Over the next three years, facility fees for cataract surgery in both ambulatory surgery centers and hospitals are scheduled to drop significantly. That means it's more important than ever to get your costs under control. At our two-OR center, our surgical team has developed several techniques for minimizing our supply costs and controlling the time we spend on each case. What follows will help explain how we did it.

Controlling Supply Costs
We have nine cataract surgeons, and each one brought along a unique way of doing things and a marked preference for equipment and supplies. We decided that job one was to get all our surgeons on the same page. We resolved to get them to agree about exactly what basic supplies we would keep on hand for each case. Our goal was to whittle down the number of supplies and suppliers we needed. Both measures, we felt, would save us money.

First, the surgical team developed a list of the items we felt were necessary for each case. We then asked for a conference with the surgeons, proposed this basic inventory to them, and then asked their advice on how we should modify it.

During the discussion, we considered each suggestion, but we also attached a price tag to each one. We showed our surgeons what an extra set of gloves or an extra set of syringes meant in dollars when we multiplied the cost by the two or three thousand cases we do each year. This was especially interesting when discussing the big-ticket items. Some of our surgeons were surprised to find out the varying cost of many of the supplies we use.

After much conversation, we were able to isolate a number of items that could be standardized. We decided our basic surgical supply pack would contain the following:
– approximately 10 4 x 4's (gauze),
– 3 Q-tips,
– 2 gowns,
– 2 gloves (in the correct size for surgeon and assistant),
– 1 drape,
– 1 Merocel instrument wipe,
– 1 container for BSS,
– 1 medicine cup, and
– 2 syringes (1 cc and 3 cc) with needles.

We also got our surgeons to agree on an economical viscoelastic and two kinds of silicone lenses.

Blades posed an interesting dilemma, because although most of our surgeons prefer diamond knives, a few prefer disposables. We finally settled on the following compromise: Surgeons who use diamond knives would have a per-case "rebate" that would essentially compensate them for the cost of the knife over one year. The surgeons who used disposable knives agreed that they would use three for each case: A 3.2, an angle crescent, and a paracentesis knife.

Now that we knew what we needed, we asked our administrative team to look into finding the most favorable pricing.

By contacting several companies that supply sterile packs, and by agreeing to buy a year's worth of packs in advance, we were able to whittle the cost down tremendously compared to opening each item individually.

By volume shopping some more, we were able to find other companies for our remaining supplies at a greatly reduced cost.

For the expensive items, including viscoelastic, IOLs, and knives, we also shopped around, but in the end we used just one supplier for all three. This supplier worked hard to create excellent pricing for us.

Controlling Overhead
Of course, supply costs are only one part of overall cataract case costs. That's why we focus just as hard on keeping our overhead down.

The most important tool we use is efficiency. By moving our cases through with no wasted time, we are able to spread our fixed costs out over as many cases as possible.

Our general rule of thumb is to save time whenever possible. When the patient enters our center and checks in, one person on the surgical team immediately dilates him and then escorts the patient back into the pre-op area and asks him to lie on one of six gurneys. An IV is started; a CRNA then administers a peribulbar block and then the patient is wheeled into the OR. On the days when we are running out of both of our ORs, a staff member drapes the patient and rolls him under the microscope while the surgeon is finishing his case in the other OR. He uses a foam re-entry scrub and regloves and redrapes, then sits down and starts operating. Once the case is over, another perioperative nurse wheels the patient out on the same gurney and into our recovery area.

Our goal is to have the entire process take about 90 minutes. When our most efficient surgeons are operating, we are able to move five to seven patients through our two-OR center each hour. Our "personal best" is 22 cases in three hours

Another part of fixed costs is instrumentation. We do two things in this regard. First, as much as possible, we buy all the same equipment for all the ORs in our group. This creates efficiency because everything is interchangeable; we only need one kind of handpiece, one kind of tubing, one kind of handle cover for the microscope, and so on.

Second, we work hard to keep our existing instrumentation running smoothly. Because we are a large group, we are able to hire our own biomedical engineers. We also try to upgrade our instrumentation only when necessary. We resist the temptation to buy new things based on bells and whistles. Our phaco machines, for instance, have lasted us for seven or eight years; our surgeons are perfectly happy with them.

Because our reimbursements are fixed and are probably going to drop, surgical facilities have only two ways to make a profit: Cut costs and increase volume. We feel we are doing well at both, while also providing the highest quality cataract surgery possible.