Boosting patient volumes can help you control your economic destiny
amid Medicare fee reductions.
John B. Pinto
Now, here, you see, it takes all the running
can do, to keep in the same place.
If you want to get somewhere
you must run at least twice
as fast as
the Red Queen, Lewis Carrolls Through the
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 countrys 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 surgeons dollar-denominated retirement savings, shrink the
purchasing power of every fixed-rate dollar in reimbursement paid by Medicare
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.
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 Pintos 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:
Steps to help increase patient
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
- 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
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
todays busy ophthalmology practice. Drawing on these experiences, she now
helps client practices. She can be reached at 617-429-6155; email: