Fine-Tuning for the Future

Follow these 12 tips to improve the mechanics of your practice.

By Sean McKinney, Contributing Editor

Improving practice mechanics will be critical to ensure that everything from patient visits to procedures flow smoothly in the years ahead. Here are 12 tips on how to meet your objectives.

1. Prepare for severe Medicare reimbursement cuts. A 21.2% cut is still on the table and will be considered by Congress in the coming weeks or months. Although the reduction may not ultimately be severe in 2010, Uday Devgan, MD, FACS, in private practice at Devgan Eye Surgery in Los Angeles, Beverly Hills, and Newport Beach, Calif., advises doctors to prepare for a cut of this size and more in the years ahead. "Future fee cuts are anticipated to be unrelenting," says Dr. Devgan, who is also chief of ophthalmology at Olive View UCLA Medical Center and associate clinical professor at UCLA School of Medicine's Jules Stein Eye Institute. "More teamwork in eye care will become essential. Surgical ophthalmologists will need to do more surgery and provide less care in the clinic. Other healthcare providers will need to handle some of the clinic load."

2. Plan for a new breed of ophthalmologist. Besides young doctors choosing retina, an increasingly popular specialty, the availability of comprehensive ophthalmologists will be affected by a shortfall in the number of ophthalmologists, as is commonly anticipated, but also by a "new" type of doctor who doesn't want to invest 50 hours a week into his career, according to Dr. Devgan. "I've been heavily involved in teaching residents for the past 10 years, working with eight graduating residents a year, and I can tell you that many of them hope to work part-time to balance work, education, family obligations, health and outside interests."

3. Modernize staffing and services. Michael Jacobs, MD, owner of Athens Eye Associates of Athens, Ga., has replaced a retiring MD partner with an optometrist and purchased an optician's optical business. Besides the optometrist and the optician, he employs four technicians and four front-office employees. After purchasing $40,000 in cabinetry for his new dispensary, he netted substantial earnings from optical sales during his first year and he expects to see continued growth. "I'm very hands-off in my approach and don't try to talk my patients into buying their eyeglasses from our office," says Dr. Jacobs. "But it's an important service that I feel we need to offer for the future health of our practice." During the next 10 years, he plans to position the practice for growth by spending more time on surgery and complicated glaucoma and diabetes cases, while delegating more primary care to the group's optometrist.

4. Take a few lessons from plastic surgery, dermatology and dentistry. Dr. Devgan says you will need to depend on more out-of-pocket payments for services and less on third-party payments. "When patients understand that their eye surgery will affect how they see the world, every waking moment, for the rest of their lives, they realize that investing time and funds in their vision is one of the best investments they can make," he says.

5. Consider productivity-based compensation models. If doctors are purely salaried, they may not be motivated to work hard enough to help practices meet the challenges of the future. "They must have a stake, a percentage, a bonus or something to reward them for hard work," says Paul S. Koch, MD, medical director of Koch Eye Associates in Warwick, R.I.

6. Reduce overhead. One smart way to reduce overhead is to control marketing costs. "Practices spend hundreds of thousands (or even millions) of dollars per year in advertising," notes Dr. Devgan. "There's a difference between getting your name out to potential patients and bombarding them with relentless advertisements. Limiting some of the advertising costs may be a reasonable initial approach."

7. Know when to stop doing cataract surgery. "Many ophthalmologists perform cataract surgery at a loss," says Dr. Koch. "They could be more productive and make more money by staying in the office. Perhaps this is not as rewarding. But when you consider time lost going to the surgical facility, especially if it's a hospital, the time it takes to do a case, the time it takes to get back, the revenue per hour for many ophthalmologists is much, much less than what they would earn simply by staying in the office." Dr. Koch, who counts an ophthalmologist among his top five referring doctors and another among his top 10, notes that low-volume surgeons can also avoid the stress of difficult cases by getting out of cataract surgery. "I firmly believe we're beginning to see the shift from general ophthalmologists to interventional ophthalmologists," he says. "I think in one more generation, that shift will be completed."

8. Invest in technology judiciously. Wavefront aberrometry and in-the-scope topography are very useful, particularly in post-LASIK eyes, according to Dr. Devgan. The femtosecond laser for cataract surgery also represents exciting, new technology that can improve cataract outcomes. But you'll need to determine how to pay for it, based on fees that are dropping, he notes. You need a mechanism for patients to elect to pay for the very best procedures.

9. Prepare to broaden your approach to refractive surgery. "The field of refractive surgery now requires both lenticular as well as corneal surgical skills," says Dr. Devgan. "It's amazing to see the LASIK-only ophthalmologists now switching gears and learning cataract surgery. I encourage all of the younger doctors to maintain proficiency in both lenticular and corneal surgery." He believes refractive surgeons who have both sets of skills will be in the best position to succeed.

10. Position yourself for the bounce-back. Committed refractive surgeons should benefit once the popularity of refractive surgery returns. Dr. Koch notes that many surgeons withdrew from the arena when the expense of renting a laser or traveling to a laser center cut into profits. Poor outcomes in some cases also presented a challenge to refractive entrepreneurs. A secondary downward trend occurred when financial weakness and bankruptcies eliminated most of the major chains. "Those of us in the middle will either feel a squeeze from disappearing patients or a boost once the economy bounces back and we're among the ones left standing," he says.

11. Eliminate unwanted procedures. "For example, pterygium surgery takes a long time and doesn't pay well," notes Dr. Koch. "Consider sending these cases out. Another example: Should all retina specialists do vitrectomies? In my area, one retinal surgeon prefers operating and several others send him their cases and stay in their offices to do consultations, tests and injections. They make more money in their offices than they would if they spent a day at the hospital on a few long cases."

12. Collect payments up front. A very high non-payment rate can develop because of emerging insurance companies that charge 30% deductibles (not $20) and use slow payment methods, according to Dr. Koch. Some patients may believe they don't have to pay until the explanation of benefits (EOBs) reaches the doctor and the doctor sends out a bill, he says. "We've begun taking credit card impressions for these patients and processing the charge when the EOB arrives," he says. "We don't send bills in these cases." OM