How to see 50 patients a day at your practice

Most ODs are not seeing as many patients per day as they think they are, says Peter Cass, OD, at SECO 2019 in New Orleans.

At the end of the month, when an OD calcuates the number of comprehensive exams by how many hours he was in the office, the number of patients seen is often much lower than was expected. 

ODs today are seeing approximately 1.2 patients per hour.¹ With the average income per patient visit around $300-eye exams being the biggest revenue generator-adding just two more patients per day can increase an OD’s monthly gross to $12,000, and lead to an average net of $3,600 each month.

Dr. Cass sees an estimated 50 patients per day.

This high number is largely due to one key component he and his staff have implemented at his practice: efficiency.

Efficiency is just one necessary adjustment Dr. Cass has had to make in order to keep up with the constant changing landcape taking over the optometric profession and more traditional form of office visits.

Related: Blog: 10 eyecare apps for more efficient patient care

Technological advancements
Services such as at-home vision testing-particularly in the large metro areas-and self-service healthcare stations are offering alternative options for patients outside of traditional in-office visits.

Kiosk service stations have popped up outside of local pharmacies using Food and Drug Administration (FDA)-cleared and Health Insurance Portability and Accountability Act (HIPPA)-compliant medical devices, receiving funding from major healthcare organizations like Novartis and the National Institutes of Health (NIH). Smartphone applications have even developed retina imaging and visual acuity tests.

These advancements lead to one question, Dr. Cass says: Why is health care changing so much?

Changing landscape
A few significant factors come into play, such as:
• Rising cost of conducting business
• Increase in state, federal, and professional compliance concerns
• Increase in payor system complexity
• Decline in reimbursement

With these changes comes a need for adaptation. “There are still opportunities in wellness care,” Dr. Cass says.

As the nation’s population continues to grow, there are fewer doctors graduating frome optometry school and more insured patients, and there is a gap, he says.

Thirty percent of children ages 6 to 16 have been reported as not having an eye exam in the last 24 months.² By 2050, the number of people with visual impairment or blindness in the U.S. is expected to double by more than 8 million.³

Related: Use technology advancements to modernize your practice

“There is a huge rural OD manpower shortage,” Dr. Cass says. “In my (rural) town, it’s pretty hard to find somebody.There are about 400,00 people-so it’s not tiny, but it’s also not a big area. That’s where everyone should want to be. There are tons of opportunies in the rural area there.”

Online threats are real for ODs, but only a percentage of patients choose to buy online. “There aree those patients who still want that personal touch, that experience of going in and trying on frames in-person. And there are a lot who are going to favor a private practice doctor.”

Some patients will always opt for lower-priced products and services, while others know they get what they pay for.

“We don’t put cheap frames in our office, and we don’t use cheap lenses because they are not the best,” Dr. Cass says. “I want to provide the best eye care-hire the best staff and personnel-and provide the best service.”

There is more medical care needed and opportunities to service discerning patients. Capture that, Dr. Cass says. Offer comprehensive and individualized care to these individuals.

Manage-do not refer, Dr. Cass advises.

“There is so much stuff in optometry that gets referred out when it shouldn’t be. Manage it and keep it in-house,” Dr. Cass says.

Related: Virtual reality, tablet devices capture visual fields in unconventional ways 

Practice efficiency
Be creative and aggressive in the ophthalmic product options you offer, Dr. Cass says. He emphasized four key points that have allowed him to increase the number of patients he sees per day, and operate his practice with optimum efficiency:

• Manage the schedule
• Hire staff with great personalities
• Leverage technology
• Optomize workflow
• Fully delegate tasks

An alternative advantage of increasing patient volume per day: freeing up an extra half-day or full day to use at the OD’s discretion.

A few key areas are crucial to increasing efficiency at your practice, Dr. Cass says.

Scheduling
Electronic health records (EHR) help the most with efficiency, according to Dr. Cass. Most EHR programs have templates with color coding that enables an OD to block out certain times of day. Train staff to handle this, Dr. Cass says.

Even with an average jam-packed schedule, Dr. Cass says he is able to leave the practice each day within 30 minutes of office hours closing.

“It’s pretty rare for me to be there later than that,” he says.

It’s all about having a good staff, putting procedures in place, and making better use of your time, he says. To handle a busier patient schedule, Dr. Cass recommends hiring additional staff members.

While more staff means more costs, bringing in just one or two more patients a day can cover expenses and still result in higher profits, according to Dr. Cass.

No-show patients are common at any practice-data reports as high as 25 percent in optometry.⁴ Well-controlled, it’s hard to get that number below 5 percent, he says.

Dr. Cass suggests minimizing the profit loss from no-shows by double-booking certain appointment slots.

“You know you’re going to have some no-shows happen,” he says.

Related: Tips and tricks for utilizing EHR

Appointments
“Patients tend to get antsy if they have to wait,” Dr. Cass says.

A typical wait time is 10 to 15 minutes at his practice. Patients are required to complete medical history forms prior online prior to arriving for their appointments.

“It is more thorough and saves us a ton of time,” he says.

Dr. Cass typically allots five minutes for patient check-in and five minutes until his staff brings a patient to the first exam room. As the practice has gotten busier, he says, he has designated one assistant to take a patient to the pre-test room, address the chief complaint, perform pre-testing, and then escort the individual to a second waiting room. From there, a second technician handles the remaining tests.

He and his technicians can usually complete both pieces in less than 10 minutes-often even less than that, especially on an established patient, Dr. Cass says.

Exam time slots are set to no more than 15 minutes, although they typically take less than that, according to Dr. Cass.

“I can routinely see patients in five minutes or so, without being rushed,” he says.

Optical exams are timed at 15 minutes as well, with an entire patient visit lasting no more than one hour.

“That’s our goal,” Dr. Cass says. “People don’t want to be there forever.”

Related: Understand millennial patients and staff 

Staff training
For a practice to be efficient, an OD needs a solid staff.

The most important thing to look at is personality, Dr. Cass says.

“Hire for personality and train everything else,” he says.

Dr. Cass uses the American Optometric Association (AOA) training program for his staff. He  offers his staff a monthly bonus if they are certified.

“You want everybody in your office to be certified,” he says.

Delegating certain tasks to staff allows for quick and efficient patient visits, Dr. Cass says. The types of duties staff can handle depends on state regulations.

Related: Know how to manage your staff

For example. Dr. Cass’s staff handles the following areas (admissible under Texas law):

• Medical history
• Binocular vision
• Pupils
• Cover test
• Visual fields
• Color vision
• Stereo vision
• Mental status
• Review of systems (ROS)
• Height/weight
• Blood pressure
• Dilation
• Astigmatic keratotomy (AK)/anti-reflective coating (AR)

Related: Why ODs should embrace new technologies in eye care

Technology
Up-to-date equipment can speed up patient visits and effiency.

A solid auto refractor and auto keratometric machine is the best way to speed up refraction, Dr. Cass says. If you have an auto refractor that is not accurate, get rid of it-a faulty machine is a time waster.

“If you have an idea what the prescription should be before a patient gets in the chair, that is going to make life easier,” he says.

Dr. Cass uses a customized workflow in his practice’s EHR with tabs like “chief complaint” and “medical history.”

Hiring a scribe if an OD is unable to do this will save time and impress patients, Dr. Cass says.

Auto-prompting and auto-fill saves time when working in EHRs and often works without complications, he says.

“Nine times out of 10 I don’t have to change anything,” he says.

Dr. Cass recommends integrating all technology in the practice. He uses the Zeiss Forum ophthalmology software to network all images and data stored on the server.

Retinal imaging and optical coherence tomography (OCT) machines Dr. Cass uses include viewing software that allows him to map and access patient data from any exam room.

Related: How OCT can help a smaller practice 

Quick tipsPredilating
Predilating patients has been found to have minimal effect on accomodation readings, with phenylephrine often used for quick results.⁵ If this is not enough, have staff dilate a patient and attend to another patient in the meantime before coming back, Dr. Cass says.

“They are going to dilate fast and good because they are already pre-dilated,” he says.

Cyclopentolate
Dr. Cass’s protocol for pediatric patients who have never worn glasses but measure +2/-1 and +3/-4, he will not attempt to refract it. Instead, staff will apply cyclopentolate (Cyclogyl, Alcon) and record the autorefraction, making for a faster exam.

Office flow
Use two rooms that have identical full lanes, Dr. Cass says, as well as one room for special procedures and testing (OCT, visual fields, optic nerve fiber analysis, pachymetery, specular microscopy).

Office flow plays a key role in keeping patients happy. Dr. Cass has found that two waiting rooms has been helpful in keeping patients moving and less impatient (one for pre-exams and another for after exams).

Routing slips
Dr. Cass says his staff treat routing slips like work orders:

When a patient calls to make an appointment, a staff member inserts the information in their program software. Information for insurance and certification is then completed.

After printing, a technician can grab the slip, input the work-up, and make the slip available for Dr. Cass to pick up and view with the patient. When a technician brings the patient up to the front for frames or contact lenses, his notes are viewable for which type of frames or lenses he recommends.

Room prep
Have your staff prep exam rooms for you, Dr. Cass says. Assistants can save time by having a charts open, patient’s visual acuity chart set, and the potential prescription ready to view in the refractor.

By the time Dr. Cass meets with the patient, he needs only to review the patient’s history, conduct a refraction, and discuss next steps before paging a staff member to conclude the visit.

Related: How staff can help differentiate your practice

Staff delegation
Employing and training a solid staff enables an OD to pass off tasks such as:

• Patient education
• Supplying samples
• Contact lenses handoff (apply, fit, adjust)
• Soft contact lenses fit (pull lenses, troubleshoot soft fits, order trials)
• Rigid gas permable (RGP) lenses (pull/prep, clean/store, document, order)
• Spectacles handoff
• Special testing (external/internal photos, topography, intraocular pressure [IOPs], specular microscopy)
• Referral letters (write and print, send to OD to review and sign)
• Patient forms (fill out, send to OD to review and sign)
• Pharmacy calls
• Prior authorizations
• Patient calls

Conclusion
Change won’t happen overnight. Dr. Cass advises ODs to think about what adjustements will work for their practices, then change just one or two things at a time.

“You don’t have to sacrifice service” he says. “You need to get smarter about it and be more efficient.”

Read more by Alex Delaney-Gesing

References:

1. Management and Business Academy. Key Metrics: Assesing optometric practice performance, 2015 edition. Available at: http://ecpu.com/media/wysiwyg/docs/paa_keymetrics_0415.pdf. Accessed 3/9/19.
2. Scheiman MM, Amos CS, Ciner EB, Marsh-Tootle W, Moore BD, Rouse MW. American Optometric Association. Optometric Clinical Practice Guideline: Pediatric eye and vision examination. Available at: https://www.aoa.org/documents/optometrists/CPG-2.pdf. Accessed 3/9/19.
3. Varma R, Vajaranant TS, Burkemper B, Wu S, Torres M, Hsu C, Choudhury F, Mckean-Cowdin R. Visual impairment and blindness in adults in the United States: Demographic and geographic variations from 2015 to 2050. JAMA Ophthalmol. 2016 Jul 1;134(7):802-9.
4. Gross S, Gable E. Evaluation of no-shows in an optometric education clinic. Poster presented at American Academy of Optometry annual meeting; Dec 12-15, 2002; San Diego.
5. Galimard NB. Pre-exam dilation protocols. Optometric Management. Available at: https://www.optometricmanagement.com/newsletters/tip-of-the-week/may-20,-2015. Accessed 3/8/19.