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| Better get that checkbook out. Things are about to get pricey. |
Office Based Surgery (OBS) Suites are all the rage now. I feel like I can't open a journal (especially the freebies) without seeing an article/interview with someone talking about how awesome it is. I have several friends who have gone forward with OBS in different states around the country. With their permission, I'd like to share some common start up costs for OBS.
I'm not going to get into the ambulatory surgery center (ASC) vs OBS debate here. I'd just like to focus on financials and equipment needed to give a broad strokes view of what it would take to add OBS to your practice. In general, the cost to build and outfit an OR in an ambulatory surgery center (ASC) is about $1M per room from an empty shell. In the office it's around $400,000 per room from an empty shell. Many young ophthalmologists are unable to buy into an ASC for various reasons, and the comparative cost makes OBS very attractive.
There are many consulting groups around that will help you build out and run your OBS. Every time you make a large capital investment into your practice, I recommend getting multiple quotes/opinions and creating a detailed pro forma before making a final decision. Hopefully the information here can get the ball rolling on your decision. We should break the discussion up into the following groups: equipment, instruments, disposables, and tenant improvements.
Equipment
There are a large amount of expensive reusable equipment purchases in your future. If you've ready my previous post about outfitting a clinical practice, you know that I don't think everything needs to be new. Used equipment comes with a great discount and works equally well for most applications.
Phacoemulsification Machine
This is a big one. Your purchase decision here will likely be guided by past experience. Collectively, my friends and I have experience with the big three (Alcon Centurion, Bausch & Lomb Stellaris Elite, and Johnson & Johnson Signature Pro). You will almost certainly have a preference based on what you've tried. The price differences here aren't that great, so pick the one you like. You'll almost certainly be able to get a deal on the intraocular lenses manufactured by the company that makes the phaco machine you purchase if you buy new. These companies will also frequently offer to finance the machine by increasing the pack price. This is a good cash flow option, but make sure you calculate the total interest paid before signing anything.
Centurion (new) - $38,000 - $45,000
Centurion (used) - $30,000
Stellaris Elite (new) - $36,000 - $39,000
Stellaris Elite (used) - $20,000
Signature Pro (new) - $36,000 - $40,000
Surgical Microscope
Another really big decision. People tend to have strong preferences here as well. In general, if you're getting a microscope from a reliable vendor it should last you a very long time (15+ years). So I wouldn't worry too much about getting the cheapest microscope possible. Get the one you like that you feel will allow you to do a good job.
Zeiss Lumera (used) - $40,000 - $55,000
Cassini Aventa (new) - $60,000*
Leica M822 (used) - $40,000
Alcon Luxor LX3 (used) - $40,000
Haag-Streit (new) - $120,000
Zeiss Artevo (new) - $350,000
*The Cassini Aventa is not currently available in the US
Femtosecond Laser
If you want to have a femtosecond laser available in you clinic, be prepared to double the cost of your project. They all cost about the same, and the click fee you'll pay is around $200-$300 per case.
Zeimer Z8 - $360,000
LensAR Ally - $350,000*
J&J Catalys - $350,000
Alcon LensX - $350,000
Bausch & Lomb Victus - $350,000
*Ally's integrated phaco machine is currently software locked because it doesn't have FDA approval. According to the company representative, this may happen in the next couple of years.
Surgical Stretcher
I don't feel very strongly about this. I am biased toward the Stryker eye stretchers because of the extra leg room below the head. The Hausted beds are also excellent, but have a little less leg room depending on the model.
Stryker (new) - $6,000
Stryker (used) - $3,000
Hausted (new) - $8,700 - $12,000
Hausted (used) - $4,000
Surgeon's Stool
Just like the stretchers, I don't think this makes a gigantic difference as long as it has reasonable ergonomics.
Stryker (new) - $2,000
Hausted (new) - $3,200
Autoclave
Steam sterilization with an autoclave is the industry standard at present. The Centers for Disease Control have recommendations for sterilization by heat, chemical, etc. I strongly recommend just doing the industry standard here. You don't want to have preventable complications because you wanted to save a few bucks.
Tuttaneaur EZ9 - $4,900
Battery Backup
You'll need to have backup power for at least 2-2.5 hours in case of a power failure. This could be a generator or a giant battery. The people I talked to have both. Personally, I like the idea of the battery better since it is more mobile, easier to install, and doesn't use gasoline. Expect to spend $6,000 - $14,000 depending on your power requirements (more ORs = bigger battery needed = more expensive).
Other Equipment
There's a bunch of stuff that's pretty easy to forget. Mayo stand, back table, vitals monitor, AED, scrubbing solution (e.g. Sterilium, Avaguard, Betadine, etc). Expect to spend around $6,000 - $10,000 on these items.
Instruments
Again, this is highly variable due to personal preference. In general, a cataract tray is going to run you about $3,500 - $10,000 each. The quality of the instruments tends to increase as the price increases. Diamond knives alone are going to run you $2,000 - $3,000 each. Separate trays for suturing ($600 - $1,500) and LRI/toric markings ($500 - $1,500) are going to be extra. So will phaco handpieces (approx $2,500 each).
I wouldn't go bargain-basement for surgical instruments, but I also wouldn't get the most expensive ones. A nice thing about having OBS is that you can tell your staff how to handle the instruments. If they are taken care of gently, even cheaper ones should last you a very long time.
Some good vendors that let you check the price online with an account: Ambler Surgical, Stephens Instruments, Bespoke Ophthalmics, Accutome, Corza Medical (formerly Katena), Storz Surgical.
Disposables
As much as you might want, there will be a considerable amount of disposable products used during each case. Depending on how you want to run things, you can get your per case cost around $160 per case at the lowest but the average is going to be around $200-$250.
Phaco pack (tubing) - $80
I&A handpiece - usually around $30 each (sold in packs of 10+)
Moxifloxacin - $17 per bottle
IOL - most single piece lenses are $95 and most three piece lenses are $65
Surgical pack (drapes, cannulas, disposable blades, gowns, gloves, etc) - $40
Ophthalmic viscoelastic device (OVD) - $17 to $20
MKO Melt (optional) - $17.50 per case
Tenant Improvements
We have entered the land of extremely wide variability. Plan for at least 750 square feet per surgical suite (800-1000 square feet will feel more comfortable). The $400,000 general cost to build from an empty shell and outfit an OBS suite is about right according to our collective experience. A suite getting retrofitted into an already finished space could be as little $35 per square foot. For a new build from an empty shell expect around $40-$55 per square foot. These numbers also need to be adjust for your practice location. Expect to spend a whole lot more if you're in New York City on the 12th floor and much less if you're in rural Kansas on the first floor.
The actual build out requires a lot of thought and planning. This is an area where consultants can be very helpful but not mandatory. If you intend to get your OBS suite accredited by a governing body (e.g AAAASF, JCAHO, etc), a consultant who has done it before is probably worth it. Most quotes are around $35,000 for space planning, policy/procedure manuals, staff training, mock accreditation walkthrough, and then accreditation itself. These seems like money well spent to me. If you do not want to pursue accreditation, I would highly recommend getting the physical space requirements from AAASF to your architect to leave the option open in the future if you change you mind. In any case, reviewing the accreditation requirements will provide a standardized way to ensure you don't forget anything in the build out.
Conclusion
Ultimately, the freedom of controlling your own operating room is fantastic. Everyone I talked to said they would do it again, and the most common regret I heard was that they wish they had built it sooner. The major hold up for most of us is how insurance reimbursement works since CMS hasn't codified payment for OBS surgeries. There are a lot of people doing it, so I assume there is a legal way to make a profit on OBS. I don't have an answer for that, but there are many consulting companies that can help steer you in the right direction. No matter what you do, consult your attorney to make sure OBS and your proposed reimbursement model are legal in your state before building the pro forma.
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