Getting Ahead: Five Steps to a High-Efficiency Practice
Make these moves now to keep pace with surging patient demand
BY FRANK CELIA, CONTRIBUTING EDITOR
If the demographics hold up, ophthalmology faces an especially challenging new decade. Experts say meeting it will likely mean boldly embracing new ways of doing things, while in some cases abandoning the status quo. But, as a previous generation of doctors ceased making house calls, today's physicians may come to view such changes as inevitable — and, ultimately, better for the common good.
The good news is job security won't be an issue, since these challenges stem from skyrocketing demand for ophthalmic care. On the one hand, the over-65 demographic, who consume eye care at 10 times the rate of young people, will grow 50 percent in the next 15 years, meaning more patients in your waiting room — and more of your colleagues retiring. On the other, residency enrollment indicates an annual net gain in new ophthalmologists of less than one percent, while demand for ophthalmic care will rise by three to five percent annually until 2015.
A consulting group recently concluded that "ophthalmologists will need to increase their productivity an average of 17.3 percent to meet the needs of their patients." The same study predicted that between 2008 and 2015 the profession will net a mere 101 new members, and, "it is unlikely that ophthalmic residency programs can react in time to avert this situation."
Other factors collude. People in their 30s and early 40s — often known as Generation X — appear reluctant to work the same grueling hours their forbearers did and continue to do, nor are they as keen to buy equity shares in existing practices. Also, more than half of new ophthalmologists are female, many of whom, having devoted their twenties to medical school, now seek part-time employment with a view toward starting families. Which is to say nothing of 50 million uninsured citizens who could receive healthcare coverage under proposed federal legislation.
It all adds up to an incipient manpower crisis, one experts call serious though not insurmountable. In fact, ophthalmologists who make preparations now stand to flourish. Below are five strategies being discussed to ease the burden.
1 The Team Approach
If we think of vision care workers as a spectrum, with ophthalmic technicians at one end and subspecialist MDs at the opposite, the team approach advocates pushing as much workload as possible toward the ophthalmic tech side (short of compromising patient care), thus freeing physicians to spend more time in surgery and critical decision making.
Surgeons, however, typically spend half their clinic day doing work better accomplished by support staff, according to John Pinto, president of J. Pinto and Associates, a practice management consulting firm with 30 years of eyecare experience. Ophthalmologists should especially concentrate on increasing reliance on optometrists, he says. “Optometrists are able to do medical optometry to support physicians,” he says. “And the physicians are able to spend a larger percentage of their time on high-yield, surgical and secondary/tertiary care.”
Some predict that surgeons' splitting their week evenly between the clinic and the OR will become increasingly rare, as the need for ever-greater efficiency encourage specialization in either one or the other. Those with a talent for patient encounters will spend the lions share of their workday in the office, while others who can handle large case loads put in longer OR hours.
Teamwork opportunities abound in the realm of glaucoma subspecialty, where so much patient-physician interaction involves routine questions and answers. Indeed, 90 percent of each exam consists of routine assessments, with only 10 percent devoted to critical judgment and long-term planning, says Steven L. Mansberger, MD, director of glaucoma services at Devers Eye Institute. He finds having an ophthalmic technician in the exam room to transcribe notes and deliver workaday advice on subjects like eyedrop instillation saves significant time, perhaps as much as three minutes per encounter. “I'm not distracted, typing stuff into the computer, writing notes in a chart,” he says. “The nice thing is it lets me spend more time with the patient, face to face. It makes the patient's experience better.”
However, the way physicians bill for their services limits how much work they can offload to support staff, Dr. Mansberger notes: “There are certain things we as physicians have to do.“
On the other hand, some question whether the teamwork approach will work in retina subspecialty care, particularly in the clinical arena, where a multifarious profession treats conditions apt to follow multifarious courses. It has been suggested that new, easy-to-operate digital fundus cameras be used by optometrists, general ophthalmologists and family practitioners to screen for retinal disease, especially among diabetic patients. But the efficacy of such efforts remains debatable. “One could argue both sides of the equation,” says David E Williams, MD, MBA, a retinal specialist from Minnesota, “but my personal opinion is that screening every retina at the family doctor's office probably won't be worth it.”
2 Greater Reliance on Technology
Vision care lavishes technological know-how on the clinical side of the enterprise, while neglecting what such tools could accomplish for practice management. Perhaps no greater opportunity for efficiency exists than those in record keeping. Physicians lag decades behind other professionals in this regard, wasting countless hours shuffling paper and inputting data. Only about 10 percent of practices have made the full conversion to electronic healthcare records (EHR), according to Mr. Pinto. Many hope the federal stimulus money being offered to encourage EHR adoption will have its intended impact.
However, it should also be noted that current EHR software packages sometimes fail to live up to marketing hype. Surgeons often complain that though the programs offer efficiencies in some areas, the large amount of information that must be typed by hand can grow onerous. “There are a lot of things you have to do as a physician within the EHR system that, because of password protection and other restrictions, you can't let someone else help you with,” explains Dr. Mansberger.
Other practitioners see room for more automation. In the same way refractive data is automatically entered into a patient's record by current software, so should pathologies. An easy-to-spot diabetic retinopathy on a digital fundus photo should not have to be typed in by hand, they argue. The computer should red flag the pathology and instantly cue up the data that needs to be input, while the physician stands by to confirm the diagnosis with the push of a button.
Advances in clinical technology could enhance productivity as well. Certainly anyone still relying on film stereo fundus photography should strongly consider switching to a digital camera system. And glaucoma subspecialists and general ophthalmologists alike eagerly look forward to any computer database breakthrough that might help to identify patients most at risk for glaucoma progression. Such an advance would save enormous resources, since practitioners spend so much time and energy managing patients whose disease never advances.
3 Stick to Core Competencies
Cosmeceuticals never really took off. Blepharopigmentation stalled at the gate. Facial skin resurfacing seldom turns a profit. “There are lots of things that ophthalmologists have trialed over the years that have sounded intuitively like they'd be real winners,” observes Mr. Pinto, “but empirically have been flops.”
“The low-hanging fruit — ambulatory surgical centers and optical dispensing — have already been plucked by most thoughtful practices of any scale in any jurisdiction where they are allowed,” he adds. Further refinement of how these contribute to the practice's finances will be a more productive use of one's time, energy and capital.
Opinions on the fate of refractive surgery vary wildly, as some speculate about a post-recession bounce while others believe the best days of refractive surgery may be past. Either way, the cost of cutting-edge equipment such as a femtosecond laser for LASIK flap creation likely prohibits general ophthalmologists from “dabbling” in refractive surgery. The larger refractive specialty centers will dominate, and smaller independent practices will be better served by playing an ancillary role in refractive surgery.
4 The Patient-Shared Cost Model
Which is not to say potential new revenue streams should be ignored. In fact, they could prove essential. Right now health care consumes 16 percent of the GDP, far above any other industrialized nation, with costs rising at nearly three times the rate of the rest of the economy. Even if all current federal efforts to reform Medicare fail completely, such growth cannot sustained; a market constriction appears imminent.
That means along with more patients, you'll receive fewer dollars for each. To offset the shortfall, many are calling for a payment model akin to dentistry's, where insurance covers basic care, and patients who want extras pay out of pocket — the so called “patient-shared responsibility” model.
It has been successful with premium IOLs: patients have proven willing to pay for lenses that correct presbyopia and astigmatism. But surgeons were only able to offer premium IOLs after a decision by the Centers for Medicare and Medicaid Services allowed it to happen. “A lot of people don't realize it but our [medical] system is extremely controlled by the government and insurance companies,” says Dan Durrie, MD, of Kansas City, “to the point where we cannot give a different level of care to anybody, based on their ability to pay. I personally think that is a weakness in our overall healthcare system.”
If such restrictions could be relaxed in other areas, surgeons might improve both their bottom lines and patient satisfaction. Possibilities here include new glaucoma valve devices that could obviate years of drug therapy or the new ORange intraoperative aberrometer that precisely determines refractions during cataract surgery for improved outcomes. Ophthalmologists should expect (and embrace) innovations that can unshackle their reimbursement from Medicare and third-party insurers.
5 Greater Patient Volume
The aim of all of the above is to get more patients through your door, treated successfully, and in due course returned to their normal lives. To accomplish this may require a level of “industrialization” in patient care distasteful to some practitioners. But in reality eye care has been moving in this direction for years. Cataract surgeries that once took 45 minutes now take 10. Physicians who once saw 20 to 30 patients a day in clinic now see 45 or more. In inflation-adjusted dollars, the capital investments necessary to start a practice have tripled over the past 40 years. And yet despite all this, for 20 years the amount paid to ophthalmologists per unit of service has steadily declined.
Are you prepared to treat 20 percent more patients per day? Opinions differ. Uday Devgan MD, in private practice at Devgan Eye in Los Angeles and chief of ophthalmology at Olive View UCLA Medical Center, says 25 cataract cases a day represents his limit. “That's eight hours at three cases per hour. That's personalized treatment, meeting with every patient before surgery and double checking everything myself. More than that and you end up cutting corners or delegating too much,” he says, adding that he could never envision confining all his time to just surgery, noting that clinic time is important to examine and educate each patient before surgery.
Dr. Mansberger states he is working at full capacity now, while Dr. Williams says despite currently examining 40 to 80 patients a day in clinic, he could handle more if necessary. “Yes, I could see 20 to 30 percent more patients. It's a matter of being completely focused, making sure there are no distractions, and controlling phone calls and staff questions,” he explains. “Though it may include skipping lunch, of course.”
Couple the surge in age-related eye disease with continued fee cuts and it's easy to see that boosting patient turnover without sacrificing quality of care will be the defining challenge of the next decade. Otherwise, the boom in “Baby Boom” brings to mind an all too apt image: a ticking time-bomb. The demographic trends are inexorable; their impact on your practice, however, is well within your control.
Incremental victories will carry the day, according to Mr. Pinto. In the average practice, he contends, accommodating just three additional patients a day can mean an annual $100,000 net profit gain. “Here's the big picture: ophthalmologists are able to change and mitigate any adverse circumstances to a much greater degree than they think,” he says. He's seen physicians outdo their expectations time and again in his career, and is upbeat about the oncoming demographic onslaught. “Ophthalmology is going to be — for the next hundred years — a splendid profession, both on the provider side and business side. We just have to keep sharpening our game every year.” OM
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