Ophthalmology

John B. Pinto

“Now, here, you see, it takes all the running
you can do, to keep in the same place.
If you want to get somewhere else,
you must run at least twice
as fast as that!”
– the Red Queen, Lewis Carroll’s Through the Looking-Glass

Several years ago in this column, writing about future trends, I said that it was unlikely that we would experience the then-first-threatened Medicare fee reductions unless — and until — a national fiscal crisis provided sufficient political cover to do so.

As this column goes to press, we are now there. Crunch time.

Serious proposals are being floated to privatize Medicare, and equally serious voices in Washington believe it would be a useful experiment to not expand the U.S. debt ceiling, which would in turn sink U.S. bonds, interrupt the country’s borrowing power and provide plenty of political cover for emergency entitlements reform.

In addition, Federal Reserve Chairman Ben S. Bernanke is now narrowly constrained between only a few equally unpleasant options that could crater the average surgeon’s dollar-denominated retirement savings, shrink the purchasing power of every fixed-rate dollar in reimbursement paid by Medicare or both.

Surgeons who want to control their economic destiny have limited options. As unpleasant as it may be for you to contemplate running faster like Alice in Wonderland to keep up the pace on your personal hamster wheel, this is still the most feasible and immediate mitigation strategy available to most surgeons today. For most of you reading this, boosting raw patient volumes will be the surest refuge you can take in the years ahead.

Below are a few action steps to start boosting patient volumes, for example, from 40 visits to 50 visits per full clinic day. A permanent spike in volume, which represents a move from typical to excellent levels of productivity, is within the grasp of any highly motivated and energetic general ophthalmologist who works in a typical community with reasonable access to additional patients. Selected subspecialists can readily make a comparable shift from 35 to 45 visits per day. It should be noted that this game plan may not be feasible if you work in a market with excess providers or limited third-party panel access.

Eight steps

1.Put on your war paint. You are not going to sustainably achieve a 25% boost in personal productivity unless you get serious about your intent, motivations and willingness to sacrifice. Be clear about what you are “playing” for. If you have a typical practice and Medicare cuts your fees by just 15% (half the amount soon to be legally obliged) while practice costs inexorably rise each year, you will have to see about 25% more patients and watch costs closely to preserve your personal paycheck.

2.Get fit. Especially in the early going, attempting to see more patients and exhort your staff to higher levels of efficiency will be physically and emotionally draining. Get more sleep than usual. Eat right. Start or expand a personal fitness routine to boost your stamina. Ophthalmology is an aerobic sport.

3. Get buy-in from your staff and family. Make sure that all practice staff individually win something tangible if the team wins — a bonus, more payroll hours, continuing education travel or the like. Discuss new volumetric goals with your spouse. Express your desire to get ahead in what may be familiar terms: the same desire that allowed both of you to readily sacrifice during your earlier years together, when you were in training or starting a practice. You will not only have to work smarter but also longer, tougher hours to stay ahead in the coming era.

4. Understand your current numbers. “Patient visits” includes all paid and unpaid clinical encounters with a provider. By way of convention, omit tech-only visits for special testing and all surgical encounters. Ideally, before you start you will graph the last 2 years’ worth of visits (overall and by provider) and then keep up a monthly graphical count to visibly measure progress. Such graphs should be posted in the staff break room, and each hallmark reached should be cause for group celebration.

5. You cannot serve more patients unless there are more patients available. So, an early step in building patient volumes is to gain access to more customers. The most fortunate practices in this regard have a backlog of patients — either a long lag time until the next available appointment or a cohort of patients who have been lost to follow-up. After internal efforts have been fully developed, referral outreach and direct-to-consumer marketing tactics will need to be pursued.

6. Make sure your facility resources are in line with volumetric goals. My simple benchmark here is one fully equipped exam room hour for every visit. Expressed another way, because the typical clinic is open (or at least could be) 8 hours a day, 2,080 hours a year (173 hours per average month), in a fully utilized facility, you should be able to see 173 patients per month per room. For a solo provider transiting 500 visits per month (and not working evenings and weekends to spread out the visits), three complete exam rooms are usually needed. If the same provider wants to ramp up visits per month or compress clinic operations into fewer hours each week, additional lanes may be required.

7. Make sure that staff resources are upwardly elastic and in line with growing volumes. For a general ophthalmology practice, for each patient visit you will need about 0.9 tech payroll hours, 0.5 receptionist payroll hours and 0.3 billing staff payroll hours.

8. You can almost always see more patients than the number you are seeing today, up to a ceiling bounded only by your personal abilities and professional tastes. Remember that whatever volume you are at now, someone is likely seeing more patients per month than you are. I have hard-charging clients who personally hit 800 to 1,100 visits per month. These settings are not for the faint-hearted. They require a level of sustained work flow intensity, provider intellect and disciplined avoidance of social banter that most doctors would find impossible or unacceptable. But I expect that such hypervolumetric surgeons can be expected to emerge more commonly as financial pressures mount. As you reach your personal best and still have more patients to potentially serve, it may be time to add another provider.

• John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. He is the author of John Pinto’s Little Green Book of Ophthalmology; Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement; Cash Flow: The Practical Art of Earning More From Your Ophthalmology Practice; The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees; The Women of Ophthalmology; and his new book, Legal Issues in Ophthalmology: A Review for Surgeons and Administrators. He can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.

Steps to help increase patient volume

by Jane T. Shuman, COT, COE, OCS

Increasing patient volume by 25% is a lofty goal and will not be achieved either overnight or simply by adding slots to the schedule. Rather, this is a process that is best achieved with planned, incremental steps.

When you explain your goal of more patients to your staff, expect naysayers and staff who are resistant to change. You should welcome their input but hold your ground. Acknowledge that you will be examining your own role as well as theirs.

Develop a plan that should include an analysis of current patient flow.

• Perform a time study including all processes involved in patient throughput from check-in to check-out. Keep in mind that any process that takes longer than national benchmarks may indicate a system that is outdated or that the person performing the task needs additional training.
• Evaluate the precise steps performed during an exam to help eliminate redundancies. Remove unnecessary steps, combine patient forms as feasible, and make sure that information gathered by a technician is not being repeated by the provider.
• Are your technicians performing in an efficient manner and providing you with consistent and reliable information?
• Are tests being performed on an as-needed basis or are they scheduled? Does your staffing ratio include people to do these tests as needed?
• Walk through the office as though you were the patient. Take notice of the distance you walk and if you are retracing your steps.
• Evaluate provider time efficiency too. Are you doing your own documentation? Consider using a scribe. Are you ready when the patients are? How much time is spent educating patients about their condition? Are you doing all of the education, or can some of this be turned over to a knowledgeable staff person?

Once you take incremental steps to change your current processes, analyze the schedule. See if the bottlenecks are due to multiple new patients booked simultaneously or add-ons that are booked in the middle of a session. Add patients at those times when the waiting room is empty, before more deeply overhauling your current scheduling templates.

Change of this magnitude is not easy and takes time. Develop a stepwise plan with incremental goals. Consider this a project that needs buy-in from everyone; ultimately, there should be an increase in the bottom line and a decrease in staff and provider stress levels.

• Jane T. Shuman, COT, COE, OCS, is president and founder of Eyetechs Inc., a nationally recognized authority on clinical flow, scheduling and technician education. During her earlier work as an ophthalmic technician and clinical manager, Ms. Shuman saw firsthand the important issues confronting today’s busy ophthalmology practice. Drawing on these experiences, she now helps client practices. She can be reached at 617-429-6155; email: jshuman@eyetechs.com; website: www.eyetechs.com.