Ophthalmologists: Will 2015 Make You or Break You?

Laird Harrison


January 30, 2015


Ophthalmology in the United States is shifting from medical arts to medical engineering, and that trend will affect many aspects of the profession in 2015.

That is the assessment of the top practice management consultants we asked to look at the year ahead. Payers are demanding more detailed accounting of how ophthalmologists do their work. And they are tightening their purse strings, forcing practices to become more efficient. As a result, the experts say, fewer ophthalmologists can operate with creativity and autonomy in the coming year, and only the pragmatic will thrive.

But the forecasts were not all dreary. On the clinical side, says a spokesman for the American Academy of Ophthalmology, rapid advances in ophthalmic research may allow ophthalmologists to help patients in exciting new ways.

Practice Management Trends

In many respects, 2015 is shaping up to be a challenging year for ophthalmologists. Above all, mounting government regulations and increasing economic pressure will force many practices to consolidate and cut costs.

Consolidation."As the pressures of a reforming healthcare system build, we will continue to see ophthalmology practice consolidation," says John Pinto, a San Diego, California-based practice management consultant. "Some of this consolidation will take the shape of independent practices joining in with hospital systems or multispecialty clinics."

"There will certainly be another run at consolidation by private investment firms, as we saw in the 1990s," Pinto adds. "But by far the most common form of consolidation will be between private practices, which will aggregate into larger organizations to better deal with a reforming environment."

As more practices are combining, they are hiring more highly skilled and talented administrators to manage the practices, Pinto says. "As practice size grows, patients will shift from being under the personal care of Dr Smith to being in the care of Smith-Jones Eye Institute," he told a recent gathering of ophthalmologists.

More regulation. One reason for the trend toward consolidation is the increasing burden of regulation, says Derek Preece, a management consultant based in Incline Village, Nevada. For example, in 2015, the Centers for Medicare & Medicaid Services (CMS) is planning a switch from the ninth revision of the International Classification of Diseases (ICD-9) to the tenth (ICD-10). Private insurers are expected to follow suit. ICD-10 allows for many more codes than were included in ICD-9.

The change was planned for October 2014 but delayed by Congress until October 2015. Still, many practices are scrambling to learn the new codes.

At the same time, CMS has instituted the Physician Quality Reporting System requiring physicians to report data on the quality of the care they provide. Also, electronic health record requirements continue to flummox many practices.

The complexity of these requirements means that ophthalmology practices will need more sophisticated administrative staff, more training, and additional upgrades to their computer systems. The adjustment may also lead to delayed payments. By consolidating, ophthalmology practices can share these costs.

Reduced reimbursement. Reduced reimbursement is also contributing to the trend toward consolidation. Both CMS and private insurers are looking for ways to pay physicians based on outcomes rather than the number and type of procedures the physicians do. In some cases, this may result in less income for physicians.

"That hasn't happened in ophthalmology a lot yet, but in general the trend for reimbursements is downward," says Preece.

At the same time, many employers are asking patients to pay a higher proportion of their medical costs. "If I have cataracts, and I have a $4000 deductible, and I haven't had anything else done, virtually all of that cost is going to come out of my pocket," says Preece. As a result, patients are often dragging out their payments and looking for ways to save costs.

On the flip side, Preece says, improved online services by insurers are allowing practices to find out what percentage of a bill the patient must pay. As a result, practices can now ask for the patient's portion of the payment up front, instead of waiting to see what insurers will cover and then having to deal with the hassle of collections.

A shortage of ophthalmologists. In the past decade, the number of residency slots for ophthalmologists has dropped 11%, while the US population has grown 11% and is also aging, Pinto says.

And recent graduates are likely to put in fewer hours at work. "Many young ophthalmologists are less workaholic than their parents' generation," says Pinto. "This 'Gen-X' factor is compounded by gender and cultural issues. Half of all residency graduates are now women, sometimes keen to balance business and family life."

Preece adds that young ophthalmologists coming out of training are less interested in owning practices. Many come out of school with hundreds of thousands of dollars of debt, unable to buy their way into a practice. As a result, it's becoming harder for retiring ophthalmologists to sell their practices. "This trend represents an opportunity for larger eye clinics to grow market share through practice acquisition," says Pinto.

Increasing specialization. Faced with a shortage of ophthalmologists, many practices are delegating their healthiest patients to the care of optometrists, leaving ophthalmologists to focus on surgery and specialty care, said Pinto.

Refractive surgery shift. Laser-assisted in situ keratomileusis (LASIK) has not recovered the popularity it enjoyed before the 2008 recession, says Preece. "Some volume has come back up, but it's still pretty soft," he says. On the other hand, new refractive surgeries for cataract patients are providing a healthy income stream for some practitioners. "Cataract patients are paying out of pocket for astigmatism-correcting lenses and presbyopia-correcting lenses," Preece says, which Medicare won't cover.

But femtosecond lasers may offer more sizzle than steak, says Pinto. "In the present marketplace of ideas, it's hard to expect that femtosecond laser cataract surgery is going to ever become the standard of care in the way that phacoemulsification replaced extracap surgery unless pricing comes way, way down."


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