October 2019


What ophthalmologists should be doing today
6 ideas to boost your practice revenue stream

by Vanessa Caceres EyeWorld Contributing Writer

A new practice location for Minnesota Eye Consultants in Woodbury, Minnesota, offers LASIK, corneal transplant surgery, and facial fillers and injections, among other services.
Source: Minnesota Eye Consultants

A mobile eyecare unit used by Boling Vision Center has helped to strengthen ties with the community and bring in new patients.
Source: Boling Vision Center


With medical reimbursements projected to decline, ophthalmic practices must take a closer look at ways to bring in new income.
The good news? This may not be so hard.
“Unlike other medical specialties, ophthalmology has the unique opportunity to charge patients for premium services. This is one of the most common and potentially attractive ways to boost revenue,” said Bruce Maller.
There are many directions that practices could potentially take to help grow business—some of them an easier fit than others. John Sheppard, MD, advises sticking with areas that are the most natural fit for cataract and refractive surgeons versus extending your business too far into left field.
Here are some practice-boosting ideas that physicians may want to consider to help grow their practice.

1. Open or co-own an ASC

Opening an ASC is not as easy as snapping your fingers. It can be a long, drawn-out process, particularly in COPN (certificate of public need) states like Virginia. That said, if you have the right surgical volume and can invest some time and effort, it often pays off. One additional benefit: Facility fee reimbursements are not likely to be cut like surgeon fees have been cut. Operating your own surgical center usually makes surgery and scheduling more efficient as well, Dr. Sheppard said.
“This could be a good opportunity depending on one’s volume and the ability to secure ownership shares in an existing surgicenter on favorable terms,” Mr. Maller said.
Richard Lindstrom, MD, said that having around 500 to 600 surgical cases a year is usually enough to sustain a small OR ASC. If you get to 1,500 cases a year, that’s often enough for two ORs, Dr. Sheppard said.
You can build an ASC for use with other ophthalmic subspecialties such as retina and oculoplastics, Dr. Sheppard suggested. If your practice is not big enough to own an ASC, consider coming together with other local surgeons and pooling technicians and billing for the ASC, he added.

2. Build your premium IOL business

By identifying patients who truly want and could visually benefit from premium IOLs, you can find a somewhat turn-key boost to your business. This tends to work well because informed patients nowadays often want education on their various options to improve their lifestyle. However, it does take some prep work. “Conversion from a standard lens to premium options does not happen by accident but instead through rigorous attention to detail and effective education of patients,” Mr. Maller said.
One key component: surgeon buy-in. “Once the surgeon is on board, successful implementation requires a significant investment and commitment to training of staff,” Mr. Maller said.
Dr. Sheppard described a commitment to offering premium IOLs as changing the culture at your practice so all clinical staff, from counselors to telephone operators to triage to techs and optometrists, are properly educated about the premium options—and the practice continually builds on that education as newer lenses come out.

3. Focus more on dry eye patients

Dry eye patients have routinely been ignored or underappreciated, but that may be changing. Greater attention to dry eye patients is potentially a win-win for practices and patients. “I am a big advocate of capturing dry eye, especially for a practice with MDs and ODs,” Dr. Lindstrom said. “Dry eye patients, in my opinion, should be captured just like glaucoma patients and seen every 3 to 12 months. With the point-of-service office tests available today and the therapeutic procedures, one could argue that a dry eye patient is even more beneficial to a practice than a glaucoma patient financially.”
If you have physician extenders such as optometrists or physician assistants, they can handle the bulk of the work with dry eye patients, said Dr. Sheppard, whose practice has a well-established commitment to working with dry eye patients. Furthermore, dry eye treatment improves visual outcomes, while successful glaucoma treatment merely maintains vision.
Just like an expanding focus on premium IOLs, a growing focus on dry eye requires solid staff education. Boling Vision Center hosted a mini-Dry Eye University onsite recently and invested in various tools and equipment for a larger focus on dry eye in the latter half of this year, said Hayley Boling.
However, targeting dry eye patients may work best only through the right business lens. “This needs to be looked at as a broader strategic opportunity to bring added value to patients,” Mr. Maller said.

4. Bring in optometrists

There has sometimes been tension in the relationship between optometrists and ophthalmologists, but this has changed significantly over the past 2 decades. In fact, most practices employ or contract with optometrists. “These are the physician extenders that essentially work as the ‘general practitioners’ of our practice. They are the first line of eyecare providers and refer any guests who are outside their scope of care or who are ready for surgery,” Ms. Boling said. Her practice maintains a 2:1 optometrist-to-ophthalmologist ratio and said this has kept surgeons busy in the ORs and also allows them to take less call. “We’ve found this integrated model to provide incredible synergy for the practice as a whole,” Ms. Boling said.
“I see no downside [in hiring optometrists] except the usual management issues, which are no harder with a doctor of optometry than they are with a doctor of medicine,” Dr. Lindstrom said.
If you plan to hire optometrists, make sure you have a business plan in place to evaluate financial and nonfinancial aspects of integrating optometry into the practice, Mr. Maller cautioned. “The potential opportunity would be based on the practice’s ability and/or desire to transition certain patients from the MD to the OD schedule, in addition to possibly growing one’s primary care patient base,” he said.

5. Add a subspecialist

This idea can work very well for some practices—for others, not so much. “Much depends on the practice size, practice vision, owner goals, and local and regional market dynamics,” Mr. Maller said.
“For a large practice, cornea, glaucoma, oculoplastics, medical retina, and even pediatric ophthalmology makes sense to me,” Dr. Lindstrom said. He thinks surgical retina may be a better fit at a single-specialty retina practice, while neuro-ophthalmology, uveitis, and ocular oncology are likely better at university medical centers.
Boling Vision Center has found it difficult to recruit subspecialists, so practice leaders have found other practices and doctors willing to contract with them part time. With this model, they are planning to add surgical retina once a week and glaucoma care two times a month by the end of the year. Local residents are currently underserved by these two areas of eyecare, Ms. Boling said. The drawbacks of adding subspecialists are that it can be an expensive and equipment-intensive endeavor for part-time coverage, she said.
Another subspecialty that can work well in an ophthalmic practice is an oculoplastics surgeon. An oculoplastics surgeon could potentially offer Botox (onabotulinumtoxinA, Allergan) and dermal fillers, among some of the cash-pay services that can boost revenue, Dr. Lindstrom said.
If a practice does not do its homework about the need for a subspecialist, there could be a less-than-ideal outcome, Mr. Maller warned. For instance, if a comprehensive ophthalmology practice hires a subspecialist, it could significantly reduce the possibility of getting referrals from other community physicians, leading the subspecialist to not meet his or her goals or the practice’s financial objectives. It’s also crucial to find a subspecialist who is the right cultural fit for your office, Mr. Maller added. The natural flow from ocular surface to refractive cataract to oculoplastics takes your patient and your practice through the journey together.

6. Reach out to the community with a mobile eye unit

At the end of 2018, Boling Vision Center started a mobile exam unit to provide free eye screenings with referrals back to the office for medical exams when needed. However, what started as a philanthropic effort has actually become a great revenue generator. “Our community sees us doing good for others and has in turn chosen us because of our social consciousness as a practice,” Ms. Boling said.

At a glance

• Ophthalmic practices must take a closer look at ways to grow business due to declining reimbursement.
• An ASC can take a long time to develop, but many ophthalmologists have found it pays off both financially and for better efficiencies.
• Solid staff education can make conversion to premium IOLs or greater commitment to dry eye patients successful.
• The addition of optometrists can help surgeons focus on what they do best.
• Adding subspecialists to a practice can be a good clinical fit at some practices.

About the sources

Hayley Boling, MBA, COE
Chief executive officer
Boling Vision Center & INSIGHT Surgery Center
Northern Indiana

Richard Lindstrom, MD
Founder and CEO
Minnesota Eye Consultants

Bruce Maller
Founder and CEO
BSM Consulting
Incline Village, Nevada

John Sheppard, MD
Virginia Eye Consultants
Norfolk, Virginia

Relevant financial interests

: None
Lindstrom: None
Maller: None
Sheppard: None

Contact information

Boling: HBoling@BolingVisionCenter.com
Lindstrom: rllindstrom@mneye.com
Maller: bmaller@bsmconsulting.com
Sheppard: jsheppard@vec2020.com

Business pearls and cautions

Do your research before any new business venture. Before making a big investment, make sure you’re in the right market for your new idea. “Just because this worked for one of your residency buddies in another market doesn’t mean it will work for you,” Ms. Boling said.
Know your break-even point. Develop a realistic pro-forma to make an informed decision.
Stick with what you know. Going into the real-estate business or partnering with non-ophthalmic specialties that might (but likely won’t) bring more business to the practice can be a stretch, Dr. Sheppard said. His practice lost money by offering space to dentistry, audiology, and dermatology—all of whom fortunately eventually needed more space and moved out.
Like your job. Many of the ideas suggested here branch off from performing cataract, refractive, or cornea surgery. Make sure you truly like the types of surgeries you perform before you delve deeper into these other revenue-producing areas, Dr. Sheppard advised.

6 ideas to boost your practice revenue stream 6 ideas to boost your practice revenue stream
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