EyeNet Magazine

Practice Perfect: Coding & Reimbursement
Boost Practice Efficiency: Part One—Stay Ahead of the Trends
By Chris McDonagh, Senior Editor

Where do you want your practice to be five, 10 or 15 years from now? Planning for the future starts with a vision, or mission, for your practice. This will dictate, in terms of strategy, how you should try to position your practice in the marketplace and the tactics you should pursue to implement that strategy. Your vision and strategic planning will, of course, be informed by your practice’s existing situation. But to plan proactively, you also will need to anticipate what’s likely to happen in the future. Some trends will be specific to your locality. For instance, is your town’s population shrinking or growing? Are your local hospitals buying or shedding practices?

More generally, there are some trends—discussed below—that are likely to impact practices throughout the United States. Successfully adapting to this rapidly changing health care landscape will require forward-looking decision making, rather than small, reactive changes in procedures. The way that you hire, train and utilize staff, particularly clinical staff, can play a key part in helping your practice succeed—and EyeNet will be discussing these staffing issues over the coming months.


Trends to Watch For

The Baby Boomers are coming. “As the Boomers age, they’ll need more eye care,” said Derek Preece, MBA, who is a senior consultant with BSM Consulting Group, and is based in Orem, Utah. “Seniors, in fact, use eight-and-a-half times more services than those under 65. So patient flow efficiencies need to increase just to keep up with the demand that’s on our doorsteps right now.”

These aging Boomers, and the costs of their care, will help keep health care positioned high on the political agenda, added Ann Hulett, CMPE, COE. “One in four voters is over age 60, so all of a sudden we have a growing population that is voting on the topic of health care.”

Physician supply may tighten. “There are signs that point to what could be a significant shortage of ophthalmic capacity,” said Ms. Hulett, who is the administrator at an eye care group in Pueblo, Colo., and past AAOE chairwoman (2006).

“A level number of residency positions coupled with retiring Boomers, including ophthalmologists, could yield a shortage of Eye M.D.s,” she said.

And if tomorrow’s ophthalmic practices are unable to meet the demand for eye care, other providers—such as independent optometric practices—may attempt to fill that void.

Increasing the number of residency positions would be one approach, but this has several potential drawbacks. There would, for instance, be a long delay before such a measure boosts the number of practicing ophthalmologists, and how would the gap between supply and demand be filled during the interim? Would an increase in the number of ophthalmologists be accompanied by a commensurate increase in payments to ophthalmologists, or would each practice’s income be squeezed yet further? And in the post-Boomer era, would the profession find itself with an oversupply of physicians?

Another solution would be for ophthalmologists to see more patients, and Academy surveys have shown that most U.S. ophthalmologists are keen to do just that. In the most recent survey, conducted last year, 56 percent of respondents wanted to increase their personal patient load, and they wanted to increase it by, on average, 18 percent.

Reimbursements may continue to decline. “In 2006, health care expenditure comprised 16 percent of the U.S. GDP, which converts to about $7,000 per capita,”1 said Ms. Hulett. In D.C., attempts to put a lid on costs—through, for instance, Medicare Advantage Plans and the annual dance over the Sustainable Growth Rate’s Conversion Factor —continue to imperil the physician’s bottom line. And whenever Medicare payments to physicians decline, commercial contracts are sure to follow, said Ms. Hulett.

More patients will ask about premium IOLs. “Patient interest in these new lenses and other technologies is escalating,” said Ms. Hulett, and this has repercussions for the practice. More time is spent in communicating necessary information to the patient; physicians devote more time to patient selection and informed consent; biometry accuracy becomes even more critical; and patients may need refractive touch-up, which will entail further communication, consent and follow-up.

Patient mentality is shifting toward consumerism. Practices that perform LASIK have long been familiar with the “refractive perfection mentality.” Now practices offering premium IOLs are seeing a similar development among an older patient base. “These patients are making a significant out-of-pocket payment, and they want the best that they can get in exchange,” said Ms. Hulett. “Getting rid of the film and the blur caused by the cataract is no longer good enough. Now we seek great vision for near, intermediate and far, with no glare and no loss of function in dim light—anything less is unsatisfactory. Furthermore, the activity level of our older patients is growing. They want to be able to do and see everything they have always done and seen.”

Similarly, as companies increasingly shift health care costs onto their employees, practices can expect to see a change in their patients’ behavior. “When patients have to offer up checks or debit cards to pay for high deductibles, they are making a personal purchase and that can change their mentality,” said Ms. Hulett. “They will increasingly expect a ‘patient-centered’ experience. If we are honest about it, many practices have traditionally looked at our procedural systems through the lens of what works best for the practice, not necessarily what works best for the patient. Shifting that practice mentality can be a challenge.”

AMD treatments mean busier times ahead. If you are offering intravitreal injections in your office, you know that all of a sudden there are more visits to handle, said Ms. Hulett. “With the current protocols, recurrent treatments are required for efficacy and this leads to increased density in schedules. The treatments also require intense reimbursement oversight—you have to watch your dollars on the drug purchases and preauthorizations. As the Boomers age, there’ll be a growing number of patients with macular degeneration.”

The march toward electronic health records gathers pace. The Physician Quality Reporting Initiative for 2008 added measures for use of EHRs (124 HIT) and e-prescribing (125 HIT)—this is yet one more attempt to hurry along the digitalization of medical records. Indeed, for many in medicine, the move toward EHRs may feel like a forced march, said Ms. Hulett, but it is only headed in one direction. According to a 2007 survey of U.S. Academy members, 24 percent of respondents had an EHR system and a further 30 percent planned to purchase or shop for an EHR system in the coming year. “The conversion to paperless records requires a cultural change in the practice that affects every employee. It is a highly customized and ongoing development process that takes a lot of time for a long time to customize the system in a way that will work for your practice.”

There will be an increasing need for capital. “Imaging systems, computer upgrades, changes in building structure —the need for capital is ballooning,” said Ms. Hulett. “It is very difficult to hold down costs while achieving what you want for your practice.” With this in mind, you may need to review your buy-in formula. “With the capital that is needed in a practice these days, your formula may have fallen behind reality. Plus, in years past, when a new physician bought into a practice, the existing physicians would often divide that money among themselves. With today’s need for capital, that money needs to stay in the practice.”


Impact on Staffing Needs

Staff will need to be more skilled. “The trends in ophthalmology, as in many industries, are leading to the need for more highly skilled, technologically savvy staff members,” said Ms. Hulett. “Practices need to transition from ‘telephone staff’ to ‘advance registration staff.’ Staff members at the front desk are dealing with the collection of more payments at the time of service—this requires math and communication skills. Their job is further complicated by Medicare Advantage Plans, which are often designed with variable coverage policies. Moving forward, as practices adopt EHRs, every employee will need to be computer literate. No one gets a free pass on this.” Staff will be harder to find. There is already a shortage of trained technicians, and the need for more highly skilled staff throughout the practice will make those positions harder to fill. The role of in-house training and the importance of staff retention will both become increasingly important. Practices must enable physicians to be more efficient. The drive for efficiency will increase the demand for able, efficient and professional staff to work alongside a practice’s physicians, said Ms. Hulett. When should your practice add new staff? How do you find and train the right people? What’s the most effective way to utilize them? Over the coming months, EyeNet will discuss how practices are tackling these key staffing issues.

1 Catlin, A. et al. Health Affairs 2008;27:14–29.


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