Point-Counterpoint: Should You Bring in a Retinal Specialist?

PRO: It improves care and convenience for patients, and the practice benefits from increased billings.

By Larry E. Patterson, MD, with Ray Mays

Like most general practice ophthalmologists I've met, for the first 20-plus years of my practice I referred patients that needed retinal care to a retina specialist. For the past 16 years, we have had a group of retinal docs that would come to our office a couple of times per month. This worked out well and saved our patients the one- to two-hour drive required to receive specialty care.

A few months ago we had the opportunity to hire a retina specialist who had left a large group and wanted to work with us. Over the course of the past few months, the decision has been an unqualified success. The success can be divided into two categories, professional and business.

On the professional front, it is nice to have him around to consult on patients and allow us to learn from each other. If I'm in the OR and have that unfortunate case of intraoperative nuclear loss, having a backup guy nearby is great for patient care. There are also those occasions where either myself or the other docs in the group have a question about a patient that relates to posterior segment care. Having a retina specialist there to come into the exam room and take a look is comforting for both the doctor and the patient.

Patients love the convenience of having just one eye clinic with which to deal — one set of staff, one set of bills, one office to visit, etc. If a referring doctor is not sure whether the patient needs to see me or a retinal specialist, they can now send them to me knowing that we can more easily access the retinal specialist as needed. We have also enhanced our brand image within the communities that we serve by letting patients and referring docs know that we have retinal care in-house.

Like any business, ophthalmic practices have overhead and fixed assets. In order to survive and grow, business owners must continuously be on the lookout for ways to leverage overhead and assets. We have a highly trained profes sional staff that took years of hard work to produce, a state-of-the-art facility, equipment, a phone system, a computer system, etc. We also have payroll, utilities, rent, taxes and other expenses that must be paid regardless of patient volume.

When presented with the opportunity to bring the retina specialist aboard, we reviewed our schedule and identified two days where we were not fully utilizing all of our assets and created a schedule for the retina doc on those days. We hired one additional staff member and purchased a new digital camera to allow him to do fluorescein angiography (we needed a new camera anyway), and we had to invest some time and effort into learning how to bill for retinal procedures, so with a relatively small investment we were able to leverage the same overhead in a manner that hopefully will allow us to generate several hundred thousand dollars in revenue.

Adding a retina specialist may not be an ideal fit for all general practices. But if the circumstances are right, the expanded scope of care at your practice will differentiate yourself in the community and will enhance the value of your enterprise.

CON: The culture is different and the efficiencies are fewer than you might expect.

By Amir Arbisser, MD

General ophthalmology groups considering the addition of a vitreo-retinal specialist face challenges. The board may wonder whether these guys speak the same language and whether they would integrate into your practice culture. There are also sizable investments to be made in both human and physical resources. Below are a few tongue-in-cheek observations:

• They cost more: Because few retina specialists are minted, they migrate to retina groups, where they share that field's language and toys. The practice must budget appropriately — salaries often start 50% higher than those of generalists. A retina specialist's W-2 may exceed a medical ophthalmologist's by a log unit. This results in "income envy" and possible dissension in the ranks.

• Recruiters rejoice, call daze: "Retinologemia," the national shortage of these VIPs (very important physicians), generates nonstop recruiting. Retina is always "in season." Any disagreement that arises with a retina specialist in your practice is vulnerable to further polarization by continual dollar dangling in putatively more glamorous locales than Truckstop, NJ. Retina fellows refuse to even consider general practice settings. No one can share pure retina call responsibilities. Rotating call doesn't prevent their phone ringing for most vitreoretinal pathology.

• Their toys cost more and cash flows differently: Adding a generalist to your group increases utilization of shared devices and decreases capital and overhead per doctor. By contrast, the retina specialist's tools include multiple imaging systems, ultrasounds, new lasers as well as facilities and staff for intravitreal injections. General practices often net 40% or more whereas multimillion-dollar Lucentis charges yield low single-digit profits. Then there's the surgery center…

• ASC angst: If generalists co-own a cataract surgery facility, the retina recruit's expectations may seem outlandish. The large investment for a handful of retina cases often matches capital costs for thousands of anterior segment procedures. Disposables and maintenance contracts also adversely affect net. Then experienced surgical staff migrates to the ASC, resulting in spotty after-hours staff and equipment at the hospital.

• Referral follies: Think you'll garner lots of new referrals? Think again. Our group's well-trained generalists performed scleral buckles until an independent retina specialist opened nearby. Medicolegal risks subsequently necessitated referral of these cases to local or out-of-town specialists. Ophthalmology and optometry "colleagues" will refer (even great distances) around a "competitive" practice. Pure retina offices often don't own phoropters! Expect to serve most Medicaid or indigent referrals. They can't afford to travel away, plus they'll consume your resources instead of your neighbors'. Your group must fill 95% of the retina specialist's schedule — for years.

• Jungle economics adversely affect both quality and efficiency. In eat-what-you-kill groups, an underused retina specialist would be incentivized to perform non-retina work. Similarly, generalists will lust after lasers and "minor" retina procedures perceived to pay well. The consequences? Practice efficiency suffers, and worse — patients may not receive the optimal care your practice offers.

• A different patient experience: Cataract/refractive surgery is a feel-good experience. It's wow and it's now. Sure, retina specialists savor improvement after successful detachment repairs and media-clearing vitrectomies, but often they're relegated to touting anatomical successes or treating progressively deteriorating AMD. The postop LASIK or cataract office enjoys a party-like atmosphere compared to the more somber retina practice. Then there's that always-festive low vision clinic…

Conclusion

Kidding aside, I was tasked with the "nay" side of this discussion despite (mostly) enjoying intragroup retina for over a decade. The polarities are real, and likely I missed some. Collegial patient-centric attitudes and a compensation methodology promoting group success with consequent benefits over internal competition enhance the quality of patients' care and our generalists' experience.

Special thanks to my group's president Bill Benevento, to retina specialist extraordinaire Michael Howcroft, to CEO Dan Craig, and my practice management guru John Pinto. OM