viewpoint
Want Chips With That?

Paul S. Koch, M.D.

I can't wait to see how ophthalmologists respond to the CMS ruling that we can bill for refractive lens implants outside of Medicare. Will we use this wisely to get fair compensation, or will we mess it up like we did with LASIK? The lesson we learned there, surely all remember, is that if we price the operation below our costs it is awfully hard to make it up on volume.

For financial guidance on this important issue I sought out the most insightful person I could find, a teenager working in a sandwich shop for minimum wage plus tips. This boy needs more than a grand for a Gibson Les Paul Studio guitar, and without an alternate source of income he has to watch his Washingtons closely. Let's look at how he manages his cash flow and see what lessons we can learn.

If you were to enter his shop he would bounce to the counter, long hair barely contained beneath a corporate baseball cap. He would take your sandwich order and ask if you wanted a drink. Almost always he would also ask if you wanted a bag of chips. If you demurred he might point out the baked ones on the bottom shelf. Whether or not you got chips, he might, or he might not, suggest some of their fresh-baked cookies. Later, as you watch him wait on other costumers, you would notice that there seemed to be neither rhyme nor reason behind his suggesting chips or cookies. You might assume he was simply an addled teen rather than a clever businessman.

However, if you take the time to discuss revenues with him, you learn his strategy for making money. "You want to get the check between $8.50 and $9.00," he explains. "If it is below $8.50, after you give back the change they'll tip you either the coins or the buck, but not both. If it's more than $9.00 you'll just get coins because that's all there is. But, if you can hit it just right, the coins alone will be too meager of a tip, so they'll toss in the bill, and usually the coins, too."

When we offer a bag of elective services to patients, we often fanaticize about the receipts and forget about the expense ledger. We have to remember that what matters when all is said and done is what's left over in the cup at the end of the day. Any kid knows that.