When should I upgrade my retina equipment?

When it comes to upgrading or adopting new technology for your OR, it can be difficult to decide what is worth investing in, when and why. Whereas refractive surgery technology can add lines of revenue for an ophthalmic surgery center, the revenue from retina surgical cases is capped by insurance contracts. New expenditures have to be justified by increased efficiency in time or costs or by an increase in safety or improved outcomes. New machines and devices are introduced to the market frequently, and researching all the options can feel overwhelming and perhaps unnecessary, particularly when you feel satisfied with what you have. However, making the right investments could benefit your clinical practice and surgery center in ways you might not have considered.

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Retina surgeons have the duality of being attracted to new technologies and simultaneously surgically averse to changes. In the operating room, this can translate to staying within the confines of one or two company suppliers or platforms and only trying the new technologies associated to their chosen platform. To achieve better return on our surgical investments, it may be best to utilize a standardized process for evaluating new retina surgery technology.

EXPAND YOUR HORIZONS, EXPLORE YOUR OPTIONS

The most obvious barriers to adopting new technology are financial. The most important, on the other hand, are logistical. Learning about new technologies should begin years before time of purchase, by constantly following the trends and exposing the surgical team to new devices and platforms. The last important hurdle is the natural resistance to change by both the surgeon and the supporting nursing and technical team. Other common barriers include:

• Being comfortable with your current equipment. A great procedure is defined by great outcomes, but also efficiency, cost and patient happiness. You can do a great procedure that lasts 4 hours, but if the patient is in pain (or has some other discomfort) it&#;s not a success. Get out of your comfort zone and try something new. Some surgeons are satisfied with their outcomes using 20-gauge instruments, then they try 25- or 23-gauge and they are amazed at the difference.
• Not knowing what&#;s available. Don&#;t automatically choose the newest version of your current machine. Consider the alternatives. Reach out to local reps and find out what&#;s available. They often let you try out new equipment before buying. Also, ask them to refer you to other surgeons who use the equipment to find out about their experience.
• Cost concerns. Consider opportunities to save money. When starting a deal with a new company, they are often willing to negotiate. You can also negotiate depending on what and how much you are buying.

EVALUATE YOUR ASSETS

Before proceeding with large expenditures, evaluate the equipment at your facility. Where is it in its life cycle? Approach the vendor and sales representatives to analyze future issues with technical support, as older equipment may soon be unsupported. Are there any available upgrades that can extend its life span or increase capacity without requiring major capital investments?

In the process of understanding your current and potential future situations, it is important to discuss with all the stakeholders their opinions, problems and needs. Stakeholders range from the surgeons, nurses and technicians to the staff members responsible for ordering supplies. When multiple vendors provide clinically equivalent equipment, other non-clinical factors become more important, like ease of ordering and payment flexibility.

When discussing equipment preferences with surgeons, some may resist any changes in their operating room. In my experience, these surgeons are usually early in their careers and are uncomfortable with any modifications in the midst of their learning curve, or they are at the tail end of their surgical careers. The best approach usually requires an open discussion of advantages and drawbacks, constantly demonstrating the benefit to patients and the surgery space. Colleague mentorship through these transitions can alleviate many difficulties.

Equipment types and considerations

From a general perspective, retina surgical equipment can be divided into three groups: large platforms, smaller consumables and peripherals. The two larger platform categories are microscopes (top right) and vitrectomy machines (bottom right). These usually require significant capital expenditures and have a life cycle of more than 7 years. Smaller equipment ranges from metal reusable instruments and disposable forceps, cannulas and laser probes. Peripherals are equipment used outside of the operating field that support efficiency, documentation and education; this category includes tools such as cameras, video screens, digital video recorders and EMR technology.

Vitrectomy machine platform selection is perhaps the most significant decision to be made. Not only does it determine the basic capacity for vitrectomy surgery, but also disposable packs and equipment purchasing depend on the machine chosen. This is a decision with large clinical and financial consequences. It is also the decision with the largest psychological component for surgeons, since many have not performed surgeries with more than a single platform. This decision is best approached with an objective and critical lens: Are you using your current equipment at its highest capacity? Trying out the different platforms to objectively compare them in surgery can help highlight their similarities and differences.

Purchasing of disposable equipment, by virtue of its lower unit cost, requires less initial financial commitment. But, disposables require adequate inventory management, which is more complex from an administrative perspective. The supply of disposable devices needs to be constantly updated and verified. The amount of inventory at hand needs to be tracked. Nursing and technical staff need to be trained not to open all pieces of disposable equipment that may be needed in a surgery, which is typical in a hospital setting. Instead, it should be available yet unopened until the moment the surgeon specifically needs said equipment. In the retina operating room, each surgical vitrectomy gauge has its line of disposable and reusable equipment. That means a whole additional line of inventory management. This not only increases the administrative burden but also decreases the ability to predict utilization of each specific instrument or device, risking not having equipment available when necessary. I personally recommend that centers agree to predominantly use a single vitrectomy gauge. That allows a more predictable inventory and purchasing system. In addition to simplification of ordering, consolidating the volume into a single line of equipment may also allow negotiations for lower purchasing prices.

ASK THE RIGHT QUESTIONS

Once you&#;ve done your homework, it&#;s time to evaluate objectively. Ask yourself: &#;Could this technology allow improved surgical efficiency or patient outcomes? Improve the patient experience at my practice? Benefit my staff and/or me (eg, ergonomic design, reduced workload, increased revenue or money saved in the long run)?&#;

Cost of equipment can be significantly offset by time of surgery. The cost of every minute inside an operating room can be calculated without including equipment costs, anesthesiologist billing time and surgeon professional services cost. The factors that then drive the cost of each OR minute are: real estate expenses (lease or mortgage and amortization of leasehold improvements), non-physician payroll (nursing, technicians and clerical staff) and other fixed operating costs required to maintain compliance (administrative, equipment maintenance and sterilization, surgical gases and supplies). The cost varies between setting (hospitals being more costly than surgery centers), but it is not unusual for costs higher than $25 a minute. In other words, reducing 10 minutes of surgery time can save upwards of $250 per case. This is a reasonable way to evaluate the financial cost/benefit ratio of an instrument.

Consider efficiencies with consolidation. Certain vitrectomy platforms are also excellent cataract surgery platforms, for example. When there are separate rooms for anterior segment and posterior segment procedures, having distinct platforms for each room may be efficient. On the other hand, if the vitrectomy room is also utilized for cataract surgery procedures, it may be advisable to consider a combined platform. Use of a single platform may require less consumables, occupy less space in the room, provide a single point of contact for sales and support and, most importantly, allow techs to learn a single user interface instead of several.

MAKE YOUR DECISION &#; AND MAKE A PLAN

Once a specific piece of equipment has been chosen, the next steps are purchasing and implementation. Depending on the type of equipment, capital cost and vendor, there may be different options for purchase or lease. The correct decision is different for each individual center based on financial situation and volume projections.

Incorporation of equipment and maximization of utilization are common problems, particularly with complex electronic systems. It&#;s not unusual to have one surgeon utilize a piece of new equipment more than his or her peers. This discrepancy is both a sign of inefficiency as well as an opportunity for improvement. This can be improved with communication and training, to allow those more resistant to change to accept and adopt new technologies. I am a strong believer in standardization of procedures inside an operating room, since standardization improves efficiencies and quality. The more the staff trains in a single process, instead of distinct processes per surgeon, the more the output of their efforts is maximized.

CONCLUSION

Evaluating new technology can be time and resource intensive, but it&#;s a critical step in ensuring that you are delivering the best possible patient outcomes and optimizing your practice. Following these steps will help streamline the process and ensure that you make decisions that maximize your return on investment. OM

About the Author

Jorge I. Calzada, MD, FACS, is founder of the specialty clinic Deep Blue Retina in the Memphis, Tenn., metro region, and of Panamerican Vitreoretinal Consultants in the Republic of Panama. He serves as adjunct professor of ophthalmology and vision science at the University of Nebraska.

YOU'RE FINALLY the owner, or perhaps co-owner, of a private practice. The lanes are fully equipped, and your patient load is comfortable. Life is good.

But the constant deluge of promotional materials for new equipment creates uncertainty. You wonder if you have all the tools you need to offer the best care and still compete with nearby practices and maximize revenue.

This question begets more questions. Do you need all the latest technology to be competitive? Do you need some of it to survive? Can you afford any of it in today's world of decreasing Medicare and managed care reimbursements?

You need a plan to analyze when it's prudent to make purchase decisions. Without a plan, you risk spending money on technology that may have little or limited use and may not provide a good return on investment (ROI).

Here are some suggestions to help you decide what to buy and when to buy it.

Sometimes It's a No-brainer

Every once in a while, deciding whether or not to buy an instrument is easy, such as when you plan to deliver a new service. In this case, nothing short of an upgraded tool is acceptable for proper patient care, and you must spend the dollars.

For example, in years past, a simple millimeter ruler costing less than a dollar was sufficient for measuring pupillary distance (PD) in the optical dispensary. Then, along came progressive lenses requiring monocular PD measurements at the visual axis. Without a new tool, the corneal reflex pupillometer, it was virtually impossible to fit progressive lenses properly. To successfully dispense the new lens technology and benefit from the higher revenues and profits of premium lenses, updating your dispensary equipment was mandatory.

Sometimes, however, the decision isn't so simple and clear-cut.

Facilitate Delegation

One of the best times to invest in new, improved technology is when it will reduce the cost of doing business. Such a purchase might be a cost-effective alternative to adding more staff.

Practices typically delegate work-up or pre-testing tasks to technicians, reserving the more technically challenging tasks, such as applanation tonometry or retraction, to the most skilled technicians. But it makes little sense for your highly skilled, highly paid technicians do work-up tasks that clearly don't require their expertise, especially if the right equipment is available. This is an area where you might justify the purchase of an autorefractor or an autokeratometer — or both.

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In this situation, the decision process becomes an accounting exercise whereby you measure what you'll spend to buy or lease the equipment against your staff costs, and then consider the additional revenue you could accrue by seeing more patients each day.

Increase Standard of Care

Although cost is always a factor, you know it's time to buy new technology when it clearly will increase the standard of care in your practice. One good example is the improvement in glaucoma care brought about by optical coherence tomography and retinal nerve fiber analyzers. Pachymetry is no longer an
optional investment in many practices.

Of course, manufacturers introduce new technologies every month, all of which promise "newer and better" performance. But sometimes, a new instrument clearly advances the standard of care. In those instances, you should look into the feasibility of the acquisition.

Buying Just Enough

It's easy to get caught up in the hype of advertising or anecdotal evidence supporting new technology. For example, a compelling sales pitch (especially when accompanied by favorable pricing), may tempt you to buy workstations for several locations in the front and back offices.

Upon reflection, however, you'd probably realize that full-blown workstations at every location would be overkill and that you could save money by forgoing all the bells and whistles. Simple "thin clients," which are stripped-down workstations consisting of nothing more than a monitor and a keyboard, would be the more cost-effective choice.

In most practices, computer terminals can and should be fed from central servers on which all programs are loaded and onto which all data are saved. In such a set-up, there really is no reason for each workstation to have a hard drive or a CD/DVD player/burner, or even a floppy disk drive.

As a bonus, by not having CD/DVD and floppy drives at each station, you're taking an important, money-saving step to protect against the unauthorized downloading of potentially infected software or data, or the removal of private financial data and patient records.

When It Just Makes Sense

Occasionally, you know it's right to purchase new technology or tools simply "because." Even if older technology works well and meets expectations, situations arise where the immediate benefits of the latest and greatest are obvious. Digital photography is one example.

Digital photography eliminates the cost of film, developing and printing, as well as time spent waiting for photos to come back from the lab. If you currently process photos in-house, digital photography will save equipment and staff costs as well as space.

When digital photography can help you avoid all these in-house or outsourced expenses and provide instantaneous results, isn't it the right time to move up? The money you save on film and processing can offset the cost of a good quality digital camera and color printer. Immediate access to electronic images (which, by the way, are easily shared with other practitioners), also improves quality of care.

When Not to Invest

"This instrument is a great investment. You can bill insurance for the service and recover the cost in just (fill in the blank) years." Ask your senior colleagues how many times they've heard this pitch.

Before investing in capital equipment or non-enforced physical plant improvements, it's essential to analyze the potential ROI. How long will it take to recover the purchase price, and how long before the investment actually increases profitability?

If you think you can recover the cost of new technology by billing insurance, do some research before you buy. Confirm that patients' insurance companies will pay for the new service. How many patients whose insurance won't pay for the service can you reasonably assume will pay out of pocket? Over the years, I've heard about quite a few practices that had a nasty surprise when they invested in new equipment, only to learn some insurance companies wouldn't pay for the service.

Eyecare practitioners across the country experienced years of frustration over Aetna's refusal to pay for CPT (scanning computerized ophthalmic diagnostic imaging [SCODI]). Although other insurance plans routinely paid for this service, Aetna deemed it "experimental" or "investigational." In areas where Aetna was the dominant third-party payer, insurance reimbursement for a considerable patient population was not available to pay down the cost of the equipment. In some instances, insurance companies informed doctors that they could not bill patients for SCODI, even though the payer deemed the service non-covered.

Ask Yourself This

When do you know it's time to invest in new technology, tools and toys? When you've identified a real (not perceived) need, when you've done the requisite research into potential ROI and when you've confirmed that "potential" has a real chance of becoming actuality. Ask yourself:

• Why do I think we need this instrument?

• What will this instrument do that we can't do now?

• Will insurance companies cover this service and will some
noncovered patients pay out-of-pocket?

• Do I really new equipment to do my job right?

• Will a current, problematic situation continue to deteriorate if I don't invest in capital equipment or improvements?

Few O.D.s can afford to buy equipment or upgrade their physical plant because they hope "things may work out." In today's world of decreasing reimbursement and increased practice costs, you must be as certain as possible before spending your hard-earned dollars.

But when, in the final analysis, investing in your practice makes sense, by all means, move forward.

Gil Weber, a contributing editor to Optometric Management, is a nationally recognized author, lecturer and practice management consultant to practitioners and the managed care and ophthalmic industries. He has served as director of managed care for the American Academy of Ophthalmology. You can reach him at (954) 915-, or at www.gilweber.com.

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