Thomas M. Aaberg, Jr. M.D.

Retina Specialists of Michigan

Michigan State University

Grand Rapids, Michigan, U.S.A.

OFFICE PROCEDURE ROOM BASED 3 PORT VITRECTOMY SURGERY:

PROOF OF PRINCIPLE

FINANCIAL DISCLOSURESSynergeticsAllergan

AS VITREORETINAL SURGEONS HOW DO WE AVOID FORFEITING CONTROL?

SYSTEMS RELEVANT TO THE OPERATING ROOM

SYSTEM COMPONENTS

Facility Equipment Surgeon

• Expense• Personnel

• Salary• Benefits

• Anesthesia Equipment costs• Property costs

• Rent• Overhead

• Maintenance costs• Influencing factors

• Efficiency• Regional Cost of Living• Regional Property values

• Income

• “Facility Fee”

• Set by Payers

FACILITY: EXPENSE AND INCOME

• Expense• Cost versus quality

• Durable Capital Costs• Surgical instrumentation• Anesthesia equipment• Furniture • Information technology

• Disposable costs• Instruments• Surgical Packs• Anesthesia Packs• Medications

• Income

• Hospitals

• Limited pass through reimbursement on disposable instrumentation, medications, etc.

• ASC

• None

EQUIPMENT ECONOMICS

• Expense And Income Dictated by:

• Efficiency

• Productivity

• Case Type

• Payer Contract

SURGEON ECONOMICS

HOW DO WE MODIFY THESE FACTORSTO BENEFIT THE PATIENTS, THE PAYERS,

AND THE SURGEON?

ECONOMICS 101

• Increase Income• Decrease Expenses

• Most challenging side of the economic equation.

• Largely at the mercy of the Payer contracts

• Increase efficiency

• Increase scope of practice

• Ability to manage previously “unmanageable” (ex: macular holes, or exudative AMD)

• Capture part or all of the global fee(professional fee and facility fee)

INCREASE INCOME

• Eliminate overhead costs

• Personnel

• Equipment

• Facility

DECREASE EXPENSES

THE GREATEST (AND SOMETIMES THE WORST IDEAS)

BEGIN WITH A FRIEND AND A BEER

Club Vit 2010Sorrento

PEARL (VERSAVIT PROTOTYPE)

Variable Cut Rate

Variable Aspiration Pressure

50 cc Cassette

Variable Air InfusionPressure

Single Variable LED Light Source

PERSONAL EXPERIENCE (PROTOTYPE)• 7 cases

• ASC = 6

• Office = 1

• Procedures

• Macular Pucker (4)

• Macular Hole (1)

• Vitreomacular traction (1)

• Non-clearing vitreous hemorrhage with retinal tear (1)

PROTOTYPE PERSONAL EXPERIENCE• Efficient• Quiet• Good illumination• Extremely user friendly…”plug and play”

PROTOTYPE PERSONAL EXPERIENCE• Prototype Glitches

• Foot pedal failure due to broken connection (cases 1, 2)

• Temporary loss of cutting ability (case 5)

• Surgical Complications• None

PROTOTYPE PERSONAL EXPERIENCE• Limitations

• No silicone oil infusion

• No fragmatome

• No diathermy

PERSONAL EXPERIENCE• Surgical maneuvers performed

• Complete vitrectomy

• Injection and removal of vital dye• Membrane peeling

• Fluid-air exchange

• Indirect laser retinopexy

• Endolaser retinopexy*

* Endolaser performed with separate unit (Iridex)

CASE EXAMPLE: CASE 5 (OFFICE)

OUTCOMES• Vision: 7/7 > 2 lines of vision

• Preop Visual Acuity: 20/102 (range = 20/40 – 20/800)• Postop Visual Acuity: 20/48 (range = 20/20 – 20/400)

• Anatomic success: 7/7 cases • Surgical time: 38 minutes, mean (range = 24 – 52 minutes)• Follow-up Period: 4 months, mean (range = 3 – 6 months)

PROTOTYPE DESIGN CHANGES• Switches/Knobs

• Eliminate the rheostats and exchange them for switches

• Illumination• Add a second light port for multiple illumination sources or in case of light source failure.

• Vacuum Pressure• Increased and adjustable

• Foot Pedal• More functional foot switch

PROTOTYPE DESIGN CHANGES• Create a platform for expansion

• In time, surgeons will push the limits as to which cases they will conquer.

• The machine will not be the limiting factor. • Accessories will be the “App” equivalents

VERSA VIT SPECS

• Weighs 25 pounds

• Footprint less that one cubic foot of space

COMPACT PORTABLE VITRECTOMY UNIT (SYNERGECTICS)

Variable cut rate from 0-6000 cpm

Variable aspirationfrom 0-500 mmHg

IOP control from 0-120 mmHg

Current version has cutter bias open, neutral, or closed option

Cassette has 2 independently functioning 50 cc volume vials

Green and Red back lighting indicates volume status of the vial.

2 Adjustable LED light sources

Rated for 25,000 hours = 3 years of continuous use.

VERSAVIT ILLUMINATION: FILTERED AT 435 NM

Output Spectral Power

23G, 25G, OR 27G VITRECTOR POWERED BY COMPRESSED GAS: CO2, NITROGEN, AIR

When using the CO2 cartridge, the unit provides 20 minutes of continuous cuttingwith a cut rate of 1250 cpm. Requires shorter tubing set.

UNIT POWER: EXTERNAL POWER SUPPLY OR BATTERY

The unit can run on battery power for up to one hour.

• Linear control of aspiration, from 0 to console setting

• Cutter on / off switch

• Rapid pressure adjustment switch

• Fixed cut rate set on the console

• Two other buttons for optional equipment

• Example: diathermy

FOOT PEDAL

Core Essentials Packs

Efficiency Pack Configuration• 20, 23, 25, and 27ga• 6502XE – 6 foot cutter design• 6503XE – 3 foot cutter design

Tyvek Lid Design• Branding Core Essentials• Stackability on shelf in office• Label on the side

Port Entry Systems

Synergetics Express™ 3-in-1 Port Entry System• Available in One-Step blade at launch• Coming soon with MID Labs blade• Cost advantages• No instrument transfer• Scleral marker on back• Cosmetic change

*Confidential*

Biopsy Kit Separate pack for biopsy

• In-line collection basin on cutter• One Cannula Set• No tubing• Minimizing cost and setup• Biopsy BT pack?

*Confidential*

Kirwin Bipolar Unit Synergetics Photon

Stand-alone Enhancements

Silicone Oil Injection

*Confidential*

VITRECTOMY UNIT COMPARISONVersaVit Innovit Stellaris Constellation

Gauge 23,25,27 23 20,23,25 20,23,25,27Cut Rate Max 2500 1200 5000 5000Illumination LED None Xenon/Hg XenonSurgeon Control Foot Pedal Finger Foot Pedal Foot PedalIOP control X Gravity X XVacuum (max) 500 mmHg Manual 650 mmHg 650 mmHgViscous Fluid X 0 X XDiathermy X 0 X XPortable X X 0 0Phaco Capability 0 0 X XLaser built -in 0 0 0 XUnit Price $30,000 $6,800 $85,000 $120,000Pack Price $300 $288 $440-465 $500-600

POSSIBLE SOLUTION:OFFICE PROCEDURE ROOM BASED VITRECTOMY• Benefits

• Eliminates significant overhead costs

• Example: no need for pre- or post-op registered nurses

• Utilize our own ophthalmic technicians…already “on-the-clock.”

• Facility

• Already “bought-and-paid-for”

• Maximizes utilization of assets

• Global Fee paid to practice (professional fee and facility fee)

• Convenience

• Efficiency

• No anesthesia costs for Payers

OFFICE PROCEDURE ROOM BASED VITRECTOMY: RISKS AND LIMITATIONS AND CONSIDERATIONS

• Patient Safety• Case limitations• Financial issues

• Endophthalmitis risk

• Mortality risks

• No Anesthesiologist in the event of cardiovascular event

OFFICE PROCEDURE ROOM BASED VITRECTOMY: SAFETY

• Case Selection Critical!

• No complex cases

• No lengthy cases

• No medically or mentally unstable patients

OFFICE PROCEDURE ROOM BASED VITRECTOMY: CASE LIMITATIONS

OFFICE PROCEDURE ROOM BASED VITRECTOMY: FINANCIAL CONSIDERATIONS• Surgeon fees remain unchanged

• Intangible cost benefits for the surgeon and patient

• Eliminates travel to surgical center

• Not dependent on surgical center availability

• Convenience factor

• Facility charges…

• Conversations with Payors

• Goal: Global fees go entirely to the practice

LOCAL PAYER FEESCPT Code Code Description Global

Professional Only

67036 Vitrectomy, Mechanical, pars plana approach $2,954.18 $1,298.53

67040

Vitrectomy, Mechanical, pars plana approach; with endolaser panretinal photocoagulation $3,578.76 $1,923.11

67041

Vitrectomy, Mechanical, pars plana approach; with removal of preretinal cellular membrane $3,449.29 $1,793.64

67042

Vitrectomy, Mechanical, pars plana approach; with removal of internal limiting membrane of retina, including intraocular tamponade (if performed) $3,705.92 $2,050.27

67043

Vitrectomy, Mechanical, pars plana approach; with removal of subretinal membrane, including intraocular tamponade (if performed) $3,852.16 $2,196.51

OVERHEAD CONSIDERATIONS

• Durable expenses and fixed costs

• Disposable costs

PROCEDURE ROOM DURABLE CAPITAL EQUIPMENT COSTS

Capital Equipment .

Vitrectomy Unit (VersaVit, Synergetics) 30,000

Surgical Microscope (Lica) 55,000

Viewing System (Merlin, Volk) 10,000

Autoclave NC

Laser NC

Cryogenic Unit NC

Surgical bed NC

Mayo stand 424.38

Surgical Tray with Instruments 2214.67

Total Capital Initial Cost 97,639.05

Requires industry leaders interested in making such an endeavor succeed.Example: VersaVit (Synergetics)

PROCEDURE ROOM DURABLE CAPITAL EQUIPMENT COSTS

Surgical Instrument Tray .

Scleral plug forcep 233.00

Troutman needle holder 333.60

Castroviejo needle holder 205.60

Wescott scissor 244.80

Speculum 29.60

Alfonso speculum 60.00

Ten Stevens curved scissor 103.20

Retina hook 66.40

Suture forcep 321.60

Fixation forcep 214.60

Irrigation cannula Autoclavable 20.80

Blunt cannula 18G Disposable 0.23

Scleral depressor 114.40

Lancaster Speculum 89.60

Mosquito hemostat 21.24

Instrument tray 156.00

Total surgical tray cost 2214.67

PROCEDURE ROOM STERILE SUPPLIES COST/CASE

Bouffant cap 0.16

Steri strip 1/2 x 4 1.17 GonioVisc 3.56

BSS 15ml 3.56

Marcaine 0.75 4.17

Lidocaine HCL 2% 3.54

Gentamicin 2 ml 4.17

Kenalog 12.50

Sterilization pouch 7.5 x 13 0.12 Sterilization pouch 3.5 x 9 0.06

Sterilization wrap 0.92

Total cost 86.86

Gloves Prep surgical gloves 0.98

Sterile scrub prep 0.73

Gloves (7 1/2 Ansell Micro Optic) 1.40

Sterile 4x4 pkg of 10 0.62

Iondine cup (autoclavable) 15.00

Providine-Iodine prep solution 1.20

Eye pad 0.16

Eye shield 1.98

U drape 11.26

Sterile drape 18x26 0.25

Back table sterile drape 2.39

Mayo stand cover 2.13

Incise drape 13.50

Sterile prep bulb 0.89

Surgical mask 0.44

PROCEDURE ROOM DISPOSABLE EQUIPMENT COSTS/CASE

Virectomy Disposables For Vitrectomy OnlyBalanced Saline Solution 10.00

Efficiency Pack (Cutter and Cassette) 130.00

AGPI (Pressurized Tubing) 31.50

Aspiration Line with 3 way stopcock 10.00

25 Gauge Stealth Trocar Cannulas 71.00

25 Gauge Midfield Light Pipe 24.38

BSS 500 mg 10.00

Total cost/Case 286.88

PROCEDURE ROOM DISPOSABLE EQUIPMENT COSTS/CASE

Virectomy Disposables For Macular CasesSoft Tip, 25 Gauge 22.00

Flat Lens 30.00

Fine Tip Eckardt Forcep, Disposable 100.00

Balanced Saline Solution 10.00

Efficiency Pack (Cutter and Cassette) 130.00

AGPI (Pressurized Tubing) 31.50

Aspiration Line with 3 way stopcock 10.00

25 Gauge Stealth Trocar Cannulas 71.00

25 Gauge Midfield Light Pipe 24.38

BSS 500 mg 10.00

Total cost/Case 438.88

PROCEDURE ROOM VITRECTOMY ECONOMICS BASED ON SINGLE PRIVATE THIRD PARTY PAYOR

Liabilities RevenuesPPV 2954.18

Sterile supplies 86.86Disposable Equipment 286.88

Surgeon Fees 1298.53TOTAL REVENUES 1281.91CASES REQUIRED TO PAY OFF CAPITAL COSTS 76

“SELECTED CASES”• Currently

• Vitreous Hemorrhage with retinal tear• Post-operative vitreous hemorrhage• Macular Pucker• Vitreous Biopsy

• Planned• Non-clearing Symptomatic Vitreous Opacities• Endophthalmitis• Uncomplicated Psuedophakic Retinal Detachment• Uncomplicated Diabetic Vitreous Hemorrhage• Dropped lens material following complicated cataract surgery amenable to vitrectomy removal

• Medically Stable

• Emotionally able to tolerate lightly-sedated surgical procedure

PATIENT SELECTION

OFFICE PROCEDURE ROOM BASED VITRECTOMY SURGERY SUMMARY• Feasible

• Profitable

• Requires more investigation

• Patient safety

• Case selection

• Outcomes

• Requires industry collaboration

• Economically beneficial to all parties

• Patients

• Payers

• Physicians

• Safe and effective• User friendly• Portable• Lower cost alternative• Potential areas of use

• Office• OR second, backup, or

primary unit• Third world countries as

primary unit• Mission work

VERSAVIT SUMMARY

“STAY THIRSTY”THINK OUTSIDE THE BOX

COST ANALYSIS OF INSTRUMENTATION CHOICES IN AN AMBULATORY SURGERY

CENTER

• Brandon G. Busbee, MD• Tennessee Retina• Nashville, TN

USA VITREORETINAL SURGEONS ASC USE OVER PAST 10 YEARS FOR (ASRS PAT SURVEYS)

• First ASRS question for ASC data 2006• * 2012 ASRS PAT survey data

WHERE ARE THE COSTS?• Turn over time• Case time• Disposable instrument use• Use of oil, PFO, etc.• Medication use

ADDITIONAL (NON-TRADITIONAL)OR EFFICIENCIES

• Move to an ASC• Vitrectomy choices• Viewing choices

MERLIN SURGICAL SYSTEM• Non-contact wide field viewing

system• 360 rotation of arm• Reusable lenses

– Large diameter widefield (ora)– Small diameter widefield (ora)– Mid field lens (vitreous base)

COST MODEL – ASSUMPTIONS• Retail purchasing of capital equipment

– Versa Vit by Synergetics - $30,000• Retail purchasing of vitrectomy packs and disposable

lenses– Retail pack pricing

• Constellation (Alcon) 100%• Stellaris (B&L) 80%• Versa Vit (Synergetics) 55%

– BIOM disposable $100 per case

•Sensitivity analysis using different case load and usage

– LV/LU - Low case load (200) / Low VersaVit usage (50%)

– LV/HU - Low case load (200) / High Versa Vit usage (75%)

– HV/LU – High case load (300) / Low Versa Vit usage (50%)

– HV/HU - High case load (300) / High Versa Vit usage (75%)

COST MODEL – ASSUMPTIONS

COST MODEL – RESULTS VV VS. STELLARIS

• Break even– Within first year for all cases

• Cost savings over 7 years– LV/LU: $160k– LV/HU: $200k– HV/HU: $330k

COST MODEL – RESULTS VV VS. CONSTELLATION

• Break even– Within first year for all cases

• Cost savings over 7 years– LV/LU: $250k– LV/HU: $330k– HV/HU: $520k

ESTIMATED COST REDUCTION:STELLARIS PC + 1-USE LENS VS. VV + REUSABLE LENS

ESTIMATED COST REDUCTION:CONSTELLATION + 1-USE LENS VS. VV + REUSABLE LENS

ASC EVALUATION WITH VERSA VIT1 WECKCELL ALCON SPEAR 2.56 2.56

1 25G NEEDLE 5/8 0.03 0.03

1 25G VITRECTOMY PACK 350.00 350.00

25 COTTON TIPS 3" INCH WOOD 0.05 1.25

3 3CC SYRINGES W/O NEEDLE 0.04 0.12

2 5CC PLAIN SYRINGES 0.07 0.14

1 25G SOFT TIP 25.00 25.00

1 ENT PACK 21.59 21.59

1 25G AWH CHANDELIER 94.91 94.91

1 NORMAL SALINE 500 ML 1.17 1.17

1 EAR SYRINGE 0.49 0.49

1 1060 DRAPE 3.26 3.26

1 RAYTEK 0.43 0.43

3 30G NEEDLES 0.07 0.21

3 20G NEEDLES 0.03 0.09

1 TB SYRINGE 0.22 0.22

1 MILTEX FILTER 2.52 2.52

1 60CC SYRINGEW/O NEEDLE 0.30 0.30

1 T-TUBE 1.70 1.70

1 RETROBULBAR NEEDLE 3.84 3.84

VV / ASC FACILITY SAVINGS BY CODE

• 67042 without gas --- 37% savings

• 67042 with gas --- 32% savings

• 67108 with gas, no buckle – 30% savings

• 67113 with buckle and oil ---- 22% savings

SUMMARY• OR choices are not limited to traditional efficiencies

• ASC can be a game-changer for time and facility margin

• My ASC has increased profits from use of Synergetics Versa Vitand Volk’s Merlin viewing system

HOW WILL I USE THE SYSTEM IN THE ASC?• Backup unit• Second unit

• Running 2 rooms• Second retina surgeon operating

• Consider using as a principle unit for designated cases (no silicone oil or lens fragmentation required)• Cost effective packs• Fast setup• User friendly

HOW WILL I USE THE SYSTEM IN THE OFFICE?• Initial cases

• Diagnostic vitrectomy

• Non-clearing or postoperative vitreous hemorrhage

• Hemorrhagic PVD without or with tear

• Endophthalmitis

• Next stage• “Simple” retinal detachments

• Macular pucker

• Macular Hole

25-GAUGE BIMANUAL SURGERY FOR COMPLEX DIABETIC TRACTION RETINAL DETACHMENT