In the fast-paced world of eye surgeries, with promises of innovative “this” and state-of-the-art “that” capturing most of the headlines, the custom surgery pack barely rates a footnote. But in the ASC setting, where every penny counts, optimizing the contents of your custom pack can improve efficiency in the OR and help offset some of what surgeon Michael Patterson, DO, calls Medicare’s “15% haircut” on cataract reimbursement.
“Could a 15% cut kill us? It sure could,” says Dr. Patterson, a partner in Eye Centers of Tennessee and the Cataract & Laser Center in Crossville, TN. “But it doesn’t have to. For example, are your phaco packs costing you $75 per case, when you could be performing the same cataract surgeries using $30 packs? The answer is probably yes. We all have ways to slim down our resources and save dramatic amounts of money while maintaining our quality.”
As ASCs reopen fully once the COVID-19 pandemic wanes, they will undoubtedly look to recoup some losses by cutting costs wherever possible. While examining the contents of your surgery packs with an eye toward potential cost savings is a good idea, making sure the items included in your packs reflect your surgeons’ preferences is a must.
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The Link Between Custom Packs and IOL Costs
If you purchase standard monofocal IOLs and custom surgery packs from the same company, you’ll likely get a price break for both. Be aware that the cost of the IOL may be linked to the number of packs you use.
Denise M. Visco, MD, MBA, president and medical director of Eyes of York in York, PA, explains: “The price you pay for your lens implants is negotiated based on a certain volume of surgeries. For example, if you estimate 5,000 cataract surgeries will be performed in your center this year, the company will calculate the price for the implants based on that performance, which they track by counting the number of packs you use.”
Complicating the issue is the fact that not all cataract surgeries will use monofocal IOLs.
“If you negotiate a contract for 5,000 monofocal lens implants, but you end up implanting more premium lenses that happen to be manufactured by a different company, then you won’t hit the target specified in your contract,” Dr. Visco says.
There is a work-around, however:“Some ASCs may project they’ll perform a total of 5,000 cataract cases but estimate that 75% of them will use monofocal IOLs,”says Dr. Visco. “Thus, they’re guaranteed 4,500 implants at a particular price. You must be as accurate as possible with your estimates and closely monitor your usage throughout the year to maximize cost savings.”
Balance Preferences With Standardization
“Surgeons are very specific in terms of what they use in their style of surgery,” says Audrey Rostov, MD, a partner and director of cornea, cataract, and refractive surgery for a large multispecialty ophthalmic practice in Seattle. “Everyone has preferences, and they are reflected on their instrument trays and in the items they choose for their surgery packs. As an owner of four surgery centers, I also want to make sure we’re paying the best price for the pack that contains enough of what our surgeons need.”
Dr. Rostov notes that most surgery centers tend to purchase custom packs from the company that manufactures their phaco machines. In her case, that’s Alcon, and among the must-haves for her pack are two ophthalmic viscosurgical devices (OVDs), DisCoVisc and Provisc, both available from Alcon.
“The custom pack has been around for so long that many surgeons take it for granted,” says Denise M. Visco, MD, MBA, president and medical director of Eyes of York in York, PA. “It’s important to remember that when everything we need is in our pack, our procedures are streamlined and run efficiently, enabling us to do multiple cases per hour.”
Typically, an ASC will aim to create packs that contain most of the items that are acceptable to most of the surgeons who operate there. This standardization minimizes the number of items that must be pulled separately.
“The goal is to have packs that are as custom as possible for the surgeons,” Dr. Visco says. “However, avoid having so many different packs that you have excess inventory, which can get confusing. I previously worked in a hospital ASC, and their strategy was to have one universal pack, as customized as possible, and then they had a list of about a half-dozen items per doctor that were pulled specifically for them. They did not have the space to carry inventory for 12 cataract surgeons.”
Some exceptions to the universal pack strategy may be made for high-volume surgeons.
“Some facilities may purchase very specialized custom packs for surgeons who have particularly high case volumes, and a less-customized pack for the other surgeons,” Dr. Visco says. “This makes sense for efficient inventory management.”
Consider Global Needs Before Discarding
The most economical custom surgery packs are those that contain only the essentials without any spares; but there are occasions when certain items in a pack aren’t needed. Audrey Rostov, MD, a partner and director of cornea, cataract, and refractive surgery for a large multispecialty ophthalmic practice in Seattle, makes sure these “leftovers” are put to good use rather than discarded.
“I’m all about decreasing waste as well as increasing efficiency,” she says. “We save any unused syringes or surgical spears, along with any items that are technically reusable but labeled for single use in the United States. I do a lot of global health and surgeon training, so I save these items to use in wet labs, or I bring them to other countries where they can be reused. When I do cornea transplants, I save trephines, which can be resterilized and reused a few times. Surgeons can do the same thing with blades that are approved for one-time use here. They can be resterilized and used in another country.”
What’s in a Pack?
Some items in a custom pack are deceptively simple: gowns, gloves, drapes, cotton-tipped applicators, eye spears, 4x4 gauze, instrument wipes, label sheets, reclosable bags, and syringes. But even for the basics, there are choices. Gloves, for example, can be thicker or thinner, more tacky or less tacky.
“The custom pack was developed as a value-add for the items we use with our machines for cataract surgery,” Dr. Visco says. “It saves the surgery center a tremendous amount of money, not so much for the items that are included in the pack, although it does save money there, but it saves a tremendous amount of staff time in pulling supplies for surgeries, keeping items in inventory, and holding inventory.
“When manufacturers provide custom packs, they essentially are trying to provide everything you’ll need for a case,” she explains. “The company representatives already know the items that are specific to their machines—for example, we use a Bausch + Lomb Stellaris Elite—such as cassettes and tubing, phaco needles, and I/A handpieces, as well as the disposable items that most surgeons use. These include disposable blades (if needed), syringes, cannulas, and small and large bottles of BSS. After observing the surgeon operate, the reps build a pack based on the surgeon’s preferences and then calculate a lump sum price for that pack.”
What makes these packs truly custom is that surgeons can request items that may be unique to their technique.
“I use a 27-gauge capsule polisher squeegee, so that’s included in my pack,” Dr. Visco explains. “I also use intracameral lidocaine at the beginning of a case, so the company includes an extra syringe and cannula in my pack for this purpose. These are not expensive items, but having them in my custom pack enhances my efficiency.
“The cost of these packs per manufacturer is fairly similar, and if we bought the items individually on the open market, they would probably cost only a few dollars more,” Dr. Visco says. “It’s the convenience that makes the difference. You don’t need so much space to store inventory. You don’t have to expend time and labor to maintain and order such an inventory.
“Also, the throughput for your procedures is dramatically improved because you don’t waste the manpower pulling all of the separate items for each case. Having that pack is a tremendous benefit to the ASC.”
Surgery Pack Options
A look at the companies offering custom surgery packs:
ALCON
Alcon offers customers Custom Pak, a comprehensive, customized surgical pack offering. Consumable supplies that can be included in the Custom Pak offering are: an Alcon phacoemulsification/vitrectomy cassette, knives, drapes, gowns, cystitomes, bowls, and many other items needed for ophthalmic surgery. These items can be sequentially packaged according to your surgical needs, maximizing efficiency for your OR staff and your surgeons.
INFO: alcon.com
BAUSCH + LOMB
Bausch + Lomb offers customers the opportunity to choose from more than 700 surgical components to build their surgical custom packs fully adapted to their unique needs. Each customer works in close collaboration with a Bausch + Lomb custom pack coordinator and with customer service, who manage all aspects of the process, from pack customization to ordering, invoicing and offering new product opportunities. When necessary, the custom pack coordinator will also recommend alternative solutions, review these options with the customer and expedite delivery of new components to avoid negatively impacting surgical schedules. Bausch + Lomb’s product selection, opportunity for customization, and individualized support are all part of the company’s commitment to customer partnership and customer service.
INFO: bausch.com
BVI Medical
BVI offers CustomEyes Procedure Packs across all ophthalmic specialties, including cataract, refractive, oculoplastics, glaucoma and retina. Their team uses the CustomEyes Configurator application to help customers select components and the order that each item will get unpacked in the operating room. Pre-configured packs are available, though most customers choose to customize from the hundreds of available components to improve efficiency and lower costs.
INFO: bvimedical.com
What’s NOT in a Pack
A custom pack does not necessarily require items for any possible situation that could develop in the OR. Mindful management of the contents keeps costs down and minimizes waste, as the nursing staff at the Cataract & Laser Center in Crossville, TN, can attest.
“We take a minimalistic approach to what’s needed for our cataract cases, and as a result, our custom pack, which we purchase from Bausch + Lomb, is very streamlined,” says Director of Nursing Marcia Conley, RN. “There are very few additional items that we have to open and pull for a basic case. These include two sets of gloves, a phaco tubing pack, viscoelastic, a tuberculin syringe (if needed for injectable medications), and BSS for the phaco machine.”
Elethia Dean, RN, BSN, MBA, PhD, an independent consultant and founder of ASC Compliance, LLC, is also director of nursing for an ophthalmic ASC and helps manage several surgery centers in other medical specialties. She encourages ASC management and clinical staff to examine their current procedures, which may have evolved to the extent that certain items are no longer necessary.
For example, Dr. Dean asks:
- Do you really need two towels in every pack? If you’re doing your scrub in the morning, and using alcohol foam between cases, do you really need an extra towel in your packs? Eliminate one and save.
- Are you still using eye pads? These days, it’s rare for surgeons to use retrobulbar blocks for cataract surgery. Most of the time, only topical anesthesia is necessary, thus eliminating the need for eye pads.
- What about those little medicine cups? How many do you use? How many do you actually need?
These items may cost only pennies each, Dr. Dean says, but multiplied by the thousands, the savings will add up. “Not only will you be able to negotiate a lower price, but you’ll also be reducing waste,” she says.
Conclusion
Custom surgery packs, built with economy in mind, contribute to an ASC’s ability to provide quality cataract surgery.
“It’s not easy to make a profit on cataract surgery these days,” Dr. Visco says. “But making a profit enables us to continue caring for patients and providing a very important service for the community. If we did not have custom packs to use with our procedures, we would have a difficult time being profitable.” ■