IN YOUR PRACTICE

MASTERINGEFFICIENCY AND QUALITYOUTCOMESStaffing and equipment are key components to success.

With Mandeep Singh Dhalla, MD; Leonard Fiener, MD, PhD; and Howard F. Fine,

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In this era of health care reform and when the Centers for Medicare and Medicaid Services is increasingly scrutinizing reimbursements for items such as imaging and injections,

maintaining efficiency and quality while keeping an eye on the bottom line can be a challenge.

Recently, New Retina MD assembled a panel of retina specialists to discuss the topics of efficiency and quality in the health care reform setting to offer tips from their own practices on how to achieve this balance.

Vitreoretinal Surgery EfficiencyNew Retina MD: Can you discuss how your practice is set

up for surgery?

Howard F. Fine, MD: After my fellowship, I initially oper-ated in a hospital setting. Approximately 3 years ago, how-ever, in a joint venture between the hospital and a physician’s group, we formed an ambulatory surgery center (ASC). We have shifted 95% of our surgical volume to the ASC. In gen-eral, this move has benefitted our surgeons. Our turnover is faster, our equipment is top notch, and we have more say in which nurses and technical staff work with us. There are, how-ever, limitations, which include that when we have emergency cases at night or on weekends, the ASC is not available and so we have to perform these cases at the hospital. This creates some issues, one of which is that the nursing staff on whom we rely are less familiar with the retina surgery equipment.

Leonard Feiner MD,PhD: I have been working in an oph-thalmology only ASC since joining my practice 8 years ago. The center is ophthalmology only and has 3 ORs—2 set up for cataract surgery and 1 for retina cases. Patient flow is very efficient. I meet and mark my first 2 patients in the holding area. The patients are then blocked by our anesthesiologist in the holding area and next brought into the OR. After I finish my first surgery, I bill the case, complete my operative report and mark the third patient. By the time I have completed these tasks, the next patient has been prepped and draped and they are ready for me (this process takes approximately 5 to 10 minutes). I average between 5 to 6 cases every Friday morning and then see patients in the office in the afternoon

Four of the doctors in our group operate at this ASC and 3 operate at a hospital-based ASC.

I would echo Howard’s sentiments that the staff and equipment at the ASC are top rate. The migration of cases from the hospital to the ASC has had an effect on the train-ing of OR nurses in hospitals, but the hospital-based ASC will open for cases on call. We have a doctor in the OR every day of the week and there is usually room to add cases. Very few cases are done after hours, as most cases can be safely be deferred until the next morning.

NRMD: Dr. Fine, are you operating in an ophthalmology- or retina-specific ASC or a multispecialty ASC?

Dr. Fine: Ours is a multispecialty ASC, which includes orthopedics, gastroenterology, and anesthesia, among other specialties. I believe this to be a benefit for physician-owners, because there is diversification with multiple specialties.

The ASC was formed in such a way that anyone within our private retina practice could purchase shares if he or she wished, so not all of the surgeons who operate there are owners; however, many are.

NRMD: Dr. Dhalla, what is your practice setup in regard to surgery?

Mandeep Dhalla, MD: We perform approximately 80% of

our surgical cases in a hospital-owned ASC, and the remain-ing cases in physician-owned ASCs. The hospital-owned ASC is in the same building as our Fort Lauderdale office, which has allowed us to expedite emergency cases and improve physician efficiency. The surgery center is relatively new, so it has been outfitted with the most up to date surgical machin-ery. We do encounter some of the challenges that Howard has described in terms of doing night or weekend cases in the hospital. The hospital in our case is on the same campus, which is a little more convenient.

Since the ASC is a very busy ophthalmic center, we are fortunate to have dedicated surgical ophthalmic nurses and technicians on call. Having ophthalmic staff available for weekend cases is great in terms of delivering the same excel-lent standard of care and not personally having to struggle to find equipment, instruments, and prepare the patient for surgery.

NRMD: Have you experienced any pushback from ASC owners, whether physician or hospital, regarding incorporat-ing retina due to the length of cases compared to anterior segment procedures?

Dr. Dhalla: These attitudes have changed dramatically since microincisional surgery has become more standardized for vitreoretinal procedures. Many of our less complicated cases, have the potential to have similar intraoperative times comparable to cataract surgery. As retina surgery has tran-sitioned into the ASC, vitreoretinal surgeons have also had to learn how to become not only more efficient with time, but with cost utilization (instrument choice, oil, PFO, etc.), but at the same time maintaining the same standard of care. Maximizing efficiency for less complicated cases helps us leverage the law of averages for more complex cases such as trauma, or PVR retina detachments.

Dr. Fine: If we have complex or lengthy cases, we tend to perform them in the hospital setting. Charity cases also cannot be performed in the ASC, and these also happen to be more complex such as diabetic tractional detachments. Careful case selection certainly improves efficiency in the ASC.

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Another thing that has helped reduce any pushback from ASC owners is that facility fees and reimbursement for retinal cases, which helps counter the fact that are cases are slightly longer than our cataract colleagues.

Dr Feiner: We have looked at the facility income by physi-cian and have found that retina is profitable for the ASC so there has not been pushback. Our presence, in fact, helps the comprehensive ophthalmologists, as we are often available to help on complicated cases as they arise, saving a return visit for patients for subsequent surgery.

The only cases we cannot perform at the center are cases requiring general anesthesia or cases on patients younger than 18 years of age. These cases are taken to the hospital. I have found that the center has been extremely valuable in caring for self-insured patients as the total bill for surgeon, facility, and anesthesia can be kept under $5000.

Health Care ReformNRMD: In the new setting of health care reform, what are

some factors that physicians can control to improve effi-ciency and profitability?

Dr. Fine: Our main concern is the impending issue of accountable care organizations (ACOs), which will signifi-cantly change how care is delivered and how we interact with out patients in terms of who is making treatment deci-sions. If you are involved with the management of an ASC, there are some steps that can be taken to make sure treat-ment decisions remain as much as possible with the physi-cian. These steps include making sure that your ASC is online with an electronic health record (EHR). The health care system is moving more toward accountability and ability to cull through large amounts of data to measure performance and outcomes. If you are already measuring these in your ASC and you have a robust EHR, you will be well positioned to be in the driver’s seat when these changes come by being able to say, “We have data and can show that we provide the quality that is being sought,”

Another way to prepare for the health care changes is to position yourself well with the hospitals so that you remain the gatekeeper and decision maker for ophthalmology, rath-er than the insurance companies or the hospital.

Dr. Dhalla: I agree. We are also likely to continue to see this general trend towards consolidation. Across the country, many previously independent, private practices (ophthalmic and others) are being incorporated into large health net-works or being bought out by hedge-fund investors.

Thus far, retina specialists have enjoyed a fair amount of independence because of our unique subspecializa-tion, and simply put: we have a lot of natural born leaders in our field. It will be interesting to see whether we are able to maintain that autonomy as ACOs become more

widespread. Larger practices will benefit from the rule of efficiencies, and those with the best treatment outcomes (data substantiated from EHR) will be in the best position to negotiate on all parameters.

Dr Feiner: Surgical centers significantly lower the costs of performing retinal surgeries. Letting private insurers know that you are saving them money can be useful when negoti-ating insurance contracts.

NRMD: Dr. Fine, is your practice currently part of an ACO?

Dr. Fine: No. Currently, this issue is an open-ended ques-tion, so although do not know any ophthalmology groups with our state (New Jersey) that are members of an ACO, this may change quickly over the next few years.

NRMD: In your opinion, is it better for your group to start your own ACO or is it better to wait to be approached?

Dr. Dhalla: So far, ACOs have been largely driven by hos-pital networks. Sometimes, the path to being in an ACO may be passive. As EHR becomes more standardized, the hospitals where we operate will have more efficient monitoring mea-sures in place for healthcare outcomes, cost basis per cases, etc. I believe that the line between independent provider and institute will become increasingly blurred due to cooperative changes mandated by budgetary constraints.

NRMD: What are your perspectives on maintaining excel-lence and efficiency and patient care while cutting costs? Is it possible?

Dr Feiner: I do not think that you can cut costs and deliver excellent care. Physician income can only be main-tained by increasing patient volume and reimbursement per patient. Technology can help us see more patients but it increases our overall costs. If a practice has high patient volume, the partners must not be afraid to hire and use non-physician employees to offload as much of the work associ-ated from a patient visit, leaving the doctor time to diagnose, treat, and talk with the patient.

Dr. Dhalla: Yes. Newer technology (surgical tools and EHR) has made us more efficient. Although there is consider-able overhead involved with acquiring new, more advanced equipment, it is balanced by the ability that technology affords for faster, more efficient procedures (higher cut rates on vitrectomy probes) and actually require fewer instru-ments (vitrectomy probes that can also be used as scissors).

Dr. Fine: I agree. More advanced technology has improved

our efficiency, safety, and outcomes in the OR. I think this applies to nonsurgical technology that we use in the clinic

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also. Between our EHR, imaging systems, and network con-nections, we have streamlined so much in our clinical prac-tice that I am able to see over 50% more patients in a day than I was able to 5 or 6 years ago. This is partly due to our methods for performing injections, laser treatments, and imaging, but we are also driven to be more efficient because we need to increase patient volume to keep up with what we are losing with cuts in reimbursements stemming from health care reform.

Dr. Dhalla: The old adage “form meets function” holds true in this regard. Walk into almost any retina office today and, comparing it to 5 or 8 years ago, the design is far improved and geared toward better patient flow, a larger volume of patients, and more physicians. We are doing significantly more office-based treatments for diabetic retinopathy and age-related macular degeneration than we did in the past and this will continue to as the baby boomer generation ages.

AdvocacyNRMD: Are your practices active in advocacy?

Dr. Fine: In general, physicians are not very good at advo-cacy because it is out of most our realms of expertise. The easiest way to get involved is via the American Academy of Ophthalmology or the American Society of Retina Specialists (ASRS). The ASRS has a very strong lobby, and there are opportunities to become involved at a local level.

Dr. Dhalla: It’s our duty and obligation to our patients to keep our policymakers informed about standard of care. Retinal physicians add tremendous value to society by ensur-ing that our patients remain productive citizens. Advocating strongly for our patients will naturally allow for our speciality to remain strong and independent.

Dr. Fine: It is critical that we do not allow politicians to come between physicians and their patients. The most important thing is that we can remain the advocate for our patients and do what is best in the interest of their health and their quality of life, rather than cater to the bottom line that’s dictated by bureaucracy, either in the government or some health care organization.

Dr. Dhalla: Policymakers on a governmental level do not have the medical expertise to make decisions about health-care. They are overseeing where the dollars flow, so to speak, and looking at it from a purely financial and national budget-ary perspective. Medical decisions based solely on financials will compromise the quality of health care at every single level.

Keys to SuccessNRMD: What are the most important things that you

think must be present in your practice in order for you to

provide the best outcomes for your patients with maximum efficiency, safety, and profitability?

Dr. Dhalla: I would boil it down to 2 things: staff and equipment. Without a truly dedicated staff, you are setting your patients up for a bad experience. Not only from an outcomes side, but the entire continuum of care. When the staff is engaged, know the routines, and understand the big picture, they can help improve upon the entire chain of events involved in a patient’s care. In terms of surgical equipment, it certainly makes life easier to have state of the art machines. However, it is a lot easier for any talented surgeon to compen-sate for inadequate/older equipment than a mediocre staff.

Dr. Fine: I agree wholeheartedly. If the goal of an ASC or a clinical practice is to provide the highest quality care with excellent efficiency, there is no substitute for an excellent team that has experience together and that is well trained.

Equipment is always a key factor. A surgeon wants all the tools at the ready and in general, substitutions are undesirable.

Dr Feiner: Well-trained staff is critical to a good experience for both the doctor and the patient at the ASC. I would echo Mandeep and Howard that working with good tools makes the work easier and more fun. We have recently upgraded from the Accurus (Alcon) to the Constellation (Alcon) largely because repair and maintenance of the older unit was becoming problematic. The capital costs of big-ticket items that will serve the center for many years are easy to justify if the surgical volume is adequate. We try to minimize the complexity of inventory management at our ASC by stocking only 1 type of laser probe, 2 types of disposable forceps, etc.

NRMD: Thank you for taking the time to share your insights with our readers. n

Mandeep Singh Dhalla, MD, is with the Retina Group of Florida in Fort Lauderdale, Plantation, and Hollywood. Dr. Dhalla is also on the medical staff of Broward Health Imperial Point and Holy Cross Hospital in Fort Lauderdale. He may be reached at mandeep.s.dhalla@gmail.com.

Leonard Feiner, MD, PhD, is with New Jersey Retina in Princeton. Dr. Feiner is also on the medical staff of Clara Maass Medical Center in Bellevue, NJ, and Hackensack University Medical Center. He may be reached at feinerl@yahoo.com.

Howard F. Fine, MD, is with New Jersey Retina. Dr. Fine is also on the medical staff of Robert Wood Johnson University Hospital in New Brunswick, and Kimball Medical Center in Lakewood, NJ. He may be reached at hffine@yahoo.com.