Feedback from early users of the pascal photocoagulator

Feedback from Early Users of
the PASCAL® Photocoagulator
8 Shareef Mahdavi • SM2 Consulting • Pleasanton, CA 7

Along with the aging population and rising prevalence of Priced higher than a conventional laser, Pascal offers a new
ocular disease, technologies are being developed to give value proposition for physicians treating the retina to consider.
clinicians new and better tools to treat patients. As part of SM2 interviewed four practices who were among the first
ongoing evaluation of these technologies and their impact, to purchase the Pascal system in an attempt to learn how this
SM2 Consulting was asked by Optimedica Corporation (Santa impacts the practice from multiple perspectives. This report
Clara, CA) to interview a sample of practices that have summarizes their insights and, wherever possible, provides
adopted the Pascal system for use in commonly performed quantifiable metrics on changes to practice patterns from this
retinal laser procedures such as pan retinal photocoagulation new technology. The interview was open-ended, allowing these
(PRP), grid and focal treatment. Findings from those inter- users (see Figure 1) to describe what the impact of Pascal on
views are presented here as a means of helping physicians their daily practice has been like since acquiring the technology.
considering the technology to better understand and appreci-
ate the impact this technology is making in practices. Awareness and Interest in Pascal
Most physicians become aware of advances in technology
Introduction through lectures, articles, or promotional activities by manu-
Ophthalmic use of lasers dates back to the 1960s, with facturers. In the case of Pascal, a paper by Mark Blumenkranz,
many of the first applications developed for use on the retina. MD et al, one of the inventors of the technology, was published
PRP has remained a standard for decades in treating and pre- in March 2006 issue of Retina and referenced during the inter-
serving the vision of patients suffering from diabetic retinopa- views.
thy. Until recently, all lasers employed a single-spot approach: Dr. John Lehr had read that article, saw an online demo on
one foot pedal depression, one shot to the retina, requiring the company’s website, and wanted to try it. “Once I under-
physicians to spread out the PRP procedure over multiple ses- stood how it worked, I thought ‘this could be great for my
sions in order to achieve a complete treatment of 1,200 or more patients.’”
burns. When Dr. Eddie Ysasaga heard about the technology, he
In June 2006, Optimedica Corporation began shipping its knew he wanted to try it. “We serve the Texas Panhandle from
Pascal (Pattern Scan Laser) Photocoagulator for commercial use, Amarillo, and many patients come from several hours away.
offering for the first time a new delivery system using a mul- The concept of doing treatment in a single session was power-
tiple-spot pattern that can be scanned to the retina with a single ful: “Diabetic patients don’t like to come back.”
depression of the footswitch, up to 56 spots in less than 620ms. Other areas of interest described the improved reliability of
a solid-state laser, potential time savings and ability to see more
Fig. 1: Date of Acquisition
patients and/or end the workday earlier.
# of Retina When Initially skeptical, Dr. Howard Lazarus told the sales repre-
Name City Specialists Acquired

Houston Eye Associates Houston, TX 4 12/2006
sentative, “If you want to waste your time, bring it by. There’s
Rick Canady, no way I’d spend that amount of money on a laser.”
Executive Administrator
Rick Canady, Executive Administrator for Houston Eye
Magruder Eye Institute Orlando, FL 3 7/2006 Associates, concurred with the initial reaction to the cost of
John Lehr, MD and
Nader Moinfar, MD
the system. His practice sees 12,000 patients per month with
32 ophthalmologists (4 retina specialists) at 12 locations. With
John Kenyon American
Eye Institute Louisville, KY 1 11/2006 practice revenue growing at least 10% in each of the past 6
Howard Lazarus, MD years, Mr. Canady is continually seeking ways to make the
Southwest Retina Amarillo, TX 2 7/2006 practice more productive, which was the attraction of the Pascal
Specialists system. “When we amortize this,”he noted, “giving back 10
Eddie Ysasaga, MD
minutes on each procedure to the doctor would add up, espe-

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cially given how many they do each day.” in how much faster may be attributed to surgeon experience.
While capital expenditures can be a critical factor in the “I’m changing my patterns and technique and am able to com-
decision process to acquire technology, all four practices pro- plete the treatment even faster than when I started with this
ceeded with scheduling an onsite demonstration and evaluation technology,” commented Dr. Ysasaga.
of the laser platform with the ability to treat patients during the This time savings can be realized in one or more ways:
day. Reactions by participating physicians are described in the additional patient slots during the week, ability to handle emer-
next section. gency treatments without upsetting the schedule, and ability
to finish the day earlier. Although each practice has a different
Consideration and Purchase philosophy on how to spend that time, they were unanimous in
Customers interviewed described a strong out of box experi- what it offered, as expressed by Dr. Lehr: “I can breathe during
ence when relating to their first impressions using the system. my workday.”
Drs. Lehr and Moinfar were impressed with the short learning
curve to perform a PRP. Dr. Lazarus said he was simply “blown 2. Patient preference The fast procedure time has led to
away” with how comfortable the Pascal was for the patient and patient reports of little or no pain with laser procedures, and
immediately saw practice-building potential for the technology. use of the Pascal has significantly reduced the need for ret-
Mr. Canady polled the practice’s retina specialists, whom he robulbar blocks prior to doing PRP treatment (See Figure 3).
described as skeptical until the moment they actually performed This is of huge benefit to gaining patient compliance, espe-
a procedure. “One admitted to me that he never would have cially among diabetics at risk of losing their vision. “Once
guessed the laser could do what it does, while another was patients saw the big needle, they didn’t want it,” explained
emphatic in saying, ‘if the other doctors don’t vote it in, I’ll buy Dr. Ysasaga. “I asked myself, ‘what would I want?’ and
it myself.’” the answer was simple: no needle at all.” According to Dr.
Collectively, these users report that the deciding factor for Lazarus, “the entire process is more palatable to the patient.”
them was the ability to use it in their offices. “You just have He further added, “I am more comfortable providing treat-
to use it. Once you get it in your office, you won’t go back,” ment at less advanced stages of retinopathy in accordance
remarked Dr. Ysasaga. His sentiment was echoed by Dr. with the recommendations of the ETDRS.”
Lazarus: “I went from being a complete skeptic to a customer Equally important is the convenience factor for patients, who
in one day.”
Fig. 3: Increased Efﬁciency Using PASCAL to Perform PRP

Impact on Practice Name Efﬁciency
From the interviews, impact on the practice could be catego- Houston Eye Associates 2x faster
rized in seven distinct areas, each meriting its own description:
Magruder Eye Institute 2-4x faster

John Kenyon American Eye Institute 3-4x faster
1. Time for the procedure The overall time to perform a PRP
procedure is significantly reduced, as Pascal’s multiple spot Southwest Retina Specialists 5-6x faster
application allows physicians to perform their laser procedures
anywhere from two- to six-times faster than using the conven- can receive in a single session what used to take two or three
tional single-spot approach (see Figures 2 and 5). The variability sessions. “For patients that drive several hours to see us, this is a
big deal,” said Dr. Ysasaga. Other practices believe wholeheart-
Fig. 2: Percent of PRP Patients Requiring
Retrobulbar Block Prior to PRP edly that condensing the number of treatment sessions means
greater compliance and, ultimately, more preserved vision.
Name Conventional Laser PASCAL Laser

Houston Eye Associates >50% 0%
3. Impact on revenue and ROI While physicians use different
Magruder Eye Institute >70% <10% scales for measuring return-on-investment (ROI) for the prac-
John Kenyon American 10% 0% tice, every practice interviewed has experienced a clear financial
Eye Institute
advantage. Houston Eye Associates, according to Mr. Canady,
Southwest Retina 10% 0% amortizes equipment purchases over a five-year horizon but
Specialists
expects a quick payoff from the Pascal. Drs. Lehr and Moinfar,

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whose practice performs 20 or more laser sessions per week, 5. Staff Morale All practices indicated that staff is highly
saw an immediate boost in efficiency using the Pascal. The laser accepting of the technology because it helps maintain control of
schedule previously included many repeat (i.e., 2nd or 3rd ses- the daily schedule and keeps the clinic running smoothly. “Our
sion) visits to complete the treatment. The Pascal technology staff loves it because they don’t have to sell the patient on use
has enabled their practice to add 2-3 new clinic spots per day, of anesthetic block,” noted Dr. Lehr. This improved time man-
which translates to $50,000 - $75,000 of incremental revenue agement translates into doctors and staff being able to avoid
per year. In their view, the Pascal pays for itself in 1 to 1½ the crisis mode that typically hits with lengthy laser sessions or
years. “Now, I’d much rather be in the office doing PRPs than emergency patients.
at the hospital doing vitrectomies,” added Dr. Lehr.
Dr. Lazarus provided data that showed the effect of Pascal 6. Increased Efficacy Although larger studies are needed to
on his practice in the first 90 days after acquiring the technology. confirm their findings, each of the physicians believes the Pascal
In the quarter immediately preceding use of the technology, Dr. is generating better outcomes due to less energy being used
Lazarus performed 36 PRPs. In the first quarter using the Pascal, (leading to less thermal bloom and less collateral damage) and
he did 74 PRPs, more than double the prior quarter. This was the ability to perform a complete treatment (because of a more
the result of being more aggressive in his treatment due to less compliant patient). The potential side effects from traditional
resistance (as described earlier) and from increased volume due PRP have kept retinal specialists from treating sooner. “There
to his merger with an anterior segment practice that had previ- will likely be less reluctance,” predicts Dr. Lazarus, based on
ously referred out its retinal laser procedures (see Figure 4). The his clinical impression that the side effect profile will be signifi-
end result is a doubling of volume and revenue for what had cantly reduced.
been a time consuming procedure. This was achieved by a single
physician and without the need to increase staff. 7. Decreased Risk Clinically, Drs. Lehr and Moinfar stress that
the Pascal laser has helped them improve care by eliminating
Fig. 4: PASCAL's Impact on Revenue: Howard Lazarus, MD the gaps between sessions, which only increase the risk of fur-
ther deterioration due to vascular growth, at times then leading
Data from consecutive 90-day periods to more invasive (and hospital-based) vitrectomy. Further, they
PRP Procedure Volume Revenue believe strongly that the “ninety-first day” approach used by
Before Pascal & Pre Merger 36 $45,000
some clinicians to delay repeat sessions until they can be reim-
bursed is “not treating patients fairly. And, patients don’t like to
With Pascal & Post Merger 74 $91,200
come back.”
Delta +38 +$46,200 Another reduced risk is in the form of litigation from the
use of retrobulbar blocks. This is a salient issue for Houston
When Dr. Ysasaga first got the laser, he began doing side- Eye Associates, which has been at odds with anesthesiologists
by-side comparisons to help assess ROI but then stopped and over the classification of a block as in-office anesthesia. Use of
knew, “this is obviously a better laser for my practice and my the Pascal has helped them sidestep the entire potential conflict;
patients.” their experience to date has not shown the need to administer a
block by any of the four retina specialists in the practice.
4. The WOW Factor Once limited to describing the immediate
reaction of a LASIK patient, the concept of a WOW Factor
seems to apply to the presence of Pascal in the practice. “The
doctors love it,” proclaimed Mr. Canady. “There’s no com-
parison between the older technology and what this offers.”
Physicians remarked that patients who have prior conventional
treatment and now have it with Pascal will ask, “you’re done?”
Referring physicians are noticing as well. “You start getting
calls,” commented Dr. Ysasaga. Added Dr. Moinfar, “we
demonstrated this to a visiting optometrist and he was over-
whelmed by what we could accomplish.”

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Summary and Discussion both physician and patient in terms of time to complete a PRP
The dramatic rise in incidence of ophthalmic diseases such treatment. Conventional lasers typically require 2-3 sessions of
as diabetic retinopathy requires innovation of new and better 15 minutes each to complete a PRP treatment. With the Pascal
tools that allow physicians just to keep up. PRP is a good exam- photocoagulator, a treatment can be completed in a single ses-
ple of a standard procedure that was in need of innovation; in sion lasting 6 to 10 minutes.
this case, that has come in the form of a much-improved deliv- The Pascal is already proving itself by having a major
ery system that drastically cuts down on the time required to impact on improving one of the most common and arduous
perform the procedure. The time savings offered by the Pascal tasks in the daily regimen of a retina practice. The improved
Photocoagulator have created a host of benefits to the physi- patient comfort Motion Required to Complete Pascal is key in
Fig. 6: Time &
and time savings achieved by a PRP Treatment
cian, patient, and practice. Conventional Laser Pascal Laser
The practices interviewed for this report represent medical # of Sessions 2.5 1
specialists with busy retina practices who strive to give the best
Total time 37.5 minutes 6-10 minutes
care possible in preserving sight for their patients. What is clear
from the interviews is that the use of Pascal radically changes Reimbursement $850-900 $850-900

the way patients who require panretinal photocoagulation can
be managed. demonstrating a rapid payback for many practices. We look for-
The experiences of the interviewees and other retina-based ward to conducting a larger scale survey in the future as more
practices were used to create pro-forma analyses that assess practices acquire this technology.
the affordability of the device as defined by how long it would
Sources:
take to recoup the capital investment. The first analysis (shown Blumenkranz, Mark S. et al., Semiautomated Patterned Scanning Laser for
in Figure 5) shows the impact of creating additional capacity Retinal Photocoagulation, Retina Volume 26, Number 9
(ie, time in the schedule) due to Pascal. Time calculations were
based on conventional laser sessions across a variety of proce-
dures typically requiring 15 minutes; each experience among
Pascal users shows similar work being performed in 3 minutes.
Using a range of 10 to 40 laser sessions per month yields a pay-
back period of under 3 years for a conservative case and under
1 year for an aggressive case.
The second analysis (see Pro Forma ROI the impact on
Fig. 5: Figure 6) shows

Key Assumptions and Variables
Retina Patient Visit: $250 average bill
Patients scheduled per hour: 6
Revenue per Hour: $1,500
Single Session time for performing retinal laser procedures:
Conventional laser: 15 minutes | PASCAL laser: 3 minutes

Practice Volume Scenario "Conservative" "Aggressive"

# of laser sessions per month 10 40

Time savings per session 12 minutes 12 minutes

Total time saved per month 120 minutes 480 minutes

Available capacity for additional $3,000 $12,000
Revenue @ $1,500 per hour

Payback period for PASCAL 31.7 months 7.9 months
($95,000 capital expense)

© Copyright 2007, SM2 Consulting. All rights reserved.

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Feedback from early users of the pascal photocoagulator

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