Lindstrom's Perspective

Focus on office-based practice can significantly increase revenue

I recently wrote a commentary on selective laser trabeculoplasty for glaucoma in the June 10, 2019, issue of Ocular Surgery News. In this commentary, I would like to extend my thoughts to include some points on the economics of office practice.

I am speaking here primarily to the comprehensive ophthalmologist who does not own equity in an ASC. This is the majority of comprehensive ophthalmologists. This “typical” comprehensive ophthalmologist sees patients in the office 4 days a week and does surgery in a hospital outpatient department (HOPD) or non-owned ASC 1 day a week. In a year, the ophthalmologist sees about 5,000 patients in the office, does 500 surgical procedures in the non-owned HOPD or ASC, and generates about $1.2 million in total revenue for the practice. With a 70% overhead, the typical ophthalmologist can take home about $360,000 per year. Of course, 50% do better and 50% do worse. And those that do better usually have ownership in an ASC and leverage other sources of income, including employee doctors, optical and in-office procedures. Again, I am focusing here on the comprehensive ophthalmologist who does not own equity in the facility where he or she operates.

Of this $1.2 million in income, about $300,000 comes from surgery in the HOPD or non-owned ASC and $900,000 from seeing patients in the office. Rounding off and averaging for Medicare, Medicaid, commercial insurance and cash pay, the “typical” comprehensive ophthalmologist is getting approximately $600 per case in the OR. If that “typical” comprehensive ophthalmologist does one to two cases an hour, which is common, he or she is generating $600 to $1,200 an hour in revenue. Ten cases in a surgery day spent in the OR generates about $6,000. In the office, the ophthalmologist is earning about $180 per examination. At four patients an hour in the clinic, he or she earns $720 per hour and for a full day, $5,760. Pretty much the same revenue generated for the office day as the OR day.

Now, what will be easier to grow? I believe for most comprehensive ophthalmologists, it will be harder to generate more surgical cases or increase the revenue per case in the OR than it will be to increase patients seen and revenue per patient visit in the office. I believe the “typical” comprehensive ophthalmologist should focus more on their office-based practice to make up for the decreasing revenues being experienced on the surgical side. How can they do this? A few thoughts.

First, simply increase the number of patients seen per hour, per day, per week and per year in the office. Six patients an hour is easy with a scribe and adequate technical support. Eight is possible without sacrificing quality of care. That increases office visits to 7,500 to 10,000 per year, working the same number of hours per day and days per year in the office. And, of course, we can also add more hours, such as seeing patients one night a week and/or Saturday mornings, which is convenient for and much appreciated by patients.

In addition, there are many ways to increase the revenue per patient visit in the office. One is the topic of this issue’s cover story, SLT, which pays about $340 per eye in the office and every glaucoma patient has two eyes. So, buy an SLT laser for the office and offer it to your glaucoma patients as a primary or secondary treatment option. Also, buy a YAG laser and do the capsulotomies, peripheral iridotomies and, if you are an advocate, laser of vitreous opacities and floaters in your office rather than at the HOPD or non-owned ASC. Then, capture and treat the ocular surface disease patients, including dry eye, blepharitis, meibomian gland dysfunction and allergy. With the multiple office-based insurance or cash-pay diagnostics such as tear film osmolarity, MMP-9 and meibography followed by the many treatments available, including BlephEx (BlephEx LLC), intense pulsed light, iLux (Alcon), LipiView (Johnson & Johnson Vision) and the like, there is significant revenue to gain here. These common ocular surface disease patients can now generate more office revenue per patient than the glaucoma patient. In addition, with the better prescription treatments now available, the ocular surface disease patient deserves to be under an eye doctor’s care.

The simple addition of SLT, YAG laser, and ocular surface diagnostics and therapeutics can add significant revenue to the comprehensive ophthalmologist’s office-based practice. For those comfortable and trained, collagen cross-linking, laser corneal refractive surgery, medical retina with intravitreal injections and the like can magnify office revenue even further.

For the “typical” comprehensive ophthalmologist, I believe it is not only possible, but fairly easy, to increase revenue per patient from $180 per patient visit to $250 per patient visit and increase patient visits to 7,500 per year from the average baseline of 5,000 per year. These two changes — more patients in the office per year and more revenue per patient — can more than double office-based revenue to $1.875 million vs. the baseline $900,000. And, seeing the additional 2,500 patients a year will also generate another 250 surgical cases, increasing the 1 OR day a week to 15 cases, making the surgery day full as well and generating another $150,000 in additional revenue. We have now nearly doubled the typical ophthalmologist’s gross revenue and, if overhead is well managed, more than doubled take-home pay by simply focusing on the office-based practice. A good practice consultant such as BSM Consulting or J. Pinto & Associates Inc. can help one make this transition.

It has been and will be difficult to halt the trend toward less reimbursement per case in the operating room. But the comprehensive ophthalmologist is in a primary care specialty, and thanks to the government’s focus on our primary care colleagues, E&M codes have been and will be going up every year. Along with the broad and increasing opportunity for office-based procedure revenue, I believe the answer for most non-ASC owner comprehensive ophthalmologists to recover the lost revenue in the operating room is to focus on their office-based practice. It is most productive to simply see more patients per hour, per day, per week and per year, and office-based point-of-service testing along with insurance-reimbursed and cash-pay office procedures and treatments are amazing opportunities that should not be neglected. As always, working harder pays off, but working harder and smarter is even better. So, hire a good practice consultant, make a careful business plan, focus on your office-based practice and take back control of your future.

Disclosure: Lindstrom reports he consults for Bausch + Lomb, Johnson & Johnson Vision, TearLab, Zeiss and several startup companies in the field of ophthalmology.

I recently wrote a commentary on selective laser trabeculoplasty for glaucoma in the June 10, 2019, issue of Ocular Surgery News. In this commentary, I would like to extend my thoughts to include some points on the economics of office practice.

I am speaking here primarily to the comprehensive ophthalmologist who does not own equity in an ASC. This is the majority of comprehensive ophthalmologists. This “typical” comprehensive ophthalmologist sees patients in the office 4 days a week and does surgery in a hospital outpatient department (HOPD) or non-owned ASC 1 day a week. In a year, the ophthalmologist sees about 5,000 patients in the office, does 500 surgical procedures in the non-owned HOPD or ASC, and generates about $1.2 million in total revenue for the practice. With a 70% overhead, the typical ophthalmologist can take home about $360,000 per year. Of course, 50% do better and 50% do worse. And those that do better usually have ownership in an ASC and leverage other sources of income, including employee doctors, optical and in-office procedures. Again, I am focusing here on the comprehensive ophthalmologist who does not own equity in the facility where he or she operates.

Of this $1.2 million in income, about $300,000 comes from surgery in the HOPD or non-owned ASC and $900,000 from seeing patients in the office. Rounding off and averaging for Medicare, Medicaid, commercial insurance and cash pay, the “typical” comprehensive ophthalmologist is getting approximately $600 per case in the OR. If that “typical” comprehensive ophthalmologist does one to two cases an hour, which is common, he or she is generating $600 to $1,200 an hour in revenue. Ten cases in a surgery day spent in the OR generates about $6,000. In the office, the ophthalmologist is earning about $180 per examination. At four patients an hour in the clinic, he or she earns $720 per hour and for a full day, $5,760. Pretty much the same revenue generated for the office day as the OR day.

Now, what will be easier to grow? I believe for most comprehensive ophthalmologists, it will be harder to generate more surgical cases or increase the revenue per case in the OR than it will be to increase patients seen and revenue per patient visit in the office. I believe the “typical” comprehensive ophthalmologist should focus more on their office-based practice to make up for the decreasing revenues being experienced on the surgical side. How can they do this? A few thoughts.

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First, simply increase the number of patients seen per hour, per day, per week and per year in the office. Six patients an hour is easy with a scribe and adequate technical support. Eight is possible without sacrificing quality of care. That increases office visits to 7,500 to 10,000 per year, working the same number of hours per day and days per year in the office. And, of course, we can also add more hours, such as seeing patients one night a week and/or Saturday mornings, which is convenient for and much appreciated by patients.

In addition, there are many ways to increase the revenue per patient visit in the office. One is the topic of this issue’s cover story, SLT, which pays about $340 per eye in the office and every glaucoma patient has two eyes. So, buy an SLT laser for the office and offer it to your glaucoma patients as a primary or secondary treatment option. Also, buy a YAG laser and do the capsulotomies, peripheral iridotomies and, if you are an advocate, laser of vitreous opacities and floaters in your office rather than at the HOPD or non-owned ASC. Then, capture and treat the ocular surface disease patients, including dry eye, blepharitis, meibomian gland dysfunction and allergy. With the multiple office-based insurance or cash-pay diagnostics such as tear film osmolarity, MMP-9 and meibography followed by the many treatments available, including BlephEx (BlephEx LLC), intense pulsed light, iLux (Alcon), LipiView (Johnson & Johnson Vision) and the like, there is significant revenue to gain here. These common ocular surface disease patients can now generate more office revenue per patient than the glaucoma patient. In addition, with the better prescription treatments now available, the ocular surface disease patient deserves to be under an eye doctor’s care.

The simple addition of SLT, YAG laser, and ocular surface diagnostics and therapeutics can add significant revenue to the comprehensive ophthalmologist’s office-based practice. For those comfortable and trained, collagen cross-linking, laser corneal refractive surgery, medical retina with intravitreal injections and the like can magnify office revenue even further.

For the “typical” comprehensive ophthalmologist, I believe it is not only possible, but fairly easy, to increase revenue per patient from $180 per patient visit to $250 per patient visit and increase patient visits to 7,500 per year from the average baseline of 5,000 per year. These two changes — more patients in the office per year and more revenue per patient — can more than double office-based revenue to $1.875 million vs. the baseline $900,000. And, seeing the additional 2,500 patients a year will also generate another 250 surgical cases, increasing the 1 OR day a week to 15 cases, making the surgery day full as well and generating another $150,000 in additional revenue. We have now nearly doubled the typical ophthalmologist’s gross revenue and, if overhead is well managed, more than doubled take-home pay by simply focusing on the office-based practice. A good practice consultant such as BSM Consulting or J. Pinto & Associates Inc. can help one make this transition.

PAGE BREAK

It has been and will be difficult to halt the trend toward less reimbursement per case in the operating room. But the comprehensive ophthalmologist is in a primary care specialty, and thanks to the government’s focus on our primary care colleagues, E&M codes have been and will be going up every year. Along with the broad and increasing opportunity for office-based procedure revenue, I believe the answer for most non-ASC owner comprehensive ophthalmologists to recover the lost revenue in the operating room is to focus on their office-based practice. It is most productive to simply see more patients per hour, per day, per week and per year, and office-based point-of-service testing along with insurance-reimbursed and cash-pay office procedures and treatments are amazing opportunities that should not be neglected. As always, working harder pays off, but working harder and smarter is even better. So, hire a good practice consultant, make a careful business plan, focus on your office-based practice and take back control of your future.

Disclosure: Lindstrom reports he consults for Bausch + Lomb, Johnson & Johnson Vision, TearLab, Zeiss and several startup companies in the field of ophthalmology.