The rise of the elective practice

Take heart: It’s not all about volume.

Fifteen years ago, I left ophthalmology. I had been a partner in a large multispecialty practice for 16 years, worked extended five-day weeks and performed nearly 750 cataract and more than 1,800 LASIK surgeries annually. I was exhausted and had hit a mid-career wall. So I exercised my buyout, moved to southwest Florida, helped my wife establish a career she had dreamed of but never realized due to my demanding schedule — and relaxed. One year of flip-flops and late mornings recharged my battery and rekindled my desire to create the practice I’d long dreamed of: nimble, sophisticated, elective surgery-focused and all mine.

Today, that dream is a reality. I perform 850 lens implant surgeries annually, and 80% of those patients choose an upgraded presbyopic or toric IOL. I have a small LASIK service line and an in-house excimer laser for these cases as well as for lens implant touch-ups. I work four-day weeks and generate essentially the clinic revenue as I did in my previous practice. I see 30 to 35 patients per clinic day, do surgery one to 1 1/2 days per week and am out of the office six to eight weeks per year. Because $1.5- to $2-million practice revenue is more common per MD for a surgical practice, I’m often asked, “How do you do it?”

Dr. Pascucci in his dream practice.

In this age of practice consolidation and expectations about how to attract patients and referrals, organize office operations and employ staff, I broke some rules. Here are the core tenets of what we did and how we charted a different course from the standard lore associated with practice building.


We opened in 2005 in Bonita Springs, Fla., midway between Ft. Myers and Naples on the state’s west coast. Bonita was bookended on the north and south by huge practices, sewn-up OD referrals and very little residential development in the area. But I looked at census projections and realized that the housing boom of prosperous retirees and service workers supporting tourism (prime premium lens implant and LASIK candidates) was going to be centered in Bonita. There was no more room in Naples and Ft. Myers; growth was headed south. If I built the “vision spa” I envisioned, patients would locate around our office.

Since 2005, the population in our 10-mile radius grew by 100%. And, despite the devastating 2008 recession that hit this area so hard, it has been projected that the population of adults aged 60 and over will grow by greater than 100% again by 2025.

We set ourselves up for success by locating where patients would be, not where they were. Many physicians locate their practices near where they live, where they did residency or close by a practice they have left, assuming patients will follow. Usually, however, those areas are already saturated with ophthalmologists. Improve your ability to attract the right patient by going where patients will be in the next 10 years, not where they are today.


In 2005, we opened with 800 square feet and one exam lane in the same room as our excimer laser. In 2007, we moved to 2,500 square feet and three exam lanes and stayed there until we exceeded $3 million in revenue. It is a myth that one MD needs six-plus exam lanes to be productive. Rather, we added the following:

  • A reception lounge that feels modern and non-medical.
  • Testing equipment and excimer laser technology that is well-lit and prominently featured, so patients see it the moment they enter the clinic.
  • Dedicated space for private counseling lounges where conversations happen face-to-face around a table, not over a cluttered desk with chart stacks and phones ringing in the background.

These patient-friendly spaces enhance the perception of your practice as technologically advanced, surgically expert and different from other medical offices. This is much more valuable than an excess of exam lanes.


Today, I have five people on our Experience Team (two front desk, two counselors and one part-time biller) and six people on our Clinical Team (one OD and five technicians). They work a three- or four-day schedule, as do I. I use a performance compensation system that is made up of hourly pay, plus monthly bonus based on practice performance. They are all paid on this bonus system, are highly motivated by it, and make 25% to 30% more than similar positions in our area. They are a team of stars, with virtually no turn-over.

We prefer to hire older, more experienced team members who have an excellent work ethic, maturity and intellect. I am less concerned about their actual previous work experience. While most have worked at other practices, I prefer to start with a blank slate rather than someone who brings previous work ideas, other doctors experiences, etc. Staff embrace that we handle inquiries, scheduling and patient education differently.

Not your father’s eye-care practice: The reception and counseling lounges as well as the testing area are modern, attractive and distinctly non-medical in feel.

My team’s appearance differs from that of a standard medical office. The Experience Team wears some combination of black office attire, leaving room for a bit of personal expression through color or jewelry. The Clinical Team wear white coats over office attire. Scrubs are not allowed. This crisp, professional appearance spills over into fanatical attention to detail in patient-handling.

The power of putting the entire clinical team in white coats cannot be overstated. When my technicians probe a chief complaint, explore vision problems or discuss lens options with cataract sufferers before I even enter the room, they are trusted as knowledgeable advisors by our patients.


If office scrubs are one of my no-gos, charts are the other: We have been chartless since we opened. Our tiny first office simply did not offer space for chart storage, and I detest the clutter and inefficiency that paper charts present. My decision had nothing to do with electronic billing or government requirements.

Rather, modern practice management and EHR systems let us streamline and improve the handling of every patient, from initial consultation through final postop. I can review charts when I have down time at the surgery center or am at home. Charts are never missing — my techs have a picture of each patient before they call them back, and I know exactly who is in the office, where they are and how long they’ve been waiting. Our system creates a heightened respect for patients’ time, which translates into patient happiness.


I’ve built this practice based on outcomes: How patients do in my hands, with the technology and the skills I bring to surgery. My techs’, counselors’ and my conversations with patients are all about vision results, not technology, and we find people respond very positively to that.

We are rigorous adherents to nomogram adjustment based on actual outcomes, using Datagraph-med Outcomes Analysis software (Ingenieurbüro Pieger GmbH) and a wavelight excimer laser (Alcon). We use Holladay and HICSOAP analysis (Holladay Consulting) in our lens implant surgery planning, and eight out of 10 of my cataract patients choose presbyopic or toric implants. We offer all FDA-approved IOL options but primarily use only those technologies that perform best for excellent outcomes.

We use outcomes in LASIK consultation and lens evaluation discussions with patients, so they see exactly what they can expect in my hands, whether its visual acuity or time spent free of glasses.


I’ve worked with my coauthor, Kay Coulson of Elective Medical Marketing, since we opened. Her approach: Fees are determined by the market, not by a physician inferring what (s)he is worth. So, our LASIK fees were initially set based on market standards, then we adjusted often over the years based on conversion.

We understand in minute detail our inquiry levels, lead quality and consultation conversion. The best fee for LASIK today is $1,000 to $1,250 per eye. When we set our fee accordingly, we attract more 25- to 35-year-old low-myope, straightforward LASIK cases than we can handle.

I raise our fee when we want to do less, but that also attracts more presbyopes and unsuitable candidates. It is simple to do more LASIK on the right people, if we respect the value the market accepts. Technology has not increased what the LASIK prospect is willing to spend.

For lens implants, we started with presbyopic lenses at $2,500 per eye and toric lenses at $1,250. Today, we are at $3,950 and $2,500, respectively, and do not offer laser cataract surgery. Ocular Response Analyzer (ORA, Reichert) and a LASIK touch-up are included, if warranted. We adjust fees upward based on conversion. Surgical outcomes precede fee adjustments; if your outcomes are extraordinary, then we adjust fees overtime as the market supports that.

Once you embrace conversion, fee-setting becomes a science, and you can separate your value from others in your market because outcomes validate fees.


As an elective surgical practice, we expected to spend 15% of revenue on marketing when we started. Today, we’ve been able to ratchet that down to 2.8%, which is similar to what comprehensive, non-elective practices spend. How? Patient referrals. Our adherence to continuously improving outcomes rather than selling technology and implanting only lenses that give the intended result has created a passionate patient following.

We have no OD referrals. Our marketing is primarily online. Patients find us through other patients. This patient-referral engine is our single biggest difference from other ophthalmology practices. We do not solicit reviews or pester patients with surveys. We do great surgery and provide a stellar experience — and they send their friends and family.

Importantly, when patients finish their surgical process, we release them. We do not provide routine care; less than 10% of our revenue is from non-surgical care.

We broke this final cardinal rule: You do not have to keep patients in the practice through routine care to generate surgery. They will send their friends and family, regardless of who sees them for routine care, if they have had surgery they consider outstanding.

Dr. Pascucci and the staff of Eye Consultants of Bonita Springs.


It’s been an incredibly fulfilling 13 years in private practice, and often I’m amazed at the success we have had. My message is that it is still possible to be a successful solo MD, create a practice performing the surgical work you love and have a balanced life. Bigger is not necessarily better. OM

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