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A look back: 20 years in practice management
As part of our celebration of the 20-year anniversary of Ocular Surgery News, our Section Editors look at how far we have come. This month, Herve M. Byron, MD, on practice management.
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The practice of ophthalmology began to change radically in the early 1980s, just as Ocular Surgery News appeared on the scene.
This was the period when the norm of ophthalmic practice started to evolve from solo private practice into a more complete service. The office model up to that time had provided medical and surgical care with a small staff without computers; this would soon change to personnel with more formal business backgrounds who were computer literate, offering multiple services.
When in the early 1980s it became apparent that health care costs were increasing at an alarming rate, new controls were instituted to halt this escalation. The introduction of diagnosis-related groups (DRGs), managed care and fee reductions by the Health Care Financing Administration (HCFA) began to impact ophthalmologists’ incomes significantly.
In 1980, most offices did everything manually, without the use of computers. There was adequate cash flow, so the business aspects of ophthalmology were not considered important. Managed care had not yet significantly invaded the practice of medicine, so the patient-physician relationship was not much obstructed by third parties. Collections were more direct and efficient. Little time was wasted in the front office trying to contact the payer of services rendered to the patient.
All these factors meant payrolls were relatively small and net profits high. The new controls on income motivated ophthalmologists to start paying attention to the business side of practice. The complexity of DRGs caused physicians to review their staff capabilities.
The intimate relationship between physician and patient began to change. Managed care companies appointed gatekeepers to screen patients, and mandatory second opinions were required before cataract surgery was authorized. Physicians found themselves losing autonomy and wasting valuable time.
Some surgeons had only recently began to augment their incomes by using the new techniques of refractive surgery to enhance vision.
At the same time, optometrists were gaining ground in their attempts to attract more primary eye care patients.
A few visionary ophthalmologists began to provide optical services for their patients. Opticians were hired to manage these new services.
Computer innovations
Technology continues to advance in all areas of the specialty. Each time we believe we have achieved the perfect operation, new developments such as wave-front technology and multifocal implants make it even better.
The computer is the most important innovation ever introduced into medicine. They have revolutionized the business side of ophthalmology. Training of office personnel in the use of computers is an essential practice but also time-consuming and expensive.
Computers are now used for patient scheduling, patient billing, insurance billing and accurate coding for every service rendered, even recording of patient data by voice recognition. They can give suggestions of therapy for many conditions. They can be a source of referrals. They are used for word processing to send information to referring physicians, letters and reminders to patients and for calculation of data necessary to perform accurate surgery. Newer and more sophisticated applications are continually being developed.
Where we are today
In 2002, ophthalmology stands at the end of the past and the beginning of the future. There are major problems still to overcome and exciting new developments to offer patients.
Reimbursements are declining and overhead is increasing, but new surgical procedures provide surgeons the opportunity to overcome these problems and add more income to their practices.
Rapid advances in phacoemulsification and refractive surgery technology, and improvements in IOL design, materials and delivery systems are occurring at stunning speed. Selective laser trabeculoplasty and other new surgical techniques for the treatment of glaucoma are gaining advocates. LASEK is gaining acceptance as an alternative to LASIK. New treatments for choroidal neovascularization and wet age-related macular degeneration are being approved. Innovative procedures for treating presbyopia are exciting refractive surgeons.
But at the same time, optometry is gaining primary care credentials through legal accreditation rather than by education and training. They are blurring the distinctions between ODs and MDs, and the public is buying their line of marketing. The American Academy of Ophthalmology has acted in response to this situation by advising that ophthalmologists call themselves Eye MDs.
The battle for patients is intensifying. Advertising is becoming aggressive and unprofessional. Ophthalmologists are battling within their own ranks, especially for surgical patients. If this self-destruction continues, ophthalmology will be severely wounded internally; optometry will be hovering to pick up the pieces.
Residency programs are turning out too many new ophthalmologists. The programs may need to downsize and turn out fewer young ophthalmologists.
Tired of 20 years of micromanagement, more ophthalmologists are opting out of managed care and developing new senses of freedom and satisfaction from their practices. These clinicians feel they must regain control of the care of their patients.
Ophthalmologists now realize that dispensing glasses and contact lenses helps their patients get the best product for their money. One-stop shopping has become the way of doing business in many offices.
Ophthalmologists realize that they must administer their practices in a businesslike manner or perish. The numbers of group practices are increasing and solo practices are declining because few individuals can afford to pay the salaries of business-trained administrators.
The future has never been brighter for ophthalmology. A new golden age will occur if the above-mentioned solutions are adopted. If not, there are dark clouds hanging over the specialty, and the future is perilous.
The immediate future
Ophthalmology will struggle in the immediate future as fees continue to decrease and overhead continues to increase. The fight for primary eye care patients between optometrists and ophthalmologists will intensify. Too many residents will enter an already overcrowded specialty. HCFA and managed care companies will continue to lower reimbursements, causing a cash flow crisis. The number of refractive surgical procedures performed will drop until the current recession transitions into a positive economy.
Organized ophthalmology will intensify efforts to stabilize and increase reimbursements with more success. These organizations will realize that more aggressive public relations must be instituted to educate the public about ophthalmology and the definition of Eye MDs.
Improvements in technology and instrumentation for refractive, cataract and glaucoma surgery will continue to produce superior results. The availability of advanced computer and telecommunication products will allow for paperless offices, which will improve the efficiency of office management and the quality of patient care.
The costs of health care insurance and pharmaceuticals will continue to escalate. As more dollars come directly from patients, they will want more benefits such as choosing the best doctors. A different form of indemnity insurance will evolve, providing those benefits to subscribers.
Further down the road, a new golden age of ophthalmology will result as the baby boom factor comes into play. By 2005, 5.5 million more Americans will be between the ages of 55 and 64 than in 2000. These individuals will require huge amounts of eye care because of their age, their desire for perfection and their exposure to more ultraviolet light in their leisure activities. The number of cataract, retinal, refractive and oculoplastic procedures will rise dramatically as this group ages.
Group practice will prevail because of the increased efficiency due to the ability to attract professional management personnel. Each member of the group will be a subspecialist yielding excellent results, which the baby boomers will demand and willingly pay for. Ophthalmology will rise from the doldrums and once again become the “queen of the specialties.”
A different profession
In the future, medicine will be a totally different profession. Genetic and nutritional physicians will eliminate many currently known diseases from birth and thereafter. The importance of nutrition in maintaining health will be taught in medical schools and will be universally practiced. This will extend life expectancy by many years. Other features of ophthalmology in 2022 will include the following:
Cataracts, if they develop, will be dissolved by a new pharmaceutical agent, eliminating surgical intervention.
Age-related macular degeneration and diabetes, two of the leading causes of blindness in 2002, will be eliminated.
Ametropias will be treated quickly and effectively by computer mapping of the cornea and feeding this data into a laser that will make the indicated corrections for myopia, hyperopia, astigmatism and presbyopia. The patient will leave the office emmetropic, wearing sunglasses with ultraviolet blockers.
The need for eyeglasses and contact lenses will almost disappear, but sales of protective sunglasses will skyrocket.
Everyone will have a personal card on which is imprinted all their personal, insurance and medical data. This will be inserted into a processor, and the information will appear on monitors. New data will be input by voice-activated digitalization. The approved fee for services will be charged to the patient’s insurance company or to the patient, and that fee will be automatically deposited into the physician’s bank account from the payer’s bank account — all accomplished by wireless telecommunications. This development will significantly increase efficiency, thereby lowering the cost of doing business for both the physician and the payer, resulting in a lower cost for health care. This will have significantly eliminated the health care cost crisis.
Are all of these predictions a fantasy? Sixty years ago, watching rocket ships travelling in outer space were also considered fantasies. Look what happened in the future!
Thanks to John Pinto and Jay Norieka, MD, for their meaningful assistance in preparing this article. Michael J. Parshall’s article “Is Ophthalmology’s Golden Age Just Ahead?” published in Ophthalmology Management, was also helpful.