LASIK
Moving LASIK to the Forefront of Your Practice
Last month we discussed why you should participate in this cutting-edge trend; this month, learn how to make LASIK a reality in your practice.
By Neil B. Gailmard, O.D., M.B.A., F.A.A.O. Munster, Ind.

PART TWO

So, let's assume that you've decided to add laser refractive surgery to your practice. Well, bringing an excimer laser and a surgeon into your practice is no easy task. If you're going to do it, be forewarned that it'll take a considerable investment in time and effort to develop this new phase of your practice. But overall, you might realize great success. We brought laser-assisted in situ keratomileusis (LASIK) into our practice last spring, and we haven't regretted the decision once.

In part one of this three-part article series, I discussed how providing LASIK in your practice won't only bring about referrals from patients, but also eliminate your worries about ophthalmologists sending you referrals or shrinking co-management fees. I also discussed the benefit of patients associating LASIK with your practice, instead of as a separate entity in the industry. Now, in part two, I'll outline the major points you need to consider when bringing LASIK into your office. Also, for further insight from other O.D.s who provide in-office LASIK in their practices, see "A Little Advice" .

Finding a laser

Many lasers are brought into surgical centers or ophthalmologic offices on a roll-on, roll-off basis. This means they're reserved for certain days of the month. A company brings the laser and patient chair on a special truck, rolls it into the center for the day and then rolls it out to another site. A highly skilled laser technician performs the calibration and set-up at each site to ensure optimum operation. These lasers are leased, usually on a per-eye basis. The fee may include the use of the microkeratome, other surgical instruments, autoclave, useable supplies, medications, etc.

It's also possible to purchase or lease a laser from the manufacturer in the more traditional way. However, the device could sit unused and unproductive a good deal of time because most practices will only have enough patient volume to fill one or two surgery days per month. Some doctors still have found that owning the laser is actually more economical and it allows more flexible scheduling.

The best way to find a laser is to ask other O.D.s and M.D.s in your area if they're aware of any companies that supply and lease lasers. Ophthalmologists generally have good knowledge of such resources, so consider the surgeon you hope to work with another ally you could ask.

Another idea is to attend the major eyecare conferences where you can meet with leading optometrists and ophthalmologists in refractive procedures and talk with laser industry representatives. With some networking effort, you'll find a source. See "Sources to Consider" for possible leads. But because this trend is so new, you'll notice firms we've probably missed because they're so new.

Finding a surgeon

My goal in selecting a surgeon to join our staff on a part-time basis was two-fold. First, I wanted a surgeon with excellent skills, a solid reputation and experience of at least 2,000 LASIK procedures. Many surgeons will quote a number of refractive procedures, which could include cataracts, or will quote laser vision procedures, which could include photorefractive keratectomy (PRK), so ask specifically about LASIK. When this procedure is done in your office, your reputation is at stake, so be sure to find a highly skilled surgeon.

Second, I wanted a surgeon who was in practice far enough away from my office so that he couldn't draw my referrals, but close enough that I'd have access to him in the event of a complication. We found one surgeon within about a 2-hour driving distance, which I think is ideal.

Your best bet may be to phone ophthalmologists and gauge their interest -- or ask if they know of a colleague who'd have interest. Some laser suppliers will help you locate a surgeon, or do it for you. Many excellent surgeons want to only perform surgery -- no primary eye care. And many of these surgeons can't build enough patient volume in one location, so they're willing to travel.

The next step after finding a surgeon who's interested is to set up a meeting to discuss goals, philosophies, financial reimbursement and fees. Consider asking to visit the surgeon's practice and observe him performing LASIK. Later in this article, I'll provide some more information about financial reimbursement and fees.

Legal issues

I advise that you meet with an attorney who's familiar with healthcare law to assist with drawing a simple contract between your practice and the surgeon. Because the laws for partnerships and employment of physicians vary from state to state, this process can be complex. As you know, laser vision procedures aren't covered by federal programs like Medicare or Medicaid, so many of the laws affecting fee-splitting, kickbacks and self-referrals won't apply.

However, if you have a relationship with this surgeon for other procedures covered by federal programs, like cataract surgery, the relationship can be problematic. It's important that the optometrist and the ophthalmologist practice within the scope of their own professions and licensure, and that one entity doesn't control the professional judgment or actions of the other.

The independent contractor agreement, or employment agreement, should specify:

• the method and amount of compensation for the optometric practice and the surgeon
• a non-compete clause to prevent either doctor from practicing in the other's market area
• malpractice and liability insurance held by each party
• services to be provided by each party
• how to terminate the contract and how much notice is to be provided
• any other details agreed to by the parties.

The surgeon who performs LASIK in our practice brings his own surgical staff, which means that he works with nurses and technicians who're experienced with refractive surgery and accustomed to the surgeon's preferences. This protects our optome- trists and staff members from liability because we don't actually participate in surgical care.

My staff provides general coordination and patient flow activities on laser days, such as greeting patients, calling patients into the prep area and helping the patients leave.

Financial considerations

As I mentioned earlier in this article, companies provide two different options for you to get your hands on a laser. Sometimes O.D.s lease it, and sometimes a group of O.D.s get together to buy one. The following are rough estimates for purchasing or leasing an FDA-approved excimer laser for PRK and LASIK, but typically:

A new FDA-approved excimer lasers sell in the $450,000 range; used lasers are also available

A fee per use arrangements for roll-on, roll-off lasers are in the $400 to $700 per eye range. The royalties (pillar points) charged by some of the laser manufacturers are included in this cost.

Financial compensation for ophthalmologists varies widely -- and could be a flat rate per eye or a division of the net revenue. The profitability of providing laser vision correction in-house is largely dependent on the fees you charge. Of course, we all know that LASIK fees are in a great state of flux, with bilateral fees ranging on average from $1,600 up to $4,800. My experience is that even with all the costs and staff time involved, providing laser vision services in our practice is considerably more profitable than the typical co-management fees optometrists currently earn.

I recommend that the patient make one payment in full to the optometric practice, and the practice then pays the surgeon and the laser fees. This is very important from the standpoint of patient perception. We want pat- ients to perceive our practice as providing the laser services. We accept cash, check, major credit cards, and we offer a finance program through a third party. Patients must make payment in full during the consult exam, about 2 weeks before surgery.

The physical space

The company that supplies the laser will help you determine the requirements for your laser room, but here are the basics:

• Our laser room is 11 X 13.5 feet, and it works fine, but it's the minimum size for a standard laser. This depends on the brand of laser you'll use; some new designs are quite compact.
• We removed the carpet and replaced it with hospital-type vinyl tile to create an antiseptic environment. We ensured that the floor could support more than 2,000 pounds.
• To reduce dust potential, we replaced the suspended ceiling with mylar-faced, low-particulate tiles and removed the carpet.
• We added a 220-volt electrical outlet, which is required to power most, but not all, lasers.
• We enlarged the doorway to accommodate a new 48-inch door with a glass window. This size is also needed in exterior entrances for a standard laser. Investigate any area with a tight-turn radius, such as hallways.
• The room already had a sink for washing hands.
• We made sure we had plenty of air conditioning power -- even when outdoor temperatures are cool. The laser and the autoclave generate heat. The laser technician monitors temperature and humidity because they must remain in a certain range to keep the laser operating properly.
• The remodeling was completed for less than $5,000.

The little things

In addition to the laser surgery room, we provide a prep area with three soft leather recliner chairs and a recovery area with one recliner chair. We also dedicate two of our six exam rooms to pre-op and post-op evaluations on laser days. Our other four exam rooms and pre-test rooms are used as usual to provide traditional optometric care while laser surgery is underway. We added additional seating in our reception room to accommodate LASIK patients and their drivers. In a smaller office, it may be best to not provide optometric services on laser days.

On surgery days, we place a second television in a semi-private area off the waiting room, which is connected to a live video feed from a camera on the laser. This allows waiting patients and companions to view live LASIK surgery, if they wish. Because viewers never see a patient's face, only a microscopic view of the eye, privacy isn't an issue. We do warn people not to watch if they're sensitive to the sight of surgical procedures.

The only instruments we needed to purchase when we started offering laser vision correction were a pachymeter (about $4,000) and an infra-red pupillometer (about $1,500). We already had a corneal topographer, and everything else is pretty standard in optometric practice.

Changes in the practice

We currently schedule one laser day per month, and we perform LASIK on 20 to 25 patients on that day, which is 40 to 50 procedures. But we feel the excitement all month long because we coordinate the entire process.

Our doctors, technicians and receptionists work with laser vision correction every day in the form of talking to patients over the phone, presenting educational seminars, conducting free screenings, performing comprehensive consult exams and providing all the follow-up care. The 1-day follow-up visit is definitely the most fun because the patients are ecstatic with their new natural eyesight.

Don't underestimate the time and effort needed to add a laser vision specialty to your practice. It takes a lot of doctor and staff training, along with extensive development of procedures, policies, office forms and record-keeping.

To me, it was well worth the effort. We're building our expertise and skills in a specialty that's experiencing great demand and growth. And it's building our traditional practice as well. It's amazing to witness the word-of-mouth praise about our practice because we provide this life-changing procedure.

Dr. Gailmard is in group practice with his wife, Susan Gailmard, O.D., Katharine Moles, O.D., Michelle Millard, O.D., and Sam Lemon, O.D., at Gailmard Eye & Laser Center in Munster, Ind. He's also OM's chief optometric editor.