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.
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
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
Sources to Consider
The following are some sources
you might want to explore for purchasing or leasing a laser:
Alcon Summit Autonomous, Inc.
2501 Discovery Dr., Suite 500
Orlando, Fla. 32826
Bausch & Lomb Surgical
555 W. Arrow Hwy.
Claremont, Calif. 91711
Doctor's Choice Laser Center
1332 West Indiana Ave.
Elkhart, Ind. 46516
Innovative Laser Technologies,
Contact Dr. Shawn Thomas
100 Northpointe Circle, Suite 305
Seven Fields, Pa. 16046
Contact Dr. Jack Melton
3601 S. Broadway, Suite 600
Edmond, Okla. 73013
(405) 478-4444, ask for Dr. Jack Melton
LaserSight Technologies, Inc.
3300 University Blvd., Suite 140
Winter Park, Fla. 32792
Laser Vision Centers, Inc.
540 Maryville Centre Dr., Suite 200
St. Louis, Mo. 63141
47651 Westinghouse Dr.
Fremont, Calif. 94539
Vision Alliance of Mid-America,
Mr. Jeff Fine
9010 SW 117th Street
Miami, Fla. 33176
3400 Central Expressway
Santa Clara, Calif. 95051
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
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.
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
- malpractice and liability
insurance held by each party
- services to be provided by
- 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.
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.
|A Little Advice
Hear what these other O.D.s,
who also provide in-office laser-assisted in situ keratomileusis (LASIK) in their practices, have to say:
Harvey P. Hanlen, O.D., F.A.A.O.
Immediate Past President, AOA
Nittany Eye Associates, State College, Pa.
"Seeking out a surgeon
isn't hard, but it's somewhat difficult getting an experienced
one who will travel. In my opinion, the most critical part is
that the optometrist must control what happens. Pay the surgeon
per procedure, pay for the laser per procedure, control your pre-
and post-op care and control the 'facility fee,' which is where
the true profit is."
Jack Melton, O.D.
Chairman and CEO
Laser Eyenet, Oklahoma City, Okla.
"I feel it's vitally
important that optometry realizes that laser vision correction is
a 'vision' procedure. Vision is optometry's domain! There have
already been 2 million procedures performed, and that represents
only 4% of the potential market. And three out of every four
patients come from optometric practices. Are some of those 2
million patients yours? Is optometry going to quietly stand by,
while we lose the next 50 million patients?"
Whit Lord, O.D.
"When an O.D. brings a
laser in-house, his office, rather than the surgeon, gets credit
for restoring the patient's vision. I've never witnessed more
enthusiastic patients than next-day follow-up LASIK patients.
Many patients tell us on their first follow-up visit that they'll
be referring others."
Morris Sheffer, O.D.
Eye Care Clinic, Charlotte, N.C.
"After using a roll-on,
roll-off laser for about a year, we found that purchasing our own
laser was more cost-effective for our five-O.D., three-location
practice. LASIK has become so price competitive that the 'per use'
fees were too costly. Now our fixed cost per patient goes down as
we build volume, rather than going up. I advise optometrists to
stay active in laser vision correction -- it's certainly not
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
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
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 Management, Issue: February 2001