Biography: Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. John is the country’s most-published author on ophthalmology management topics. 
December 09, 2016
5 min read

Trump and health care: Seven things to do now

Biography: Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. John is the country’s most-published author on ophthalmology management topics. 
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Whether you voted red, blue or purple on Nov. 8, by the time Jan. 20 rolls around, we are in for interesting times and potentially material changes in America’s health care system.

As this month’s column goes to press, President-elect Donald Trump has named Georgia Congressman (and physician) Tom Price to head the HHS. Price has been a vocal critic of the Patient Protection and Affordable Care Act, also known as Obamacare.

As reported by the New York Times, “If President-elect Donald J. Trump wanted a cabinet secretary who could help him dismantle and replace President Obama’s health care law, he could not have found anyone more prepared than Representative Price, who has been studying how to accomplish that goal for more than six years.”

Transformation can also be expected at the CMS. As of this writing, Seema Verma, a health care consultant with a master’s in public health from Johns Hopkins University, has been tapped to head CMS. Her firm worked closely with Vice President-elect Mike Pence to design Indiana’s Medicaid policies, including small monthly direct-pay premiums for Medicaid beneficiaries and a lockout from insurance coverage if these payments are missed. Verma’s free-market instincts could perhaps signal greater support in a Trump administration for shifting Medicare from an insurance plan to a voucher used by beneficiaries to pay for private insurance.

Although these two critical health care agency picks are coherent and align with each other, our next president’s stated positions on health care reform have been everything but consistent, even in the recent past.

After a post-election meeting with President Barack Obama, Trump said he would be keeping key portions of the health care law, including those that bar insurance companies from refusing coverage to those with pre-existing conditions and allow young people to stay on their parents’ insurance policies until they are 26 years old.

Going back a few months earlier, according to pre-election policy pronouncements, “Mr. Trump will be proposing a health plan that will return authority to the states and operate under free market principles. Mr. Trump’s plan will provide choice to the buyer, provide individual tax relief for health insurance and keep plans portable and affordable. The plan will break the health insurance company monopolies and allow individuals to buy across state lines.”

But before this, Trump was an advocate of universal health coverage and said he backed a single-payer system paid for by the government, citing the health care systems of Canada and Britain as models for the U.S.

And despite Trump claiming earlier in 2016 that he does not support cuts to Medicare, Speaker of the House Paul Ryan has suggested that massive revamping to Medicare must also happen, so there are going to be a lot of cooks in the kitchen.

All the same, we do not know if Trump is:

  • A Socialist who will advocate to replace the ACA with Medicare-for-all?
  • A price-control/volume-control wonk who will wean patients from needed care, or ration dollars from doctors, or both?
  • Or a free-market Republican, who will — as signaled by selecting Price and Verma — unwind Obamacare, eliminate mandates and push for nationally brokered, tax-deductible insurance?

And it seems unlikely that the practical consequences for ophthalmologists flowing out of a new administration’s policies will be seen in the coming year — things just do not happen that quickly.

So here are some practical things to do now in the present breath-holding moment (besides dig a Medicare bomb shelter in your backyard).

1. Stay tuned for developments. Most of us have been news addicts for the past year’s election cycle. As much as we would all like to tune out, now is the time to stay plugged in to what is trending. In addition to the usual news outlets, pay a bit more attention to “Washington Watch” or similar emailed news feeds from the American Society of Cataract and Refractive Surgery, American Academy of Ophthalmology and your subspecialty societies. (And keep taking your blood pressure medicine.)

2. Replace worry with meaningful work. Even if you voted for Trump, there is much afoot to be alarmed by: an expansionary business cycle that is getting a bit long in the tooth and poised for a downdraft, material headwinds in the international business climate, and a host of smoldering military hotspots that could erupt, providing a political pretext for shrinking health care dollars. You cannot personally do anything to avoid these monsters in the closet, so try to ignore them and instead:

  • Double-down on the enjoyable parts of your practice, so that even if fees are hit in the next 4 years, you will be better paid than ever in career satisfaction terms.
  • Bond more closely with your staff and become the kind of physician leader who warrants staff loyalty, long tenure and even wage concessions if the news from Trump Tower goes against you.
  • Re-engage with the business details of your practice, so that any profit or operational wobbles are caught early and reversed.

3. Search out missing revenue-enhancing, cost-containing and profit-boosting opportunities. Harness the uncertainty you may be feeling today to go after low-hanging performance fruit, such as:

  • Elevating your refraction fee to $49 or higher, and the frequency with which you charge this fee to 20% or higher in the typical general practice.
  • Learning (or relearning) one or more aspects of subspecialty care that interest you, such as plastics, medical retina or glaucoma, in order to retain fees within the four walls of your practice.
  • Sending staff home when patient volumes taper, whether that is seasonally, during the course of the week or on quieter days.
  • Auditing recall and continuity of care paperwork to assure than each provider’s return-to-clinic order results in an actual visit, rather than a patient who drifts away.

4. Watch the numbers. Now is the time to develop a memorized command of your practice’s key performance indicators and benchmarks as compared with norms:

  • Profit and cost margins
  • Labor productivity
  • Segment cost ratios
  • Surgical density
  • Testing utilization
  • Growth rates
  • And many more

5. Mind your personal outlays. I have long advised clients to live on well under 100% of their after-tax incomes. The happiest surgeons live on less than 70% of what they make and invest the rest sensibly. Remember that even a modest 10% cut in Medicare professional fees can result in a 20+% income cut for the physicians in your practice. You will rest better knowing that any conceivable hit to your income over the next 4 years will not materially impact your lifestyle.

6. Stay flexible about retirement plans. If you are in your 50s or 60s (or later), you likely have some fairly developed opinions about when you would like to slow down and retire. Try to lean toward flexibility in these plans — anything could happen:

  • Regulatory reform, including another stab at Medicare payment reform, might remove some of the more onerous aspects of CMS and reduce professional frustrations, adding years to your career.
  • Alternately, “Trumpcare” may make you nostalgic for Obamacare and accelerate your retirement from medicine.

7. Remember your senior patients, who are probably scratching their heads even more than you are. Some patients will want to accelerate care, under the assumption (probably wrong, let’s hope) that their Medicare benefits are about to degrade. And some patients are going to put off needed care, thinking that Trump is going to improve their benefits and lower their future out-of-pocket costs. Time will tell. Reassure them, and do not pick political fights, no matter which side of the aisle you are on.


For more information:

John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. John is the country’s most-published author on ophthalmology management topics. He is the author of John Pinto’s Little Green Book of Ophthalmology, Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, The Efficient Ophthalmologist, The Women of Ophthalmology, Legal Issues in Ophthalmology, Ophthalmic Leadership: A Practical Guide for Physicians, Administrators and Teams and a new book, Simple: The Inner Game of Ophthalmic Practice Success. He can be reached at 619-223-2233; email:; website: