My first week of ophthalmology solo pracrice

March 7, 2011: I need a tech.  J/k.  I just took an RNFL OCT on a patient, and it took me 20 minutes to get it right.  Partly because I had no idea what I was doing and partly because my patient was looking all over the place.  I ended up settling for a signal strength of 6/10.  Nevertheless, he was happy with my service.  Turns out that he was the “scout” amongst his group of friends.  Now that he knows what I’m like, he’ll be returning with an army of 70+ year olds, including his wife.

I have 3 patients on my schedule today.  At this point, I don’t think I’m even capable of handling 15 patients.  I’m still getting accustomed to my EMR and the equipment.  So far, I’m pretty satisfied with EyeMD EMR.  The customer service, for one, has been absolutely phenomenal.  I’ll need to spend more time customizing it to make it optimal, but there’s lots of potential.  So far, my fastest new patient visit was 40 minutes from start to finish with my EMR.  Looking forward to seeing what it can do for return visits. 

March 9, 2011: Wow.  As I have said time and again, financing has been the complete bane of my startup.  I finally closed on all my equipment today!  I’ve been in limbo with my Ellex Ultra Q YAG laser for about 2 months now. 

My credit is pure junk right now.  My FICO score is 715 with 15+ hard inquiries.  Still, I can’t believe how difficult it was to finance this $30,000 piece of equipment.  One company offered me loan shark rates at nearly 30% over 5 years with a 20% security deposit!  If I wasn’t able to get anything better, I was actually going to take it.  However, before I signed on the dotted line, I just had to look around one last time.  Thank goodness I did.  I figured, how much worse can my credit get, and at this point would it even make a difference?  

I ended up going with another broker at 15.5% with no money down.  Still high, but much prettier than 30%. 

I’m finally done.  O’Connor hospital will be getting a Lumenis Selecta Trio soon, so I should be able to do my SLTs, PRPs, and focals over there for the time being. 

I never ever want to fill out another personal financial statement again.

March 11, 2011: I know I’ve been on a high horse all along saying how money doesn’t matter and what not, but as I’ve been submitting electronic claims to insurance companies, I can’t help but realize how much potential there is as a solo practitioner.  Having been paid $20 an hour in residency regardless of how many patients I saw, it really behooves me to know that the more I work, the more I will make.

Let me give you an example.  Today, I saw only one patient, but I will have paid for my rent and my front desk person’s salary for the day through him!  This guy came in with a metallic corneal foreign body in both eyes.  I was able to bill him for a 92004 (new patient comprehensive eye visit) with a 25 modifier (for same day procedure), and I was also able to bill a separate 65222 (removal corneal foreign body with slit lamp) procedure code for each eye (RT and LT modifier)!  If this patient had Medicare, I would receive $165 for the 92004 code and $85 for each 65222 code.  In addition, corneal foreign body removal has no global postop period, meaning that I’ll be able to bill him for the follow up visit tomorrow also!  Now this guy has commercial insurance, so I’ll probably get an extra 10% more than the Medicare fee schedule.  And all this for a 30 minute visit. Crazy.

Of course, as my new patient volume settles down as I get more established patients, the reimbursements will be a bit lower.  Obviously, my volume will be much higher though.

Howie’s notes: when you first open you’ll need the time to train on everything and learn how to run your office. If you know how to do every task, no employee will ever be able to hold you hostage or be irreplaceable. Don’t feel like you need to do stuff you don’t want to do such as see vision plan patients or do inpatient and ER consults just to get patients though the door (but if these fit into your long term plans by all means go for it). Focus on the long term goal of running your practice efficiently.

Yes seven years later everyone in our google group including myself and Ho Sun who uses EyeMD still thinks it’s great.

You don’t need a tech when you’re starting from scratch. Five years later I still have only one employee and Ho Sun two. 15 patients is the most I can handle without a tech unless some of them are quick IOP checks or post ops. Many folks fresh out of training might be eager to see as many patients as possible, and in some ways this is wise to get clinical experience, but you can make a great living running a low overhead micropractice. Indeed, many (but not all) folks who are independently wealthy would prefer to chuck their 50 patient per day mill and not have to deal with the headaches and keep it simple and run a small practice.

Similarly, you don’t need every piece of equipment when you’re first starting out. Comprehensive ophthalmologists will still want a OCT which was the most expensive ticket in my start up. But five years later I still don’t have a Yag laser and do the procedures at my ASC. This is off topic, but this makes it MUCH more expensive for society due to ASC facility fees, which can be multiples of the surgeon fee, and more expensive for the patient (copay or coinsurance for the facility fee). Most of our google group has a Yag simply for the convenience of going to the ASC and to attract more referrals. My Yag volume simply isn’t high enough to justify getting one for my office. If you decide you want one, you could wait six months after opening until you’re in the black and your credit score is better to proceed. You probably won’t be doing that many the first few months after opening day.

If you’re a retina specialist, you may not need a visual field to start off with. And to conserve capital I didn’t even get a second exam lane until last month, my fifth year in practice. This may be overkill, but my point is you don’t have to open up with three exam lanes and every piece of equipment. Add it gradually.

One key metric is your revenue per patient seen. This is calculated by total revenue divided by total encounters (including surgeries and postop visits). Don’t bother calculating it your first few months of practice because your payments will probably be delayed. For comprehensive ophthalmologists, it’s all over the map, from $130-200, I’ve heard many folks are around $150. This would be a good number to use for pro forms projections (which I didn’t do; I winged it and had no idea what my income would be, when I first started up). It depends on your insurance reimbursements, number of procedures, surgical density, aggressiveness with elective cash pay procedures, whether you take vision insurance, whether your are conservative with testing or overtest, etc. For retina and oculoplastics specialists I hear the revenue per patient is higher. Retina perhaps $180-250(?).

An important point about benchmarks is they aren’t a be all end all. If you are higher or lower than national averages it’s important to understand why, but you may purposely want to keep things that way. For example, my total revenue is way less than than average, but my overhead is also much lower at 30% (36% with equipment deductions). We will have a post on benchmarking later!

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