In August 2005, after 11 years in practice, Sienne Van Enk, O.D., finally fulfilled her dream of opening her own practice. Now a year into the management of Optometric Concierge, in Harbor City, Calif., Dr. Van Enk hasnt yet reached the breakeven point, but she thinks it is just around the corner. 

Right now, Im just enjoying being able to spend a lot of time with my patients, she says. Shes also steeping herself in practice management and the business side of the practice to ensure she reaches profitability and can stay in business for the long haul.

Dr. Van Enk had hoped to start her own practice long before now, but health problems and family matters dealt her a few setbacks. She graduated from UC Berkeley School of Optometry in 1994 with a pile of school debt, a 15-month-old child, and newly diagnosed leukemia. Board exams and a job search were put off for extensive medical treatment that, fortunately, put her cancer in remission. At that point in my life, security was really important and being an employee seemed more attractive than private practice, she says. 

Dr. Van Enk spent seven years at Kaiser Permanente in Harbor City. It was a great situation for methe income was steady and the hours were convenient. I was able to really focus on patient care without worrying about budgeting, marketing or managing employees, she says. She enjoyed treating entire families, from infants to senior citizens, and watching them grow and change.

But, eventually, the pleasant atmosphere began to break down, particularly after Kaisers optometrists unionized and the administration began pushing for greater productivity, she says. I realized that I could work just as hard and feel much more gratified in my own practice, Dr. Van Enk says. 

She realized there was never going to be a perfect time to open a practice, so after a year of planning and working with a consultant (Gary Gerber of the Power Practice), she took the plunge. Dr. Van Enk financed the equipment and initial operating expenses through a leasing company, HPSC Inc. Together with some savings and a line of credit, it was enough to get going. Buildout of the space she chose took four months (twice as long as anticipated), and marketing and finding the right staff have been ongoing challenges. 

Nevertheless, launching a practice when shes already very confident in her clinical skills has made everything much easier, Dr. Van Enk believes. Working for an HMO, I was a gatekeeper for the ophthalmologists, so I had an opportunity to see a variety of pathologies and treat a much broader range of patients than I would ever have seen in a typical private practice, she says. 

Now, Dr. Van Enk is seeking to build a high-end market niche that focuses on treating patients like family. This is sort of the opposite approach from a high volume HMO, she says. My hope is that, in creating a practice that reflects my ideals and the right balance for me, patients will also feel special and will become patients for life.

To that end, her reception area is set up to feel like a living room and appointment slots are long, something she hopes to continue even as her practice grows. Patients just want a little of your time, they want to feel heard. If patients come back to me year after year, it wont matter how much Im able to sell them at any given visit. I think the financial rewards will come as a consequence of providing good patient care, she says. 

Running the Numbers

To analyze your insurance plan participation, run the following reports by insurance plan, listing plans in rank descending order:
  • Number of patients.
  • Total revenue generated.
  • Average revenue per patient.
  • Timeliness of payments (% paid within 30 days, 90 days, etc).
  • Frequency of claims denials or request for resubmission.
  • No-show rate.

Once you have the data in order, consider dropping plans that rank poorly on the above measures.

Working Smarter

Many optometrists in the early to mid-career phase already have several years of private practice under their belts.  The initial hurdles of starting a practice and keeping the business in the black have been overcome and the clinical skills are honed. This is the time, says practice management and managed care consultant Gil Weber, M.B.A., to start working smarter.

When you are just getting started in practice, the natural inclination is to get on every insurance panel out there, Mr. Weber says. But after 5 to 7 years, you really should be re-evaluating which vision care plans are most appropriate for your practice.

He recommends running some simple reports in order to rank all the plans in which the practice participates (see Running the Numbers, above). Essentially, you want to know which insurance plans are bringing in patients andeven more importantlywhich ones are bringing in profitable patients, he says. If lots of patients from a poor-paying plan are filling your appointment slots, they may be displacing better paying patients.

The key is to watch for discrepancies, he says. If most of your patients come from a plan that is only your fourth largest revenue generator, for example, you are working too hard for too little revenue from those patients.

A plan might generate more revenue or more revenue-per-patient because the plan compensates better or because patients with that plan are more likely to upgrade to premium frames.

In any case, the savvy O.D. might want to adjust the appointment schedule to be more available to patients from these plans. You might want to reserve premium Saturday or early morning slots for private-pay patients or those from better-paying plans, Mr. Weber says. You can do this simply by encouraging other patients to book weekday appointments.

Another way to insulate yourself against the vagaries of vision plans is by practicing to the full extent of licensure. The revenue stream from vision care alone is limited, says Mr. Weber. As optometrys scope of practice has expanded, optometrists have the opportunity to practice more medical eye care, which can be both more fulfilling and more lucrative, he adds

Full Scope of Practice

Vito J. Guario, O.D., agrees that expanding into disease management is important for practice success. The Davie, Florida-based optometrist did post-graduate training in ocular disease and went to work right out of school for an ophthalmology practice. Since 1989, hes been a staff optometrist and director of optometric relations at Aker-Kasten Surgical Eye Institute, a large ophthalmic practice in Boca Raton, as well as maintaining a private optometric practice of his own in Davie.

I practice full-scope optometry, Dr. Guario says. Although hes been medically-oriented from the start of his career, he says its never too late to move in that direction.  If you dont regularly use the medical skills you learned in school, you wont be comfortable providing that care for your patients when the need arises. 

For doctors who want to diversify their patient care, but havent done a residency or post-graduate training, he recommends increasing the number of continuing education (CE) hours in ocular disease management, reading trade journals, and attending wet labs on advancing technologies such as glaucoma imaging and punctal plugs. Shadowing a medically-oriented colleague can be very helpful.

You also need to purchase the equipment necessary to support an increased scope of practice, Dr. Guario says. Additional equipment to consider might include jewelers forceps for suture removal, spud and Alger brushes for corneal foreign body removal, a goniolens or vitreofundus lens for more in-depth examinations, a pachymeter, and a visual field analyzer. Once the education and equipment are in place, inform your patients about the full scope of services you can offer through internal and external marketing and, most importantly, through patient education in the exam room, he says.

Dr. Guario thinks developing these skills is important not only for an individual doctor or practice, but for the profession as a whole. The ability to provide medical eye care and to triage patients to the appropriate specialists or surgeons when needed solidifies our position as the primary gate keeper for eye and vision care, he says

7 Tips for Working Smarter

  •  Build relationships with patients so they come back to you even if their vision coverage changes.
  • Avoid being too dependent on a single vision plan for the majority of your patients.
  • Participate in a broad range of plans IF they make sense financially.
  • Expand your scope of practice into medical disease management and, where possible, participate on health care insurance panels.
  • Be aware of the local marketplace so you can act fast when the school district or a large local employer shift gears.
  • Consolidate multiple fee schedules into one fee schedule that makes sense for private pay patients and all your plans.
  • Review usual and customary fees at least annually to ensure you are at least at Medicare allowable, higher than all of your contracted third-party payer allowables, and at or above local averages.

Source: Gil Weber, M.B.A.

Grow Your Reputation

Dr. Guario has also developed a reputation for excellence in his community and in the profession by helping to educate optometry students and fellow clinicians. He regularly hosts Nova Southeastern optometry students for ocular disease rotations and has given numerous educational presentations.

Becoming an adjunct clinical professor for a nearby school of optometry can be a great addition to the C.V., as well as a nice way to give back, he says. Optometry schools are always looking for clinical rotation sites and generally welcome contacts from interested optometrists.

In addition to academia, organized optometry, local health departments and the eye care industry all present opportunities for optometrists to get involved outside of clinical practice.

There are enormous opportunities for optometrists within industry, agrees Derrick Artis, O.D., M.B.A., director of professional affairs for Vistakon, Division of Johnson & Johnson Vision Care.  Dr. Artis practiced for 10 years before leaving active practice for the corporate world.

The companies that make and market contact lenses and solutions, spectacles, and ocular pharmaceuticals all hire optometrists to do research on new materials and product designs, serve as medical directors, work on clinical and regulatory claims, or manage relationships with and continuing education for their customer networks.

Such positions need not even mean giving up on patient care, Dr. Artis says. Vistakon has a number of consultants who work two days a week with the companys Professional Affairs Team, but continue to see patients in their own practices the rest of the week. There are many similar arrangements at other companies, in academia and with local health departments.

Optometrists also play an active role with industry by serving as clinical test sites, participating on speakers panels, and lecturing as continuing education providers. I think doctors benefit from these activities because they develop patient care and other skills that they might not otherwise develop.  They can also use their industry connections as a marketing tool in their practice, Dr. Artis says.

How do O.D.s get connected with a particular company in the first place?  Sometimes its enough to just express an interest to professional affairs staff like Dr. Artis. But many are approached through their sales representatives, he says.

Thats exactly what happened to Michael A. Slusky, O.D. He now teaches optometry students how to fit bifocal and toric contact lenses at Vistakons Vision Care Institute, and lectures nationally. He originally came to the companys attention when his sales representative asked him to share with others how he successfully introduced a new product to patients. Today he is considered a key opinion leader, according to Dr. Artis.

The relationship works both ways, says Dr. Slusky, who practices in Chicago. A good sales rep can really help you expand your potential as an optometrist, he says.  They can provide tremendous in-office support on how to use and prescribe products, and show you how you can maximize your practice.

Make Any Setting Work

Dr. Slusky has a long history of going the extra mile to maximize his practice. While still in optometry school and even as an undergraduate, he schooled himself in the business of optometry by working as an optician and technician, getting lab, sales and patient care experience. After graduation, as the managing optometrist at a Lens-Crafters, he didnt settle into coasting mode as some might have done. Rather, he grew the practice dramatically, turning it into a top producer with one of the highest patient satisfaction rates in his region.

He was keeping an eye open for a chance to open his own practice, but couldnt afford to buy or start a practice cold. When Costco came to Illinois and advertised for leaseholders, he thought it looked like a cost-effective way to launch a practice.

I have great exposure to a captive audience, which really helped to drive patient traffic in the beginning, before Id had a chance to develop a reputation, he says. Costco leases him the space and equipment and runs the optical shop, retaining all the frame and contact lens revenues. This setup really puts the optometrist to the test of building the practice based on the quality of his professional services, he says. 

Dr. Slusky has nothing but praise for the way Costco runs the optical shop, the range of cost-effective products he has access to, and how that has helped his practice. Costco is very supportive of any fitting challenges and really put the needs of members or patients first, he says.

He has relished the opportunity to work with the contact lens industry as a consultant.  My patients truly value this role because they know that with every annual examination I will have something new and healthier to prescribe. This allows me to distinguish myself from other colleagues in the same mode of practice, he says. 

In seven years, hes grown the practice tremendously, expanding to a second Costco-based office in Chicago and adding other optometrists, clerical staff and specialized equipment.  

Of course, there are challenges to this mode of practice. Even though the practice is his own, Costco has more hands-on involvement than a typical landlord. The lease is year-to-year with just a 30-day notice required, compared to a standard commercial five- to ten-year lease for office space, so Dr. Slusky knows his situation is not as secure as he would like it to be if Costcos priorities should change. 

My wife is currently an optometry student, and we plan to expand our practice as a team, he said.

Dr. Slusky admits he initially had a bit of a chip on his shoulder about practicing inside a shopping warehouse that people associate more with bulk snacks and diapers than with professional eye care. But a mission trip to Morocco highlighted for him that service is the key whether you are on Main Street, in the middle of a desert, or next to the electronics aisle. The minute I close the exam room door, it doesnt matter where I am. What matters is who I am with my patients.  Ive chosen to define myself by the quality of care I provide, he says.

Next in the series: In October, well look at practice expansion for the mid-career optometrist.

Vol. No: 143:09Issue: 9/15/2006