One day this week, when you have a moment of downtime, stop and look around your office. In all likelihood, you’re seeing a landscape unlike anything you could have imagined at the start of 2020.

Chances are your waiting room now has far fewer seats to accommodate patients, who are no longer accompanied by family members. At the front desk, you’ll likely see a plexiglass divider separating your staff from patients. And your staff — and yourself — are wearing masks at all times.

COVID-19 has forced ophthalmologists to make significant changes to their practices. In some cases, massive furloughs have occurred; in others, staff have remained in place. New expenses have arisen for “wipeable” furniture, cleaning supplies and disinfection work. And ophthalmologists have used telehealth to see patients virtually when they were prohibited from seeing patients in person.

In this article, we’ll take a closer look at those changes and how practices are getting back to business. But first, let’s see how some practices in various areas of the country have fared.

REPORTS FROM THE TRENCHES

From Washington to Florida

Let’s start in Washington, one of the first states to experience COVID. By March 23, Northwest Eye Surgeons, based in Seattle, had closed its four surgery centers except for emergent patients and was seeing only emergent patients in its nine clinics. That continued until May 18, when Washington allowed the resumption of elective surgeries, according to Lance Baldwin, vice president of operations. Northwest has 28 providers, including surgeons and optometrists. When the practice transitioned to emergent services in March, it furloughed 80% of staff. By July 1, all furloughed staff had returned.

During the last two weeks of May, the practice, which focuses primarily on cataract surgery, ramped up to 50% of the production it experienced in January and February. In June, it reached 80% of production and hit 100% in July.

In Bloomington, Minn., Carrie Jacobs, COE, CPSS, OCS, executive vice president of operations at Chu Vision Institute, was forced to lay off 75% of her staff on March 20 after an executive order from the governor to stop all elective procedures and nonessential services. Within the next few weeks, she had to furlough another 10% of the team. Y. Ralph Chu, MD, is the practice’s sole surgeon, supported by three optometrists.

The governor permitted elective services to restart on May 11, and the practice resumed surgery after Memorial Day, with COVID procedures in place. Roughly 70% of furloughed staff has returned and they continue to rebuild staff, notes Ms. Jacobs. What helped them survive during this time when there was “very little” revenue was a booming first quarter, which provided a financial cushion, as well as a Paycheck Protection Program (PPP) loan, Ms. Jacobs explains.

Dell Laser Consultants in Austin, Texas, which has a single location that focuses on refractive and cataract surgery, with two surgeons and three optometrists, was shut down except for emergent care and telehealth from mid-March to early May. During that period, the practice was handling less than 10% of its normal load, estimates Steven J. Dell, MD, medical director. The practice temporarily furloughed most staff but rehired nearly all staff when PPP funds became available. Within a week after restart, the practice was handling about 80% of normal volume and returned to almost 100% of the normal clinic load during the next two weeks. “We are very close to our normal revenue targets,” says Dr. Dell.

At Goldman Eye, Palm Beach Gardens, Fla., no staff were furloughed although it “got a little grim,” according to founder David A. Goldman, MD. The practice, which has three practitioners, endured a roughly two-month lockdown starting in March. With PPP and telehealth, the practice was able to ride out the storm. “Now we’re back to quite solid volumes,” says Dr. Goldman.

The tide begins to turn

Besides these individual accounts of weathering the pandemic, industry statistics indicate a comeback. According to a July survey from the AAO, 80% of respondents said they exceeded 50% of pre-COVID in-clinic levels compared with 4% reporting that volume in May. Also, 64% reported that they exceeded 50% of prepandemic operating room volume compared with 19% at that volume in May.

GETTING BACK TO BUSINESS

The COVID world

In returning to business, ophthalmologists have made significant adaptations with various effects on the bottom line. These range from adding cleaning supplies and protocols; procuring PPE; installing dividers and partitions; adding staff or staff duties; and implementing telehealth.

The first priority is minimizing “any possible chance of transmission,” says Dr. Goldman. “But then the second is relaying that to patients so that they feel safe coming to the office.”

Cleaning costs

Cleaning supplies and masks are the biggest costs to the practice for Mr. Baldwin. In fact, he estimates that PPE and cleaning supplies cost $1 to $2 per patient, compared to five to 10 cents per patient before the pandemic. With nine clinics that see more than 1,600 patients per week, the practice is bearing a cost of at least $150,000 per year for the clinics, he estimates — this doesn’t include the cost of the staff hours needed to perform the cleaning.

However, some relief may be in sight. “A new CPT code, 99072, has been created to cover the cost of PPE in the clinic, which we are pretty excited about,” Mr. Baldwin says.

Ms. Jacobs has a similar story. Sourcing PPE is “incredibly difficult” she says. “From a business perspective, learning to source and manage the PPE has been a huge learning curve because supplies are so hard to manage and to get hold of.” Every day, a staff member is dedicated to sourcing gloves, masks, bonnets and all the supplies needed to perform surgery.

Barriers and chairs

The acquisition and installation of physical barriers and revamping the physical environment also has imposed financial burdens on practices. For Dr. Goldman, obtaining plexiglass dividers for the front-desk staff was his most expensive outlay, with demand for these partitions going up and increasing the price. Fortunately, he notes this is a one-time purchase and he plans to keep the barriers in his office in place for some time.

Even where the patients sit in the waiting rooms and exam lanes can cause unexpected expense. “We threw away or donated literally hundreds of chairs” that had fabrics that couldn’t be cleaned, says Mr. Baldwin. The practice replaced them with chairs that have a cleanable synthetic surface.

Staff changes

While cleaning and equipment are one type of cost, staff costs are also a big consideration in the COVID era. For Ms. Jacobs, her practice still needs to provide an experience that exceeds patient expectations, which requires significant staff. With such activities as outdoor greeting, you need more people to see fewer patients, she says. Jacobs has hired a half-dozen employees, not all full-time, for clinic cleaning and outdoor greeting.

At Northwest Eye Surgeons, almost every one of its nine clinics had to add a half-time to full-time employee to the front desk. Besides assisting with screening patients, those front desk staff help with cleaning the reception area.

VIRTUAL VISITS

Less risk, more efficiency

Although the jury is still out on whether telehealth will remain a viable care option, virtual visits have undeniably provided a way for ophthalmologists to stay in touch with patients during COVID. In May, some 54% of physicians said they were performing telehealth exams, according to a survey from the AAO. That percent declined to 38% in July as physicians started seeing more patients in clinic, says the AAO.

During the two-month lockdown in Florida, Dr. Goldman saw emergent patients in person and also conducted virtual visits. As an anterior segment cornea specialist, he feels he can use telehealth more effectively, perhaps, than a retina specialist.

“The patients really appreciate being able to have that human connection, to see the doctor,” Dr. Goldman says. “They can pull down on their lid, show me their eye. We can now diagnose virtually so even now that we’re back open, we can minimize exposures in the office.”

During the shutdown, as the staff at Chu Vision Institute reviewed their resources and considered how to minimize the time patients needed to spend in the office, they started to work on how they would conduct virtual consults. “We spent about 6 weeks training and really making it the focus of our return to business,” Ms. Jacobs says.

And when a patient is seen via telehealth rather than on site, the practice saves resources such as PPE and cleaning supplies, she adds.

For both cataract and refractive patients, her practice uses telehealth to obtain the patient’s complaint, history and medications and discuss the surgery. Patients also talk with a financial counselor. When they come into the office for their exam, “the length of visit has been dramatically reduced because we’ve done all the heavy lifting virtually,” Ms. Jacobs says.

Besides the patient, surgeons can also benefit, notes Ms. Jacobs, in that they can quickly move through a number of telehealth visits.

But it can’t replace a live visit

Not all doctors are convinced that telehealth provides an effective way to see patients. Although Northwest Eye Surgeons tried telehealth, as a surgical practice that doesn’t do much ophthalmic primary care, “It was very difficult to make telehealth effective with our business structure,” says Dr. Baldwin.

In Dr. Dell’s view, telehealth has limited value. “It’s very difficult to diagnose anything over telehealth that you could not diagnose with a careful history over the phone,” he says. “We have slit lamps and ophthalmoscopes for a reason, and that is because a lot of what we do is just not visible to the naked eye. There are obviously exceptions, but for most definitive diagnosis, it really does require an in-person visit.”

Yet, Dr. Goldman’s view is that “telehealth is here to stay.” Similarly, Ms. Jacobs sees telehealth lasting into the post-COVID era. “I really do see it continuing because the amount of chair time has been reduced so dramatically.”

TAKE ADVANTAGE OF THE SHUTDOWN

Room in the budget

One perhaps unexpected outcome of stay-at-home orders and other COVID restrictions involves freeing patients’ money and time. Dr. Dell notes that patients aren’t spending money on such items as vacations or going out to dinner. “It’s clear that there seems to be more room in the household budget for eye surgery than perhaps there has been in the past,” he says. “We’ve seen very strong demand for premium IOL surgery, which requires out-of-pocket patient participation, as well as for laser vision correction.”

Dr. Goldman has noticed the same phenomenon. “When we talk to them about things like cataract surgery, they’re actually pretty open to premium multifocal and toric lenses and even desiring LASIK.”

Premium takes prep

In general, many ophthalmologists appear not to have added premium services as a way to cope with the loss of revenue from COVID. If a practice wants to increase premium IOLs from say 5% to 20%, “that’s a huge cultural change,” says Ms. Jacobs. “Unless you have the infrastructure in place, it’s not that easy.” Increasing premium IOL conversions or adding a dry eye line of service may be great ideas, she notes, but “they just take a lot of implementation and staff education. You have to look at what you’re actually capable of doing while you’re trying to navigate all of these crazy changes.”

Flexibility is critical

Managing an ophthalmic practice during a pandemic like COVID entails not only putting in place measures like greeters, barriers and telehealth, but also attention to the needs of staff. A mindset of flexibility is key, Dr. Baldwin explains — “flexibility with our staff, flexibility with our doctors,” he says.

He points to the needs of parents as school returns. “We’re trying to be as flexible as we can with schedules to allow employees the time they need to not only take care of the kids but also help their kids get the education they need,” he says. That can involve flexing staff between part time, full time and per diem and possibly bringing in staff to backfill.

At Chu Vision Institute, Ms. Jacobs recommends being compassionate and allowing staff to be vulnerable. “Not having that emotional connection could have made this a lot more difficult than it is.”

RETURNING TO HEALTH

As you contemplate today’s COVID landscape with its many changes, keep in mind that practices are returning to a healthy bottom line. Patients and revenue are returning, and well-managed practices will flourish as COVID becomes, at some future point, a thing of the past. OM