At issue: ability to expand your practice

At Issue posed the following question to an international panel of experts: “With the current economic climate in your country, is it feasible to expand your practice? If yes, how? If no, why?”

Conditions favor expansion

Noel A. Alpins, MD, FACS: The economic climate in Australia in the past 2 years has been relatively buoyant. External factors, such as economic slowdowns in the United States and Japan, the tragic events of Sept. 11 in New York and recent adverse publicity in North America regarding LASIK surgery, have had no perceivable negative impact on the demand for laser vision correction here. In fact, the recent slump in overseas travel as a result of the terrorist attacks has probably given people considering this surgery more time at home and surplus funds to act upon their plans to undergo treatment.

My practice enjoys continued growth for general ophthalmology as well as cataract and refractive surgery. In-house optometry staff play an important role in comanagement and technical support. Their involvement in the entire therapeutic process enhances communication with patients both pre- and postoperatively. We are currently expanding professional and office staff numbers to effectively service patients whose expectations of both cataract and refractive surgery are high. Advances in technology such as laser and microkeratome capabilities are being upgraded together with the ongoing process of expansion in patient numbers and facility space.

In recent years the actual number of laser vision correction practices in Melbourne has diminished. Significantly, there has been no local participation by corporate players that might have affected the market. Fortunately, patients have become more educated in their selection of a surgical practitioner, relying on confidence in word-of-mouth referrals from friends and acquaintances. When it comes to extremes of advertised pricing and outcomes, there has been a healthy amount of consumer skepticism. Consequently, established practices that value patient loyalty continue to thrive and grow.

Noel A. Alpins, MD, FACS, can be reached at 7 Chesterville Rd., Cheltenham, VIC 3192, Australia; +(61) 3-9584-6122; fax: +(61) 3-9585-0995; e-mail: alpins@newvision clinics.com.au.

Possible but risky

Ehud Assia, MD: It is possible to expand an ophthalmic practice; however, the competition is tougher than ever and the financial risk is quite high. Under Israeli law, every citizen is insured by one of four medical care providers and is guaranteed full medical care. In addition, the major insurance companies offer various programs of expanded medical coverage in private facilities.

Because of the overload in the public service and the inability to choose a surgeon, many patients seek out-of-pocket private services. In recent years the recession and the sociopolitical situation in Israel have negatively affected the economic status of many potential patients, yet high-quality private medical services are still in demand.

Refractive surgery is not included in the “basket” of public medical services and is therefore done in private institutions only. It has become the most significant turn in the expansion of ophthalmic private clinics. Several refractive centers emerged in the past 3 to 4 years, and this trend is still growing. Apparently, the traditional borders between anterior segment, retina, glaucoma and oculoplastics specialists become blurred when it comes to refractive laser procedures. However, the more invasive procedures, such as phakic lenses and Intacs, are still reserved for the more experienced surgeons.

The competition between surgical centers and the involvement of health care providers resulted in a significant drop in the cost of refractive surgery, but it is still regarded as a profitable service. Other advances in ophthalmology, such as photodynamic therapy, glaucoma laser procedures and the newer diagnostic and imaging equipment, broadens ophthalmic services, but to a lesser extent.

In recent years the law has allowed medical services to be advertised, including physicians’ names. The open advertisement in the media exposes the public to private medical services, and especially to refractive surgery.

Ehud I. Assia, MD, can be reached at 9 Kehilat Pozna St., Tel-Aviv, 69989, Israel; +(97) 2-3-5493566; fax: +(97) 2-3-5408323; e-mail: assia@netvision.net.il.

More patients, lower reimbursements

Michael C. Knorz, MD: In Germany, we must look both at the government health system and the private market, with refractive surgery as the most important force. In the German health care system, we face an increasing volume of procedures, namely cataract cases, due to an aging population and a decrease in reimbursements due to cuts in the health care system.

Even in this segment, however, the answer is still yes, we must expand our practices because the number of patients is increasing. But we also have to cut costs because reimbursements per case are decreasing, so this growth must be economically sound. Growth will predominantly occur in highly specialized centers. More single low-volume practices will disappear or join forces with others to achieve a certain level of growth.

An even more important market is refractive surgery, which is still in the very early stage in Germany, with approximately 50,000 to 70,000 procedures performed last year for a population of 80 million. Growth rates are between 20% and 100%, despite the increasing number of surgeons entering the field. Discount centers are not an issue, as marketing is very restricted and patients are more concerned about quality of care than price at this early stage of market development.

Refractive surgery is therefore clearly a growing market, which means those in the business should expand their practice. We did not observe a drop in procedures after Sept. 11, but instead saw an increase both in the last quarter of 2001 and the first quarter of 2002.

Growth in refractive surgery also means combining forces, because equipment is expensive and high-quality care is mandatory. Growth means an increasing number of surgeons using highly specialized laser centers, and postop care provided by a network of nonsurgical ophthalmologists.

Michael Knorz, MD, can be reached at 14 Leibniz St., 68165 Mannheim, Germany; +(49) 621-383-3410; fax: +(49) 621-383-1984; e-mail: knorz@eyes.de.

Private sector growing

Dennis S.C. Lam, MBBS: Ophthalmic care in Hong Kong is provided by two parallel systems: the public and private sectors. All Hong Kong residents are eligible to see an ophthalmologist in the public sector for a nominal fee. It currently employs 56 of the 126 registered ophthalmology specialists in Hong Kong and all the trainees. The remaining ophthalmologists work in the private sector, which is based on fee-for-service care.

The 1997 reunification with China and the establishment of the Hong Kong special administrative region have strengthened the ties between Hong Kong and the mainland, while Hong Kong retains its autonomy. The special economic relationship with China is helping Hong Kong to come out of the recession that has engulfed various neighboring Southeast Asian countries in the past few years. Meanwhile, there has been great economic progress in China itself, culminating in its recent entry into the World Trade Organization. With the advent of the age of information technology, there is an increase in health awareness among the general public.

Increasing numbers of prosperous mainland Chinese patients cross the border to seek eye care in Hong Kong. At the same time, Hong Kong patients are also more able to demand and afford high-quality eye care. To cater to their needs, there have been changes in eye care delivery patterns, especially in the demand for and provision of subspecialty care.

In the public sector, expansion is difficult due to lack of additional government funding. However, in the private sector, the solo general ophthalmology practice is gradually evolving into group practices that allow more subspecialization and the purchase of more expensive, up-to-date equipment.

I am cautiously optimistic about the future development of eye care provision in Hong Kong, and I believe there is certainly room for its expansion in the coming 5 to 10 years.

Dennis S.C. Lam, MBBS, is professor and chairman of the Department of Ophthalmology and Visual Sciences at the Chinese University of Hong Kong. He can be reached at 3/f Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, Hong Kong SAR, China; +(852) 2762-3157; fax: +(852) 2715-9490; e-mail: dennislam@cuhk.edu.hk.

Expansion feasible, advisable

Amparo Navea, MD, PhD: The economic climate in my country is currently “benign” in my opinion. It would be possible to expand a private practice, taking into account the sociology and market conditions of where ophthalmology is heading.

Before, a good professional career was in a public hospital or at the university. A private practice was a single office to see patients, with surgery performed in a private hospital. Investment in an office was affordable, and the hospital provided some of the more expensive technology like operating microscope, sterilization or fluorescein angiography.

Now, patients are influenced by advertising that makes it appear fashionable to choose their doctor or clinic.

In this context, successful expansion of a practice must meet certain goals. A few professionals (three to five) with different subspecialties must work together. They have to build a smart clinic with some offices and facilities for intraocular surgery and refractive surgery. There must also be a budget assigned to marketing and advertising.

This concept of a practice has two main goals. First, a practice must be able to attract a large number of patients through an integrated service covering as many ocular problems as possible. Second, colleagues in a group practice can share the costs of always-evolving technology.

Actually, not only is it feasible to expand our practice, it is highly advisable. Refractive and outpatient surgery have changed the climate of ophthalmology. We have to compete not just with other colleagues but with large companies, and we have to transform ourselves if we want to be competitive.

Amparo Navea, MD, PhD, can be reached at Hospital La Fe, Avda Campanar s/n, 46009 Valencia, Spain; +(34) 96-386-87-67; fax: +(34) 96-398-73-32; e-mail: Amparo.navea@uv.es.

Teamwork, education are key

Abhay R. Vasavada: Yes, it is feasible to expand the practice. The economic climate of countries like India is conditioned by local economic and cultural forces. At the same time, India, since independence, has recognized the importance of health and education as crucial factors in socioeconomic development. It has consistently received moral and material support from the developed countries in progressing toward this goal. In the current context of globalization, health care is indeed a vital aspect of improvement of the quality of individual and social existence.

In this context, one cannot overemphasize the importance of good planning to cater to the needs of local communities. This calls for adopting a “professional approach” at all stages of patient care and eye care delivery systems.

For example, a clinic can raise the quality of all its services by employing specialized administrators and managers. We would also provide a special focus on purposeful education and counseling for patients with the help of interviews and written and audiovisual material.

It is crucial to build a good team, including competent ophthalmologists, administrators, paramedical, secretarial and other supporting personnel. Encouraging ophthalmologists to gain proficiency in different subspecialties would raise the overall caliber of eye care. If necessary, we should join hands with other centers to ensure
adequately supervised eye care for patients.

The chief should remain updated in his or her own specialty. Continuing medical education is an important aspect of fulfilling this need.

It is fashionable today to add related specialties like refractive surgery, contact lens care, etc. This certainly is a workable concept. However, one should ensure the quality of the additional subspecialties is compatible with the existing strength of the institution. For example, our practice has set a very high standard for cataract surgery. It is important for us to ensure that any additional subspecialty does not compromise the current reputation of the practice.

In short, one should aim at achieving high-quality care and make all efforts to accomplish and maintain it over a period of time. Growing numbers of satisfied patients will strengthen the reputation of our total health care management, which in turn will increase patient flow.

Abhay Vasavada, MD, can be reached at Iladevi Cataract & IOL Research Centre & Raghudeep Eye Clinic, Gurukul Road, Memnagar, Ahmedabad - 380 052, India; +(91) 79-7492303 or 7490909; fax: +(91) 79-7411200; e-mail: shailad1@sancharnet.in.