December 2017


Preparing for changes in ophthalmology
Facing changes in ophthalmology practice

by Michelle Stephenson EyeWorld Contributing Writer

Physicians discuss how they’re addressing practice today

Ophthalmologists are under increasing pressure to see more and more patients and provide optimal outcomes, while also navigating new and complex rules and regulations.
“Ophthalmology is in an extraordinary state of flux right now, and our increasing caseloads are making it very hard to stay on top of practice management,” said Eric Donnenfeld, MD, Rockville Centre, New York. “The rules and regulations that have gone into effect have made it almost impossible for ophthalmologists to fulfill all of the obligations that the government is asking of us while keeping up a good clinical practice.”
Ophthalmologists have traditionally been paid a fee for services rather than outcomes, which incentivizes volume. However, recent federal and private policies have turned to a “pay-for-performance” model.

Pay for performance

According to John Hovanesian, MD, Laguna Hills, California, healthcare is moving toward physicians being paid for outcomes rather than for services. “The push is to force doctors to assume the risk of caring for patients,” he said. “Currently, the risk of taking care of a complicated patient is on the health insurance company. They pay for whatever care the patient needs. To a small extent, we assume risk when we do surgery because there is a certain amount of postoperative care included, and complicated patients require more time. In general, there’s going to be a shift toward more of that, so practices need to know the real costs of taking care of their patient population. If you’re going to negotiate a contract that doesn’t pay you a fee per service, you need to know what your outcomes are likely to be.”
Dr. Hovanesian noted that this has big implications for electronic health record (EHR) systems. “For the past 10 years, we have been working for the EHR system, and we need to change it around so that the EHR system works for us,” he said.
Dr. Donnenfeld agreed. “Outcomes will be crucial, and documenting those outcomes will be equally crucial. You must have a place where you can document that you are providing good outcomes, and that’s where EHR systems are going to play a bigger role,” he said.
According to Drs. Donnenfeld and Hovanesian, MDbackline and Veracity (Temple, Texas) are two examples of new systems that work for ophthalmologists. For more information about these systems, see “Update on EHR” on page 18 of this issue of EyeWorld.


Electronic health records have become an important part of ophthalmology practice, and they have advantages and disadvantages. “I was unhappy that I was forced to move into an area that I was uncomfortable with,” Dr. Donnenfeld said. “That said, EHR systems have become an important part of our practice, and I now enjoy the freedom that they give me to provide patient care. They have become easier to use and allow us to mine data and analyze results in a meaningful way. At first, they were more difficult to use, but now we have information in our EHR where we can bring findings together, collate data, and create better spreadsheets for patient care.”
Dr. Donnenfeld noted that Veracity and MDbackline allow ophthalmologists to practice in a smarter, more efficient way and increase patient satisfaction and patient outcomes. Additionally, they can help grow practices. “We view these changes in healthcare as sometimes difficult but important, and they are something that we all need to embrace,” he said.

Patient shared billing opportunities

In recent years, reimbursement rates have declined, making patient shared billing opportunities important for practices. “We don’t expect reimbursement rates to go in the opposite direction for the foreseeable future, but the opportunity to see patients for premium services is becoming more and more robust,” Dr. Donnenfeld said. “As the technologies that are associated with premium services, such as LASIK, multifocal IOLs, toric IOLs, and laser cataract surgery, become more and more effective, there’s an increased opportunity and certainly an increased demand for these services. This has changed dramatically over the past several years.”
Vance Thompson, MD, Sioux Falls, South Dakota, said this has been an area of tremendous growth since cataract surgery has become a powerful refractive procedure. “This restores clarity and restores reading range and allows patients the opportunity to have refractive cataract surgery and function without glasses,” he said. “Because patients’ insurance will often pay for the therapeutic side of cataract surgery and patients are able to invest in the elective side of refractive cataract surgery, it can become complicated for patients unless you have clear forms and your staff is comfortable with explaining what could sound like a complicated offering to patients.”
As practices are increasing their patient loads, it is difficult to educate patients because there are many options that take time to explain. “Sometimes we just don’t have the time to explore optional cost extras like premium lenses,” Dr. Hovanesian said. “There are many great surgeons who do a fabulous job for their patients, but they are so geared up for doing high-volume surgery that they don’t have the time to communicate about premium options with patients. So their adoption rate of those is low, and it’s hard to overcome the challenge of being short on time.”

Mega practices

To overcome some of these difficulties, some practices are joining together or are joining hospitals to become mega practices. This allows within-practice referrals as well as economic benefits. “There’s a strong movement over the last several months to private equity, forming mega practices that have economies of scale and are willing to negotiate contracts that beforehand would be impossible for individual practices to provide,” Dr. Donnenfeld said. “They also bring in revenue that allows the practice to grow and develop new opportunities that would not have been available previously. I see a strong movement toward practices coming together.”

Well-educated patients

Added to the mix are patients who are better educated and informed than ever before. “This is a good thing, but it’s important to be prepared,” Dr. Thompson said. “There are so many options these days with advancements in technology. It’s important to be fully educated yourself. My practice has adapted by focusing even more effort on educating ourselves and our staff along with our referring doctors. We put a lot of effort into educating patients through newsletters, e-mails, webinars, and symposia.” 

Editors’ note: Dr. Hovanesian has financial interests with MDbackline and Veracity. Dr. Thompson has financial interests with Veracity. Dr. Donnenfeld has no financial interests related to his comments.

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