Expanding Your Breadth of Care

How to position your practice for growth by meeting more patient needs.

By Amir Arbisser, MD

Within a decade, nearly one in every three Americans will be a Medicare beneficiary, representing a 35% increase over today's enrollment.¹ Medicare patients have traditionally required much more ophthalmic care than younger patients. In addition, more than 30 million new patients may appear in doctors' offices with coverage for the first time because of healthcare reform. This unprecedented increase in waiting room traffic commands far-reaching changes in how we provide service, including care of perioperative surgical patients.

Just how will you treat patients in this new environment? Here are 10 strategies to consider.

1 Diversify and expand your practice

Our Midwest practice has charted two decades' of growth and profitability as we have continued to add new services. Our group now includes 20 doctors distributed among urban and suburban settings in five locations on the Iowa and Illinois sides of the Mississippi River. We joined a surgery center that includes one of our competitors in ophthalmology, a urology group and a hospital system. (We may be the only ophthalmologists who own a lithotripter!)

When building your practice, I recommend that you try to incorporate as many ophthalmic specialties as possible. We have included cataract/refractive, pediatrics, cornea, retina, glaucoma and plastics/oncology. We now lack only neuro-ophthalmology and uveitis. Primary care and nonsurgical patients receive services from our four medical ophthalmologists and six optometrists.

Currently, 11 of the 14 ophthalmologists own equal equity in our professional corporation; none of the optometrists own shares. Even a modest-sized practice is generally able to add a staff optometrist to provide routine primary care more efficiently. In our practice, ODs contribute at least $50,000 each to the owners' bottom line (after salary and expenses) per year.

I recommend that you also look for supplemental opportunities that contribute to your bottom line, such as the four optical locations and hearing services we have opened in our two main bases. Hearing services seem especially appropriate for practices with large chronic disease patient bases that include primary care. The success of optical and hearing services completely depends on the physician directing trusting patients to take advantage of these reliable options.

2 Don't micromanage

We rely on skilled administrators to manage our growing practice. The management team includes a chief executive officer (a PhD with an extensive healthcare business background) and a chief operating officer (an outstanding ophthalmic technologist with years of clinical experience). During growth periods, a CFO frees the CEO for creative opportunities. We also employ a quality control/compliance RN with a background in the insurance industry. Developing this type of talent pool will maximize the clinical time of your physicians and optometrists.

If you join or own an ASC, try to stay flexible and open to opportunities. For example, we teamed with urology surgeons at our facility. Another example: I've always perceived our practice as analogous to a bank with local branches. Even though most bank customers have access to multiple branches, they generally gravitate toward the closest branch. Similarly, we don't operate exclusively at our ASC. Several of our surgeons regularly use community hospitals in our metropolitan area because of patient needs, insurance mandates, and/or referring doctors' preferences.

Focusing on primary care, Amir Arbisser, MD, and his 10 partners at Eye Surgeons Associates of Iowa and Illinois have expanded and integrated care to create a practice model that challenges the future — instead of vice versa.

Our refractive cataract surgeons implant premium intraocular lenses in about 30% of our patients. We also have busy LASIK and elective plastic areas. Because of our compensation model, doctors are motivated to direct care to the surgeon who is most skilled to meet an individual patient's needs.

3 Commit personally to practice growth

A bigger practice doesn't always mean more rental space and equipment. Your ultimate success depends on the physicians' commitment, which your staff will emulate, within reason. Simple examples of model behavior include arriving to work on time or even starting 15 minutes earlier and shortening lunch from an hour to half an hour. When doctors accept the direction of their administrators, then staff, space and equipment can be more optimally scheduled.

You should be willing to grab charts and work up patients when the staff is overburdened and the schedule slows down. Although you cede some autonomy, such commitment results in providing better care because you're making patients your top priority, creating a happier staff and improving your bottom line.

4 Follow clinical guidelines

Clinical protocols, such as Preferred Practice Pattern Guidelines from the American Academy of Ophthalmology, enhance your quality of care and recommend appropriate treatment intervals and diagnostic studies that should prove to be productive for your practice.

These tools help guide your staff 's scheduling of patients and will stand the test of time, no matter how much our practices change because of future demand and manpower shortages. I believe guidelines also reduce patient healthcare anxiety, because they help patients see that the practice and doctors are in command.

5 Write out your goals — and implement them

I recommend that you put realistic goals on paper. As you review your charts and consider your patient base, concentrate on achieving those goals. We've implemented almost all of our goals, beginning with our plan to expand the doctor cohort to 20 so far.

When expanding in this way, establish a compensation model that diminishes internal economic strife while promoting external competitive behavior. Our model promotes specialty care by the most experienced practitioners, based on shortest time in office and in the operating room (OR), the fewest complications and re-op surgeries, the fewest and shortest post-operative visits, the fewest spectacle remakes, and the happiest patients.

This approach is better than basing compensation strictly on production. The "eat what you kill" model (pure production-based compensation) tends to make partners compete with each other for cases and patients instead of concentrating on growing the practice.

My partners and I compete with each other only in a friendly way that best meets the needs of individual patients and produces optimal outcomes. There is a clear incentive to perform procedures better than our colleagues.

6 Emphasize your strengths

For example, medical ophthalmologists are encouraged to perform the services and procedures they're best at providing. They can do well by limiting themselves to office-based care, and they don't feel compelled to perform cataract or LASIK procedures, which may entail multiple, uncompensated post-operative office visits.

Sharing a surgery center with a competitor is one way you can succeed. Lisa Brothers Arbisser, MD, co-owner of Eye Surgeons Associates, performs cataract surgery at the practice's ASC.

7 Develop your collaborative instincts

Competing isn't the only way to win. We've pursued collaboration by strategic design for more than 20 years. We do this inside the practice and by inviting appropriate outside practitioners to join our enterprise. We've also incorporated retiring practitioners' practices, when appropriate. (Make sure you rely on the oversight of your legal consultants to set up a legal firewall between the departing doctor's potential unidentified chart and clinical "surprises" and your practice.)

We've also created a vision care program that shares equity with outside practices (mostly independent optometry offices) to offer as an alternative to national vision plans. This is appealing to locally owned businesses. The program includes optical, low vision, sports vision, computer vision and local LASIK discounts.

You'll find that most collaborative enterprises in the therapeutic arena become more profitable when you share equity and increase volume with like-minded, quality-oriented practitioners. As I mentioned earlier, we increased volume and profitability in our surgery center by sharing ownership with one of our competitors.

We also provide perioperative services as a team so that the OR time of our skilled surgeons is maximized while patients benefit from in-house care and, when needed in rare circumstances, rapid access to the surgeons.

8 Introduce technology that produces results

I recommend using new technology aggressively when it improves clinical care. Of course, equipment is more easily shared and purchased when many have a stake in your success.

We've already had several generations of OCT units, Humphrey visual fields analyzers, IOLMasters, and multiple generations of lasers, which now include the Pascal Pattern Scan Laser, latest Nd:YAG lasers, and selective laser trabeculoplasty systems.

We generally make our selections with yearly six-figure budgets (guideline not cast in concrete), based on the quality of patient care and the promise of physician efficiency, rather than ProForma alone. The ProForma becomes more critical (but not rate-limiting) when we exceed the yearly budget. Obviously, any service that enhances the patient's experience (easier access, less pain, faster procedure, and so on) or the physicians' productivity or both (like the Pascal laser did a few years ago) helps our bottom line and improves clinical outcomes.

9 Connect with your patients

To build a solid practice for the future, you'll need to acquire more patients. Besides developing a local vision care plan, you can educate existing patients about the options you offer during their yearly visits and make appropriate recommendations. We invite family members and friends to visit. This is not a stretch for a pediatric ophthalmologist, such as myself. I have always invited siblings, and our practice has evolved once the parents and grandparents have also begun requesting care. It's still amazing to me that patients don't realize they can be seen without a referral or consultation request.

We're firmly committed to education at both the professional and community levels. Our group's earliest educational efforts targeted physicians, nurses and optometrists. That orientation has not abated.

Simultaneously, you can initiate community education for almost anyone who asks — community service organizations, elder groups and so on. Actively participate with public and private education — from preschools to and colleges and universities, the arts community, 501c3 entities, and local religious congregations. You can engage in the political process at local, state, regional and national levels. Offer to match donations made by staff as an incentive for them to participate. Celebrate your patients' successes by inviting them to special events. For example, we hosted 9,000 post-operative cataract patients at the Ringling Brothers Circus. We have also taken a large group of successfully treated AMD patients to attend an IMAX screening.

An optical dispensary is one of many supplementary services that can help diversify a practice and position it for future success.

10 Put it all together — every day

What does all of this have to do with treating patients in the future? Everything. If you create the right delivery model, reach out to patients and provide a positive experience in a community context, you will succeed, no matter what decisions come out of Washington. OM

Reference

1. 65+ in the United States: 2005. U.S. Department of Health and Human Services. National Institutes of Health, National Institute on Aging. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau.

Amir Arbisser, MD, is co-founder and President Emeritus of Eye Surgeons Associates, a multispecialty practice with 20 doctors and five locations on the Iowa and Illinois sides of the Mississippi River. He specializes in pediatric and comprehensive ophthalmology.