Adding Retina to a Comprehensive Ophthalmology Practice

The Ophthalmic Consultants of Long Island explain the ins and outs of expanding to the posterior segment.

By Daniel F. Kiernan, MD, Eric D. Donnenfeld, MD, FACS, Richard T. Sturm, MD, FACS, Glenn L. Stoller, MD, FACS, Ken B. Carnevale, MD, FACS, Tom Burke, Thomas Pannullo, JD

Over the past 25 years, several factors have increased the demand for vitreoretinal subspecialist services: the increasing population of baby-boomers and their associated age-related macular conditions, increasing development of effective and efficient treatment options for common sight-threatening disease such as diabetic retinopathy and age-related macular degeneration that require an increased frequency of follow-up care, improvements in surgical instrumentation and outcomes, and an increasing concern about medicolegal considerations in areas that have other retinal physicians readily available to treat potentially blinding emergencies.

As this market demand has increased, so have the costs associated with starting a retina practice. The likelihood of new graduates acquiring the necessary capital to hang out their own shingle, especially in an area already densely saturated with retina specialists, is slim. Thus, the majority of graduating retina fellows take positions with established practices. Classically, many newly minted graduates would join a distinguished academic faculty or another retina-only consultant group. But in response to the increased demand for retina, the virtual abolishment of consult codes and the “trade deficit” traditionally experienced by anterior segment practices, many comprehensive groups have taken up serious recruitment efforts to expand their retinal services.

This article explores the perspective of one such group, Ophthalmic Consultants of Long Island (OCLI), and our integration of the vitreoretinal subspecialty while continuing to expand as a whole.

Getting Started

OCLI was started 30 years ago with a group of ophthalmologists who had a cornea and cataract focus and merged with a large local glaucoma practice with the intent to bring on vitreoretinal subspecialization as soon as economically possible. Since then, there has been one additional eyecare professional hired by the practice on average every year. OCLI currently has nine offices, 24 eye doctors and sees over 150,000 patients per year. The enterprise has a central business office, chief executive officer and dedicated practice attorney.

The physicians and staff of OCLI felt that providing comprehensive quality care to their patients required adding retina to the services their practice already provided, as they had been dedicated to providing high-level primary, secondary and tertiary care to their patients. Adding retinal specialists enabled the practice to further meet the needs of their patients, their referral community, and provided improved communication between the internal referring physicians and the growing retina team. Patients can now be seen quickly and efficiently, and those with complex or emergent problems can be evaluated the same day by a team of specialists to provide optimal medical and surgical management. OCLI currently has three full-time vitreoretinal surgeons who rotate between five of the offices.

Dr. Dan Kiernan performs indirect ophthalmoscopy in an examination lane. Electronic medical records and digitalization of all imaging, including SD-OCT, facilitates follow-up.

An Expanded Patient Market

From a patient perspective, there is really no downside to hiring a retina specialist. For internal referrals, patients can usually return to the same clinic that they were initially evaluated at, or a different office location if it is more convenient. As OCLI has retina offices across Long Island (the farthest offices are approximately 65 miles apart), there is availability to a very large population of patients, the majority of whom would not travel that far on a regular basis.

There is also the advantage of one completely contained medical record documenting the patient's visual system and scope of treatments and one set of paperwork and billing for the patient to deal with. Familiarity with overlapping technicians and office staff makes everyone more comfortable. In terms of differentiating a practice in the community, the expanded scope of retinal care within a comprehensive practice may certainly enhance its value to its patients and its referral sources.

A professionally designed, well-maintained practice Web site (www.ocli.net) has also been instrumental in allowing the viewing public to keep up-to-date with OCLI's practice advancements, new doctors, locations and services offered, as well as offer opportunities to give back to the community through organized charity events. The ability to make appointments online is another helpful way to increase patient appointment volume.

As far as patient referrals, the size and history of OCLI makes it understandable that most of the new patients seen by a retina specialist are internal referrals or the product of existing referral relationships. However these are usually “high-yield” and often require imaging work-up and one or more procedures or surgeries. OCLI has a dedicated outreach coordinator who helps spread the company's image and promote new physicians to nearby ophthalmologists, optometrists and other medical doctors. Because of word-of-mouth referrals, the practice has a self-propagating mechanism whereby patients seen by one specialist may mention that their friend has a specific eye condition such as diabetes, and thereby get them “referred” to the retina specialist for screening.

Management and Staff Balance

From a management standpoint, it is important to have a well-organized central structure when communicating between offices and setting up retina eye exam appointments. Assigning office hours by location and doctor, balancing doctor and technician time off, doctor location preference, and unmet need within a geographic area is a monumental task and requires the input of multiple managers, centralized analytics and hardware, and smoothly running software. OCLI uses the NextGen Enterprise Management software and also Brevium, an add-on contact management software application from Brevium, Inc., of Eagle Mountain, Utah.

Oftentimes, there would be an available set of rooms on a given day at a busier office with one or more doctors taking some time off. If timely identified, communicated and coordinated, this worked well for scheduling patients for a newly hired retina physician. Days where there is simply no room for a new retina doctor to have office hours are allocated for surgery or community outreach. Electronic medical records have added to the challenge of integrating important (and soon to be mandated) technology into the practice, and OCLI has used NextGen for patient charting and records, and EyeRoute software from Topcon Medical Systems for storing and transmitting retinal imaging modalities among the nine offices.

In the same practice, Dr. Eric Donnenfeld performs one of the first femtosecond laser refractive cataract surgeries on Long Island, New York.

As there are a finite number of available rooms for each doctor, it's critical for each office manager to allocate the right number and location of technicians. Having a retina specialist requires a different skill set than ophthalmic technicians may be used to with other specialists, and they need to be trained accordingly. Strong leadership at the office level is critical to staff development. For example, at OCLI, setting up for an intravitreal injection involves a specific protocol that is the same for all the retina doctors to avoid confusion and improve efficient patient flow and care.

To increase efficiency with retinal imaging, it is good to have the OCT scan ordered by the referring physician in advance of the patient visit, especially in a patient being treated for macular edema. If the test is done prior to when the retina specialist first sees the patient, a medical decision can be made without an additional visit. Staff, technicians and physicians should communicate about protocol for ordering medically indicated tests ahead of time.

Balancing Practice Cost

Financial dynamics at a large company like OCLI may be different from smaller practices, but like any business, there are overhead and fixed assets that necessitate constant monitoring. The addition of a single retina specialist will likely be a large one-time cost due to a need to provide modern imaging modalities including fluorescein/indocyanine green angiography, OCT, fundus autofluorescence and integrated software.

The ophthalmic biologics as gold-standard treatment for many macular diseases also necessitates a capital investment in proper storage equipment and potentially tens of thousands of dollars in upfront cost of individual treatments such as Avastin, Lucentis and Ozurdex. Access to or securing favorable financing and negotiating payment terms with critical vendors can significantly mitigate the impact to cash flow when factoring in these new expenses.

Additional training of staff and hiring multiple technicians for each retina specialist's schedule is another practice expense. Rent, utilities, taxes, employee benefits and other fixed costs are usually not affected much by adding a retina specialist. In OCLI's experience, analysis of overall revenue demonstrates that the retina subspecialist revenue is around 20% of the anterior segment revenue. Since OCLI has maintained steady growth and expansion, the practice has had enough volume and need to recently add a third retina specialist. This benchmark may be a good gauge for budgeting to see if a practice can afford to add or expand more full time retinal sub-specialty coverage.

A question is often raised about the salary cost of a retina specialist. Starting salaries vary by practice, geographic region and the overall economy, but the bottom line is that the decision to hire a retina specialist is about increasing revenue over time based on the expanding number of patients presenting with retinal pathology and recently available treatment options. The fact that many patients regularly require time-consuming, higher-level, comprehensive examinations with OCT imaging, B-scan ultra-sonography, extended ophthalmoscopy, baseline and follow-up fluorescein/indocyanine green angiography on one or both eyes during each appointment leads to higher average per-visit reimbursement levels in comparison to general ophthalmic evaluations. Intravitreal injections, pneumatic cryopexy retinal detachment repair, focal laser treatment, panretinal photocoagulation, prophylactic retinal detachment and other laser procedures are also necessary in-office procedures that provide time-efficient reimbursement.

Dr. Kiernan demonstrates how to perform argon laser photocoagulation using a Pascal laser.

It should come as no surprise that retina specialists who have received additional fellowship training often receive greater reimbursement per patient and higher starting salaries on average than non-specialty trained physicians. Of course, as any veteran ophthalmologist will tell you, it is foolish for a new graduate to base his or her employment decision solely on the basis of a starting salary — however high it may be — without also looking at the big picture of the practice and other physicians they are joining over the long run.

Ribbon cutting at eighth and the newest office, Port Jefferson. Dr. and Mrs. John Wittpenn with local dignitaries and office staff.

Practices also have to prepare to balance the surgeon time slots and expenses of a surgery center with cases that may take longer to perform, as many retina surgeries may require when compared to anterior segment procedures. At OCLI, retinal surgeries are performed in a hospital setting, not at the surgery center, thus efficiently polarizing retina and comprehensive cases. This way, if a complex retinal detachment repair takes longer than expected to perform, it doesn't affect the patients and surgical volume of another non-retinal surgeon. In addition, higher-costing surgical adjuvants like perfluorocarbon heavy liquid, expensive disposable devices and the option of general anesthesia aren't conducive to some tightly run ASC models.

Physician Call

At OCLI, call is divided into General and Retina call. Three retina specialists split the retina call and the other ophthalmologists split the general call. An answering service handles the triage of patients and contacts the retina doctor on call via text message if the patient is a retina patient or if they have new flashes or floaters. Other questions are referred to the general ophthalmology call. Each hospital that the physician has privileges for has their own divided call separate from the practice call. OCLI physicians with academic affiliations may also contact the retina doctor on call if they're on-call institution has a retina emergency and no retina doctor available.

This split-call schedule has been in place for 15 years and seems to work very well, with a fair balance of after-hours patient inquiries shared between the two groups. This extensive availability for call coverage Island-wide helps OCLI differentiate itself and affords us a great number of additional encounters per year.

Medicolegal Considerations

Medicolegal considerations have also been a basis for some comprehensive practices to expand and include a retina specialist into their practice. For example, previously, laser photocoagulation was the mainstay of treatment for diabetic retinopathy and macular edema. But new pharmacologic agents have arisen that are making treatments and the associated economics more complex.

Non-retina specializing ophthalmologists may consider: Should you inject off-label Avastin for a patient with center-involved diabetic retinopathy? Do you know practices or universities that have clinical trials in your area that your patients may benefit from? Are you comfortable using PDT, interpreting ICG, and injecting anti-VEGF agents in to the eye of a person who's had a recent heart attack or stroke? How are your scleral depression skills for that patient who has a new floater that you're thinking about doing a YAG on? All of theses questions may make any ophthalmologist nervous, and often prompt a referral to a retinal specialist, not only for the benefit of the patient but also from a defensive medical-legal standpoint.

Conclusion

General ophthalmology groups considering the addition of a vitreoretinal specialist face numerous challenges, including sizable investments to be made in both human and physical resources, but the efficient integration of retina can pay dividends — both financially and in terms of patient care.

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. Collegial, patient-oriented attitudes and a compensation methodology promoting group success will enhance the quality of patients' care and the success of the entire practice. OM

OCLI is a renowned, multispecialty eye care group that offers a wide range of eyecare services including LASIK, cataract surgery, glaucoma diagnosis and treatment, treatment of retinal disease, and comprehensive family eye care.
	Daniel Kiernan, MD, is an associate specializing in medical and surgical diseases of the retina. He continues his interests in investigating both non-invasive and surgical approaches for the diagnosis and treatment of sight debilitating retinal diseases.
	Eric Donnenfeld, MD, is a partner and recognized as one of the leading refractive surgeons in the United States. He is on the executive board of ASCRS and is the Chief Editor of Cataract and Refractive Surgery Today.
	Richard Sturm, MD, is a partner specializing in glaucoma and cataract surgery. He has served as clinical instructor and director of glaucoma service at St. Luke's/Roosevelt Hospital Center.
	Glenn Stoller, MD, is a partner specializing in medical and surgical diseases of the retina. He is a member of the Retina Society and continues to be a very active researcher of promising new therapies for retinal diseases.
	Ken Carnevale, MD, is a partner specializing in medical and surgical diseases of the retina. He is an Assistant Clinical Professor of Ophthalmology at The New York Presbyterian Hospital in Manhattan and currently participates in several clinical trials for retinal diseases.
Thomas Pannullo, JD, is the Chief Operating Officer for OCLI. Tom Burke is the Chief Executive Officer for OCLI.