocoagulation. Just buying a laser is a bit expensive; if you can retrofit an existing laser, you can cut the cost of your initial outlay.
• Looking at the basic instruments needed for retinal surgery, I found a lot of them already on the ASC's anterior segment tray. There were only three or four retinal specialty instruments missing, and those were easily added to the existing surgical instruments. By doing this, I avoided the cost of buying a whole new tray of retinal instruments for $20,000 to $30,000.
• The last item needed was the vitrectomy machine itself. Our cataract machine is modular in design, which means existing modules can be replaced - and new modules can easily be added. So I was able to have a posterior vitrectomy unit added to our cataract machine for a fraction of the cost of a new vitrectomy unit.

In general, I was cautious about buying instruments or machinery that could be used only for special retinal operations once or twice per year. This greatly reduced the financial burden of setting up retinal surgery in our ASC.

Keeping time
For retinal surgery in the ASC, you need to consider two time-related factors: OR availability and procedure duration.

If an anterior segment surgeon is performing cataract procedures Monday, Tuesday and Wednesday, but the OR is shut down Thursday and Friday, this could lead to a lower profit margin. You're still paying the ASC staff for five days of work despite only three days being productive. Adding retinal surgery to fill those gaps in the schedule makes financial sense. If a retinal surgeon is not part of your group, invite one to join the group or to move some cases from the hospital to your ASC. This is profitable for your facility and makes his life a lot easier, because he has block time - he can schedule elective cases without having to follow general surgical procedures in a hospital inpatient setting, where there's a possibility of being delayed.

Surgeon speed is of the utmost importance in deciding whether to add retinal surgery to your ASC - a slow surgeon is a sure way to lose money on retinal cases. If you look at "Average Case Times," you'll see that I have below-average operating times. This is an important part of making sure your ASC shows a profit for retinal cases. If you're thinking about inviting a retinal surgeon to operate in your ASC, keep in mind that a 40-minute case is reimbursed the same as a four-hour case, but the overhead staffing charges are much greater for the longer cases. You've got to keep the OR moving and on time.

The last piece to the timing puzzle is anesthesia time. All our cases are done with monitored anesthesia care (MAC), not general anesthesia. That way, we cut the patients' risk of adverse reactions to anesthetic agents and are able to shorten patients' time in the recovery room. The nurse anesthetist gets reimbursed for the MAC, so that fee doesn't come out of our pockets.

What about staff? A cataract staff can easily work on the retinal procedures with little additional training. You don't need to add new staff or replace old staff. Our CRNA did not have to change his technique for retinal patients - it's the same anesthetic block used on cataract patients. The only difference is that the medication used for the block is slightly longer acting.

Some retinal surgeons have moved 70 to 75 percent of cases to the ASC, but you have to know your limits: Choose easy cases for the ASC and do the rest at the hospital. Proper case selection is paramount to making sure your facility will profit on retinal surgery. I exclude very sick eyes and patients with high co-morbidities. I don't do cases for which silicone oil is needed and I don't operate on patients with extensive profilerative vitreoretinopathy (PVR). Silicone oil is not a reimbursable ASC facility expense, and PVR cases take too long. These cases are better performed in a hospital setting with its extensive equipment, instruments and time.

Ideal retinal cases for the ASC are macular hole surgery, diabetic vitreous hemorrhages, cellophane retinopathy surgery and simple retinal detachments. The logic is simple: Less complex cases will take you less time to do, which keeps the OR moving and keeps overhead low. If you choose difficult cases that may go into overtime for your staff, you'll end up losing money or, if you're lucky, breaking even.