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There is no denying that we eye care providers are practicing medicine in a dynamic era. As more patients gain access to care, there are fewer dollars to pay for that care, yet the demand for high-quality delivery has grown. It is also no secret that eye care has seen the unintended consequences of these changes: our little corner of medicine is facing provider shortages, dwindling reimbursement, and market forces that threaten the viability of solo and small practices.
For years now, increased efficiency has been the buzzword. The thinking has been that eye care practitioners need to figure out a way to increase patient volume to create more revenue. What has followed has been a bottom-up change in the way eye care is delivered in response to the top-down forces (namely, regulation and changing economic realities). The net result has been positive for the eye care industry, and, ultimately, for patients. Several innovations have changed the eye care space, including integration of care extenders, a more complete understanding of practice management dynamics, and a generally more thoughtful approach to how technology can make us more efficient.
All of these approaches are aimed at increasing numeric volume within a practice (fitting more patients in during a given day), which is certainly one approach for expanding revenue to offset lowering reimbursement. There is perhaps another model for growing one’s practice, however. The demand for aesthetics and the ability of eye care practitioners to participate in this field represents a means to expand the practice and diversify as a way to escalate volume.
TRULY INTEGRATED CARE
My current practice model is admittedly a bit out of the norm compared with most of my colleagues in ophthalmology. Belcara Health is a multispecialty practice in the sense that we offer the full gamut of aesthetic and cosmetic services from the toes to the top of the head. Our clinic has practitioners in plastic surgery, dermatology, ophthalmology, and podiatry. We are in the process of incorporating an internist who specializes in weight loss, hormone therapy, and other wellness concepts. We also have a medical spa, two ORs, and a retail area that combines products from these different areas. Although atypical, our practice philosophy is simple: we seek to create a truly integrated model where a patient can come in and get head-to-toe care in a high-end setting—one that encourages a sense of wellness and attention to detail that might not be present in a traditional ophthalmology practice.
The selection of the clinic’s specialties was deliberate because of the natural “cross-pollination” among them. On the one hand, we have a set of trigger medical diagnoses that automatically prompt referrals to other interoffice specialists. Patients with diabetes, for example, are recommended to follow up with the staff dermatologist to review potential skin issues that I have already seen, to understand if any ocular complications are occurring and are also sent to a podiatrist as needed. We know from experience that individuals who express a desire for cosmetic procedures, such as LASIK, might be amenable to other services, such as face-lifts or breast augmentation.
My practice consists of more than boutique services. In addition to aesthetic and cosmetic procedures, I also treat diabetic eye disease, macular degeneration, glaucoma, cataracts, and other ocular conditions. This is important because as ophthalmologists and optometrists have begun offering aesthetic services, there has been some push back from other medical specialties. A potentially sensitive area, this is something that physicians should think about, both within their clinic and in their geographic location.
In our practice, we have defined where one set of services begins and another ends, creating clear boundaries. Rather than an atmosphere of contentious competition, we foster an environment of complementary integration. We intentionally offer services such as a full wellness program, where a patient can get a mole checked, have a cataract evaluation, and receive a cosmetic injection in the same day. A patient with facial rosacea can see the dermatologist and the eye care provider, because the condition may require treatment by both. A patient undergoing an eyelid procedure in our plastics clinic is also sent to me, so that I can assess the functional status of their lids and look for dry eye disease. There are medically relevant reasons for our care to overlap.
I think that the underlying principle of our practice model may be applicable to the larger question of how eye care can fit into the overall aesthetics market without creating territorial disputes. One could take the negative viewpoint that the aesthetic and cosmetic services eye care providers seek to provide are the natural territory of other medical fields. However, eye care should be able to add its expertise to what other specialties offer, resulting in greater total services to the patient population. Our training in eye care issues and expertise in the skin around the eye is an asset to patients’ overall health. Thus, we do not have to be only a number of different medical specialties paying rent to the same landlord (or, really, competing for the same insurance dollars or pool of out-of-pocket expenditures). Instead, the idea of collaboration offers a model to address the multiple needs of a shared and diverse patient base.
Our practice model can be seen as analogous to the age-old financial advice, “Don’t put all of your eggs in one basket.” We have diversified our service offerings so as to obtain revenue from different sources, thereby insulating ourselves against financial cutbacks in health care. In addition to the insurance-based services of traditional eye care, we have added a number of cash-based options for patients who want them.
The US health care system is subspecialty based, and providers typically pull from a finite set of patients (further confined by one’s geography). When multiple subspecialists practice in the same locale, they compete for the same patients, thus creating a natural ceiling on the potential for growth. Expansion potential seems then to exist in lateral growth by diversifying the patient base.
I have come to realize some things while practicing aesthetic medicine that have allowed me to maintain a solo practice mentality. I think one of the unfortunate unintended consequences of the hospitalist movement in the health care system is that solo and small practice ophthalmologists have been forced into larger conglomerates to gain purchasing power. A larger economic framework is good insurance against lagging revenue. Yet, our practice has achieved economic flexibility through subspecialist integration. Our technicians and office staff are cross-trained (another aspect of integration), and we have centralized marketing and billing services that handle our collective back office needs. The fact that I have been able to maintain a personal approach to medicine appeals to me. I imagine aesthetics and cosmetic services could offer a similar level of freedom to like-minded practitioners who want to maintain a small-office approach to eye care.
STRENGTH IN NUMBERS
There are many aspects of our integrated model that are easily identifiable as beneficial for the provider side. From the patient perspective, we are able to provide an exceptional level of easily accessible care and unprecedented convenience. Many patients are interested in lifestyle health, which describes a positive construct built around the idea of empowering patients to better understand and manage their disease condition. In addition to emphasizing preventive medicine, lifestyle health invites patients to seek enhancement of their health through wellness and beauty. It is built on a philosophy of holistic care.
The eye care field lends itself naturally to introducing aesthetic services. Most obvious is that many patients have concerns about aging around the eyes, which is a natural entry point into a discussion about injections and fillers. Ophthalmologists and optometrists receive training in the anatomy of the area around the eye, and ophthalmology has always been one of the core specialties that has been involved with the use of onabotulinumtoxinA toxin (Botox; Allergan). Speaking to patients about services around their eyes offers a path into discussions about the skin around their nose, chin, and neck. From there, it is not hard to imagine becoming a trusted advisor on other health and wellness topics.
When providers are thinking about new services to their practice, whether or not it will enhance patients’ outcomes should be of utmost importance. There is overall value in diversifying one’s practice to be successful during times of change. Adding clinically meaningful services brings in new revenue streams, allowing the practice to maintain economic viability and ensure the continued delivery of the core services that eye care patients expect.
Richard A. Adler, MD
• director of ophthalmology, Belcara Health Premier Multispecialty Center, Baltimore
• assistant professor of ophthalmology at Wilmer Eye Institute, Baltimore