moving slt procedures to the ascthe lumenis selecta trio (nd:yag + slt + photocoagulator) represents...

By E. Randy Craven, MD

As ophthalmologists, we’re familiar with the bene-fits that can be realized by performing procedures in anambulatory surgery center (ASC) instead of a hospitalor, in some cases, our offices. ASCs give us the opportu-nity to improve our patients’ experiences and outcomes.They also provide additional benefits, such as increasedefficiency in the procedures themselves and how weschedule those procedures. For example, we’re general-ly able to schedule several procedures in a row in anASC and perform them more efficiently with much lessdowntime in between.

ASCs usually have enough staff to assist with roomturnover, and those staff costs are covered by the sur-gery center rather than the practice. Also, if a piece ofequipment is needed, sometimes the surgery center canacquire it, which saves money for the practice.

In my practice, I’ve been reviewing theprocedures I frequently perform to determinewhether shifting them to an ASC would makesense for my patients and my practicefinances. Recently, I analyzed how I could usethe Lumenis Selecta Duet (Lumenis, SantaClara, Calif.) most productively.

The Lumenis Selecta Duet is two lasers inone. With this one instrument, we can per-form selective laser trabeculoplasty (SLT) forglaucoma patients and Nd:YAG capsulo-tomies for cataract patients. I was accustomedto performing YAG capsulotomies in an ASC,but the Duet led me to consider moving mySLT procedures to an ASC as well. My analy-sis showed it does indeed make sound clinicaland financial sense. In this article, I share myanalysis, which you can use to help determineif the same may be true for you.

Wise Clinical ChoiceThe advantages of SLT, which is indicat-

ed for IOP reduction in patients with open-angle glaucoma, are well-documented.1 SLT

selectively targets pigmented cells, leaving trabecularmeshwork intact. It doesn’t cause the coagulativedamage associated with argon laser trabeculoplasty.Therefore, it’s believed to improve aqueous outflowand regeneration of the meshwork. SLT is repeatable,and it can be used as primary, adjunctive or replace-

Moving SLT Procedures to the ASC The Lumenis Selecta Duet laser can make the shift an attractive option for your practice.

S p e c i a l S e c t i o n S p o n s o r e d b y L u m e n i s

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Figure 1. The Lumenis Selecta Trio (Nd:YAG + SLT + Photocoagulator) representsthe next generation of multi-modality products, offering retinal, cataract and glaucoma therapies in a single platform.

The clinical benefits of selective lasertrabeculoplasty are the same whether

the procedure is performed in theoffice or in an ASC.

1209OMD415-OK.qxd:ADV 11/30/09 2:09 PM Page 1

ment therapy to decrease the need for topical med-ications. The clinical benefits of this treatmentoption are the same whether the procedure is per-formed in an office or an ASC.

The same can be said of YAG capsulotomy.Clinically, we can expect the same results in theoffice or an ASC. The Lumenis Selecta Duet in par-ticular has very fine focusing capability and an excel-lent range of magnification. Its 8-micron spot size isideal for capsulotomies. The laser features a highlyaccurate Super Gaussian beam profile, which causesphotodisruption with low energy levels. Thisenhances the safety profile and lowers the risk ofIOL pitting and other potential adverse effects.

Foundation for a Financial AnalysisTo compare the financial ramifications of per-

forming SLT and capsulotomy in an ASC versus inthe office, we have to consider what type of practiceand patients we have. If we have a referral-basedpractice, we may need the ability to provide same-day treatments in the office. Also, some patients mayprefer to have procedures done in the office ratherthan at a different location. Both situations couldlimit how much we would utilize an ASC.

In this financial analysis, we make four assump-tions. First, we assume SLT and capsulotomy proce-dures are performed in our practice. Second, weassume we own a stake in an ASC or have access to

an ASC. Third, we assume the cost of support stafffor an office or an ASC would be similar. In otherwords, we need a technician to assist us, regardlessof whether we’re performing the procedure in anASC or an office, so the cost to hire a technicianwould be comparable. Our fourth and final assump-tion is that the laser is being financed, which meanswe’re able to use the laser to perform proceduresand generate revenue while we’re paying for it. Thisavoids a large financial outlay up front and providesus with an opportunity to create a payment scenarioin which the laser pays for itself over time.

Also, for the purposes of this analysis, we’re usingthe estimated allowable amounts Medicare or ourinsurance carriers can reimburse us for performingSLT (code 65855) and capsulotomy (code 66821).For the analysis presented here, I used the publishedestimated payment a physician in my state can beexpected to receive on average. Your paymentamounts will be different depending on where youpractice and your specific insurance carrier contracts.

First, let’s look at how much we’re paid in theoffice. Let’s say we’re paid $280 by Medicare butslightly more by commercial carriers, $301, for per-forming SLT in the office.

The rates paid for physician services are lesswhen we perform SLT in an ASC; we receive $247from Medicare and $265 from commercial carriers.Practice collections would be $33 to $36 lower for

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Figure 2. The Lumenis Selecta Duet is an ideal option for physicians who would like to perform both SLT and Nd:YAG capsulotomy procedures in an ambulatory surgery center.


doing each procedure in an ASC. However, as you’llsee below in Scenario 1, we can still come out ahead.

SLT physician SLT physician Net differencepayment (office) payment (ASC) office vs ASC- Medicare $280 - Medicare $247 $33- commercial $301 - commercial $265 $36

For YAG capsulotomies, the difference betweenphysician payment amounts between the office andan ASC is much less, approximately $12 to $15 percase.

YAG physician YAG physician Net differencepayment (office) payment (ASC) office vs ASC- Medicare $264 - Medicare $249 $15- commercial $272 - commercial $260 $12

Of course, we must take into account the cost ofthe laser. If the purchase price is $75,000, financedwith a 3-year loan at 7%, our monthly expenditurewould be $2,316.

Scenario 1 To examine various ASC ownership scenarios, we’re

going to assume we have an average busy ophthalmolo-gist who performs approximately four SLTs and 1 YAGper week in the office. This will be the basis for theremainder of Scenario 1.

A typical breakdown for many of us is this — 75% percent of our patients are Medicare beneficiar-ies, 25% are covered by commercial insurance. Per-forming the SLT procedures in the office — 12Medicare and four commercial per month — wewould be paid $4,564 each month. Performing theYAG procedures in the office — three Medicare andone commercial per month — we would be paid$1,064 for the month. Our total monthly collectionsfor in-office SLT and YAG would therefore be $5,628.After paying our $2,316 loan for the month, wewould net $3,312.

• No Ownership in ASC 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, $5,031vs. $5,628. However, the laser payment isn’t comingout of the practice finances, so our net is consider-ably more.

Practice Monthly collections: Monthly collections:(procedures in office) (procedures in ASC)SLT $4,564 SLT $4,024YAG $1,064 YAG $1,007

Total $5,628 Total $5,031

Minus laser payment No payment – $2,316 for laser Net $3,312 Net $5,031

• 100% ASC Ownership As the sole owner of an ASC, using the Lumenis

Selecta Duet for SLTs and capsulotomies can be evenmore lucrative because there are two separate rev-enue streams. We would collect our physician pay-ment of $5,031 for doing procedures in the ASCeach month (as calculated above). In addition, as theASC owner, we would receive related facility fees.Using the average fees a facility in my state can beexpected to receive, Medicare would pay about $174for each SLT, and commercial carriers would pay asmuch as $1,000. For each YAG capsulotomy,Medicare would pay about $292 in facility fees, andcommercial carriers would pay as much as $1,200.As such, for our 12 Medicare and four commercialSLTs per month ($6,088) and our three Medicareand one commercial YAG per month ($2,076), wewould receive a total of as much as $8,164 in facilityfees. From that we would subtract our $2,316monthly laser payment, which nets the ASC $5,848.To the ASC’s net, we would add our physician pay-ments of $5,031, for a total of $10,879 potentiallyavailable. The difference in collections to the 100%ASC owner versus in the office would be $7,567

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($10,879 less $3,312) or more available for the100% ASC owner.

Monthly physician payment (procedures in ASC)SLT $4,024(12 Medicare @ $247; 4 commercial @$265)YAG $1,007(3 Medicare @ $249; 1 commercial @$260)

Total $5,031

Monthly facility fees SLT $6,088(12 Medicare @$174; 4 commercial @$1,020)YAG $2,076(3 Medicare @$292; 1 commercial @$1,200)

Total $8,164

Minus payment for laser – $2,316Net to ASC $5,848

Physician paymentplus ASC net $10,879

• 10% ASC OwnershipEven if we’re one of 10 owners of an ASC, the

numbers for using the Lumenis Selecta Duet in thefacility remain favorable. We would earn $5,031 in physician fees for the procedures we perform.Also, based only on the procedures we personallyperform, the ASC nets $5,848. As one of 10 owners,our ownership distribution probably decreases to10%, 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 wouldhave collected in office) or a total of $2,303 morefor performing procedures in the ASC, assumingyour ASC makes a profit and you receive some distributions based on that profit.

Furthermore, if only four of our ASC co-ownersdo 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 inthis scenario.

Scenario 2If your procedure volume is higher, the financial

argument for using an ASC becomes even stronger.Doubling the volume of procedures performed inyour practice will increase practice collections to$8,940 after deducting the laser payment. With noownership in an ASC, it’s $10,062, for a net of$1,122 more. This tells you that you need to per-form more than the cumulative amount of 8 SLTsand 2 YAGS each week to make owning your ownSLT/YAG — outside of an ASC — financially advan-tageous during the time you are financing it. Ifyou’re 100% owner of an ASC, the overall increasedcash flow available from physician fees and distribu-tions increases to $15,308. This would be true in the10% ownership model, as well, at $2,540 more.With more surgeons using the laser in the ASC, yourreturns would be even higher.

A Worthwhile SwitchBased on my financial analysis of the Lumenis

Selecta Duet, I do all of my SLT procedures in theASC instead of the office. This change has workedfor my patients, but it has also boosted my efficiencyand my practice finances. Considering a similarchange should be worthwhile for any practice thatperforms both YAG and SLT treatments, whether thephysician 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.

REFERENCE1. 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.

Based on my financial analysis of theLumenis Selecta Duet, I do all of mySLT procedures in the ASC instead ofthe office. ...This change has worked

for my patients, but it has also boostedmy efficiency and my practice

finances.


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