Trevor Elmquist, DO, has an integrated eye-care practice in Florida with an optometrist as a partner. Here, Minnesota ophthalmologist Bridget A. Sundell, MD, asks him about creating such a practice — the benefits in bridging the traditional MD-OD gap, the concerns involved and the nuts and bolts of making it work.

“My aim is to tell a story of what has been a very successful business strategy,” says Dr. Elmquist. “Many eye-care practices may benefit from this sort of cooperation, as the projected shortage of ophthalmologists in the next five to 10 years is significant.”

Bridget Sundell, MD: Dr. Elmquist, why are you interested in telling your story of a successful integrated eye-care practice?

Trevor Elmquist, DO: Perhaps it is because this model of MD-DO/OD partnership has been so successful, at least in my practice. I’ve been an advocate of success through cooperation for a long time. If two parties come together and do what they are licensed to do, and do it well, then the practice as a whole is successful. If we focus on the practice, and work together for the benefit of the practice, then naturally all owners, as well as staff and patients, benefit.

BS: What do you mean by the term “integrated eye care?”

TE: The discussion of integrated eye care or a practice that includes optometrists and ophthalmologists working in the same practice has gone on for decades. My feeling is that the integrated practice uses all levels and skill sets of professionals who are trained and licensed to deliver services to patients.

In other words, ophthalmologists, optometrists, opticians, orthoptists, ocularists, scribes, COAs, administrators and others come together to provide highly skilled services for those in need. For the most part, integrated eye care and discussions about this practice arrangement revolve around ophthalmologists and optometrists working together in the same practice.

Personally, I do not consider optometrists who provide co-management of surgical patients in a separate practice a fully integrated eye-care model. At this point, I would like to state a principle that guides my thinking on this subject: It matters very little what the two letters are on the end of your name. As long as you are practicing and caring for your patient at a high level of skill and quality, and within the bounds of your license, then have at it.

Consider that there are roughly 44,000 actively practicing optometrists and roughly 18,000 practicing ophthalmologists in the United States. With 76 million baby boomers creating a tsunami of retirees in the next decade, there is no doubt that we will need to rally all our eye-care forces to deal with the needs before us.

This is not to say that optometrists should obtain legal rights to do surgery through legislation. There is a way to become a surgeon: Go to medical school and complete an ophthalmic residency. But working together can be a way to efficiently care for the vast needs and spectrum of eye patients.

BS: How did you find your optometrist partner?

TE: Over the last 25 years, I have had five or six optometrists work with me part time as employees. In 2006, I expanded our practice to include a satellite office at an upscale retirement community. At the same time, we hired a full-time optometrist.

From the interview on, it was obvious that this optometrist excelled at all levels of professionalism, and in one year I offered stock in the practice to become a partner. Not all states allow ophthalmologists and optometrists to share ownership of a practice, of course, but fortunately Florida is one state that does.

BS: What caused you to go as far as making the optometrist a partner of your practice?

TE: This step was not my idea. It was proposed by our friend and consultant, John Pinto. About eight years ago, John suggested that we make our full-time OD the managing partner (see “It’s destiny,” page 66).

Performing managing partner duties can be rewarding — but it can also be a constant grind. To manage practice details, train staff and implement projects, you need an unrelenting and perspicacious leader. My skills tend to be classified as “big picture,” while my OD partner excels at implementation of procedures and policies.

The new roles have worked out fabulously for our practice. We have a culture that attracts skilled workers, and people are proud to be part of Elmquist Eye Group.

BS: Have you been criticized for selling stock in the practice to an optometrist?

TE: A few older ophthalmologists have been critical of this cooperative management, especially when it reaches the level of partnership. One ophthalmologist went so far as to call me “unethical” to my face. It is interesting to note that at the time, he employed an optometrist in his own practice. Perhaps he just objected to the compensation model or the partnership aspect of my integrated eye-care practice.

Our philosophy is that we work with, and beside, partners who excel at meeting the needs of our practice, and especially our patients.

BS: Florida allows such a partnership between ophthalmologists and optometrists, but not all states (and state medical boards) allow this sort of business relationship.

TE: This varies from state to state. It is essential that anyone considering this type of partnership consult an attorney experienced in these arrangements for the state of interest. For example, health-care law in New Jersey contains the following language:

“A partnership, professional association, or limited liability company may be formed, but the entity must be composed solely of health care professionals, each of whom is duly licensed or otherwise authorized to render the same or closely allied professional services within the State.

Closely allied fields include chiropractic, dentistry, nursing, nurse midwifery, optometry, physical therapy, psychology, and social work. However, in the event that a practitioner with a plenary license (i.e., a medical doctor) forms a partnership with a practitioner with a limited license (i.e., a nurse) the plenary licensed practitioner must have a greater ownership interest in the entity than his or her limited licensed partner. Similarly, if a medical doctor and two nurses form a limited liability company, the medical doctor must have a greater ownership interest in the practice (i.e., 51%) than the limited licensed members (i.e. 25% and 24%).”

BS: Can you describe the financial benefits to working with optometrists as a partner in a surgical ophthalmic practice?

TE: We are fortunate in ophthalmology to have access to a constantly improving stream of technology that directly benefits patients. This is especially true in the area of diagnostics. Much of our diagnostic armamentarium is noninvasive.

Therefore, ODs can also use most of these testing modalities (i.e., OCT, visual fields, widefield fundus photography, corneal topography, pachymetry, etc.) to care for patients. The revenue from these OD-provided services that can be generated in the clinic on a per-hour basis is approximately the same, whether it is generated by an MD or an OD.

Our managing partner OD generates seven figures annually for the practice working on average four full days. Our ODs naturally refer in-house to one of our ophthalmologists if a patient’s problem requires an MD, or to an outside ophthalmologist if the situation requires skills outside our expertise.

BS: Would you recommend a percentage of ownership and/or a waiting period before offering a potential OD shares in the practice?

TE: The percentage can of course vary greatly and may be restricted by state statute or board rules. My partner OD owns less than 50% of the shares in our corporation. Consulting an excellent contract attorney skilled in buy-sell agreements is prudent.

BS: There are two sides to every story; what are the negative aspects of optometric partnering?

TE: While the positive aspects have far outweighed the negative, these are a few considerations for any ophthalmologists thinking about taking the plunge.

The world views optometrists differently than it does ophthalmologists. Patients often insist on seeing only an ophthalmologist. If the patient prefers one provider over another, we accommodate them.

Optometrists do not have hospital privileges. This is probably appropriate because ODs are not surgeons, and the majority of the hospital call and consultations may require a surgical solution.

Insurance plans may differentiate between MDs/DOs and ODs. Our practice does not take vision plans, because they tend to be a poor financial path. Yes, with vision plans your reception area may look full, and your schedule booked, but profit margins are sketchy at best.

Our practice tends to be much more medical than optical, even though we have three offices all with highly skilled opticians and well-appointed optical inventory.

In some areas, optometrists tend to see patients who are young, including children. Children can bog down a busy surgical practice. This younger patient population may also have a higher no-show rate. This has not been a problem in our area because it has a demographic heavily weighted toward Medicare patients.

To those ophthalmologists who still object to partnering with an optometrist, I say okay, take your own path. But remember, not one of us does this alone. We need a team.

If you could have a team member who builds your practice, enhances your revenue and eases your stress, and that person just happens to be an optometrist, why would you reject him as a partner?

Team up with him before your competition does. OM

ABOUT THE AUTHORS

Trevor Elmquist, DO, MBA, established a general ophthalmology practice in Ft. Myers, Fla., in 1990 after eight years of active duty in the United States Air Force. Elmquist Eye Group is an integrated eye-care practice that includes two ophthalmologists, two optometrists, four opticians and a staff of 20. Contact Dr. Elmquist at trevor@elmquist.com.

Bridget A. Sundell, MD, founded Sundell Eye Associates, a comprehensive ophthalmology practice, in Virginia, Minn., in 2010. She also serves as president and medical director at Northwoods Surgery Center. Contact Dr. Sundell at bsundell@sundelleye.com.