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Competency plus output equals productivity
It’s not just what you know, it’s what you can produce that will help you.
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The year is 2141, 139 years in the future. Based on current trends, I can nearly picture the ophthalmologist of the future. In profile, he or she looks more like a gymnast than a clinician. He’s wearing a Lycra body suit, high-traction shoes and a wireless ear piece and microphone that were implanted years earlier for convenience and better sound quality.
With a word into the mike, “Dr. Lycra” can call up data on the next patient, including the provisional diagnosis and treatment plan, which have dropped out of a formula from all prior, automated workups and pre-testing. Around his waist, looking a little like a futuristic cop’s crowded holster, is a tool belt, festooned with a hands-free indirect, an occluder (a sentimental antique from his great-great-grandfather’s practice) and a solid-state, infinitely tunable, hand-held laser.
An array of drops and ointments can be delivered to his fingertips with a simple voice command. During each exam, the practice’s voice recognition software records the doctor’s chart notes, and without being asked provides prompts for any missing data or overlooked questions. Annoying, but effective. And it’s virtually eliminated malpractice suits.
After the exam, color-coded lights that seemingly float mid-air in the center of the hallway direct patients to their next destination in the practice.
“A pleasure seeing you this morning, Ms. Hays,” Dr. Lycra says. “Based on our tests, that cataract in your left eye will be ready for laser extraction in about 38 or 39 months; we’re not precisely sure yet. Please follow the green flashing light to Robby in optical. He already has your complete record going all the way back to 2041 when you were a girl. He also has your new prescription and has picked out the 10 most popular frames in the North American Alliance for women with your skin coloring and bone structure. I know you’re going to love what you see! It’s amazing, really. You know we almost stopped selling glasses 40 years ago, until they became big fashion again. But listen to me talk. Here I am 72 and going on like a guy who’s ready to retire. I’ll see you right here in 37 months.”
At 10:04 a.m., just 26 minutes after she arrived in the clinic for a complete exam, Ms. Hays is on her way out of the office. She only interacted with two real people, her doctor and her optician. The rest of the time, she simply followed the logical directions of one video screen and one gentle, disembodied voice after another. Meanwhile, in not much more time than it’s taking you to read this paragraph, Dr. Lycra has seen another patient and squeezed in a few more seconds to push the button that rebalances his nutritional and energy state. He’s all set for the last 47 patients of the morning before meeting his wife for lunch at noon. Incidentally, he’ll have to remove about three or four cataracts that afternoon to pay for lunch. Unless they order dessert.
Getting there from here
Unfortunately, we don’t have a time machine. We can’t come back here to 2002 after a trip to the future and bring back all of Dr. Lycra’s labor-saving and energy-boosting devices. But we had better do something. And fast. Based on current trends in reimbursement, and the slowly rising cost of doing business, your personal income as a surgeon is destined to be falling year after year unless you are able to improve productivity.
The math is rather simple, and I’ve covered it in this column before. Let’s say you see an average of 35 patients per day, 3.5 days a week, 48 weeks a year, and you have an average ticket of $150 per patient visit and run a practice with a 60% overhead. You’ll make about $350,000 this year. If there’s a net fee reduction of just 5%, and all expenses stay the same, you’ll be taking a 12% pay cut. If expenses also increase a typical 3%, you’ll take a 17% net pay cut.
To make up for these impacts, you would need to see about another 7% more patients, or 2.5 patients per day. This productivity gain is a lot more likely to be accomplished than the 8% cost savings it would take to yield the same profit restoration. (Getting rid of 8% of your costs in a single year would be equivalent to lopping off one full-time staff member in a solo practice, or nearly all of the marketing or facility costs.)
The best, most practical, reasonably sustainable way to slay the fee reduction dragon is with increased personal productivity. And you don’t need Dr. Lycra’s slick suit or tool belt to get there.
Measure your productivity
The starting point is to first measure productivity for every doctor in your practice, and in every setting if you have multiple offices. There are numerous, meaningful ways to measure a doctor’s productivity:
Weeks worked per year. This is the grossest measure of a doctor’s output, and doesn’t really count much, except to ask, “Is the doctor showing up for work?” Most physician and optometrist employment contracts specify the maximum allowable number of vacation days or weeks permitted. For partner-level doctors, this usually tops out at about 13 weeks off per year before a partner has to revert to being an associate.
Hours worked per year. This metric is a bit more precise and constraining. I’ve seen doctors who didn’t like being boxed into 8 or 10 weeks of vacation per year by their partners, so they started working 6 hours a day to get even. Anything more than 2,000 hours a year is a reasonable target for a full-time doctor; hard-working practice owners often work more than 2,500 hours per year.
Patient visits per doctor per month. Now we’re getting somewhere, measuring more than attendance. We’re looking at raw throughput. For an energetic general ophthalmologist, I like to coach clients toward not less than 550 patient visits per average month. If you see patients in clinic 3.5 days per week, 3.5 weeks in the typical month, that comes to about 45 patient visits per day, or about one patient every 10 minutes, not counting breaks and other time off the clinic floor.
Optometrists should be able to see 300-plus patient visits per month. Subspecialist ophthalmologists should fall between these two extremes, seeing somewhere in the range of 450 or more patient visits per month.
Surgical and optical density. Of course, clinic time and volume is just part of the equation. Under many managed care fee schedules, the cost to transit a patient is barely covered by the basic exam fee. In most practices, profits flow from surgical procedures and optical products. Divide the number of patient visits you see in a month by the number of cataract, LASIK and other major surgical cases.
Unless you have a young practice, an especially conservative practice or work in a competitive market, the result should ideally be a number at or under 25. In other words, you should see about 25 patients or fewer before coming across each surgical case (a single eye). If you dispense, the optical density of your practice should mean that you sell about $200 in optical goods for every $1,000 in professional medical/surgical services you sell (omitting ASC fees, but including special testing fees).
Revenue per patient visit, or “average ticket.” Divide your annual collections by the total number of patients you see in a year (including unpaid postop visits.) If you’re a typical physician, the number should come close to $150. It will be higher if you dispense glasses, and much higher if you include collections from an ASC. It might be lower than $150 if you’re surgically conservative, or are constrained by a managed-care heavy market.
Profit per doctor-hour. This is where the rubber truly hits the road and gets traction. In at least purely commercial if not especially professional-sounding terms, it’s the gold standard for seeing how your productivity measures up against your peers.
Simply take the total annual profits before depreciation and doctor compensation and divide it by the number of hours your doctor(s) worked in the same year. The number may be as low as $60, or as high as $600 or more.
What counts is not so much how you stack up against your peers — inside or outside your practice — but how you’re doing compared to yourself in each successive year of your career. As an aside, this is a great way to determine if your satellite office work is worth the time, trouble and travel compared to your main office.
Patient satisfaction counts, too. Raw productivity, without both the perception and reality of great caring, is a prescription for practice disaster. If you’ve recently turned up the heat and are now more highly productive in raw patient visit terms, but in your hurrying convey a sense of disregard or indifference, you’re just going to do harm to your practice all the faster, not help the bottom line.
No magic
There’s rarely anything magical about increasing your productivity. The most productive surgeons I know move through their clinic with an economy of motion, a sort of ophthalmic ballet, that’s probably as hard to master as the real thing.
If you can’t work more elegantly, you’ll have to settle for longer hours and greater intensity, and thrash along as best you can. You’ll have to avoid as many wasted steps as possible, stay on the clinic floor and stay off the phone as much as possible. Save your internet and e-mail time for the end of the day. You should arrive somewhat before the first patients, huddle with technical staff about the day and then start the clinic alongside them, helping them work up the first few postops and quick checks.
If you find yourself mentally foggy at the end of a day of seeing patients, you’re doing something wrong. Get more sleep. Take a noon nap of not less than 20 minutes (anything less will not work against any sleep debt, and may actually leave you groggier than you started.) Eat better and smaller and more frequent meals. Exercise. If appropriate, take off those extra few inches; imagine how much more energy you would have at the end of the day if you didn’t have that extra 20 pounds hanging around.
Ultimately, like so much of your professional life, it comes down to discipline. Have the discipline to examine thoroughly where you really stand and where the trends are taking you. Don’t be an ostrich and assume you’ll somehow muddle through as you always have in the past. The last decade of Medicare fee reductions have been nibbles compared to the considerable “chomps” ahead of us. Have the discipline to admit to your soft points, and commit to their improvement.
With any luck, like the future Dr. Lycra, by taking lots of small incremental steps, year by year, you’ll stay ahead of the falling fee curve, and ahead of the doctors to the left and right of you in town, who you had better assume are reading this article and tuning up their game, too.