Three years after the start of the global pandemic, ophthalmologists are facing new challenges.

The initial impact of the pandemic on medical practices was purely financial. Fortunately, that impact was less than expected and was short-lived. “We thought it was going to have a longer effect. Most practices were able to briskly pivot to provide patients and staff with a sense of personal safety, and, within six months of the start of the pandemic, most of our clients were back up to their accustomed business level. And, after accounting for the PPP and associated grants, they were either made whole or better than whole compared to the previous baseline in 2019,” says Corinne Wohl, MHSA, a practice management consultant based in San Diego.

“I believe the most challenging adverse impacts of COVID arose after it was no longer a public health emergency, and they are mostly in the form of very strong human resource headwinds,” Ms. Wohl continues. “It’s been very hard to retain staff, to recruit either new and/or experienced staff, and to train new staff well because of the staffing shortage.”

She adds that the best way to attract and retain staff is to treat them well and pay them well. “Hourly wages and salaries have increased over the past couple of years due to the competition in the marketplace,” she adds. “To stay competitive, it’s essential to treat employees consistently and fairly, pay market rates, make it a fun place to work, and have good communication within an organization.”

John Berdahl, MD, in practice in Sioux Falls, South Dakota, agrees and says that a psychological shift occurred during the pandemic. “We all realized that life is short and fragile,” he says. “In our practice, probably the key to us surviving and thriving during and after pandemic was a culture of taking care of our team, and our team’s willingness to take care of each other. So we haven’t had the typical challenges that you see around the country of turnover and recruitment, in large part because of our culture of caring for each other.” 

He adds that his practice has looked for new ways to take care of staff members post-pandemic. “We now do a better job of ending the day on time than we ever have before, so that people can enjoy their evening. We have dedicated time where we get together with them and their families once a month,” Dr. Berdahl says. “Maybe half of our staff makes it to any one event, but it’s an opportunity to make sure that they know how much we appreciate them. We have implemented little things that signal trust. For example, we have free vending machines with healthy snacks. And, we don’t have signs that say limit one per day. We just trust our staff members because we’re in this together. Those are just small signs of being grateful that they’re willing to give us the best hours of the best days of the best weeks of the best years of their life to our common cause.”

Some of the challenges ophthalmologists are facing post-pandemic aren’t even a result of the pandemic. Instead, they are a result of growing pains, as many practices are expanding to serve more patients. “We’ve been growing a lot, and any time there’s growth, new structures are needed, but you don’t want to lose the love. And, in fact, you want the structure to enable the love of going to work every day. People need to know how to communicate and where to bring their problems to get solved. Mark Twain has a great quote: ‘I’m all for progress. It’s change that I don’t like.’ The biggest challenge that we’ve faced is growth and change in our organization. It’s important to remember success is not all about more surgeries and seeing more patients in a day. It’s really about being in this together and taking care of each other,” he says.

A willingness to take care of your employees, and their willingness to take care of each other, can be key in keeping a practice healthy post-pandemic. (Courtesy Getty Images)

How to Grow a Practice 

It’s important to be creative when considering ways to grow your practice. Jeffrey Whitman, MD, who is in practice in Dallas, says his practice was invited to set up an office in a building with a large primary care medicine group. “It’s a hospital system primary care center that includes a number of primary care doctors. They had extra lease space, and some of those doctors knew one of our ophthalmologists, and he said, ‘We need a lot of diabetic exams, etc. I think we could keep somebody busy if you put an office over here.’ It was kind of a service to them, as well. We have both an MD and an optometrist rotate through that office,” he explains.

Opening a surgery center is another opportunity for growth. “Our practice already has four operating rooms in one location and two in another location,” Dr. Whitman says. “We’re considering the possibility of building another surgery center in the future. We’re looking for areas of growth to continue to grow into. Additionally, we’re not at capacity at our surgery center, so we can feed more into those surgery centers. We actively think about how to maximize what we do.” 

Dr. Whitman adds that ophthalmologists should consider building their own surgery center if they are performing 800 to 1,000 cases a year. “You can usually find other ophthalmologists or surgeons in other specialties who want to invest, because that can be a very big profit center, as opposed to giving it away to a hospital or somebody else’s surgery center. If you’re operating in someone else’s surgery center, you may want to find a way to buy in. These are all good ways to grow,” he says.

Daniel Durrie, MD, in practice in Overland Park, Kansas, adds that office-based surgery is a trend that has grown significantly over the past several years. “People are thinking about office-based surgery more post-pandemic because of the decreased access to care and the desire to not be around sick people. Lots of practices are either doing it or thinking about it. Ophthalmologists want to move surgery closer to their staff and patients,” he says.

According to Dr. Whitman, having the right office staff is important to growing a practice. “Respect your administration, and pay them well. If you want to have a busier practice, that means your time is going to be taken up in the OR and in the clinic,” he says. “You have to make sure you have good people you can trust who are doing the administrative tasks, which includes everything from purchasing real estate to doing build outs for a new space, bringing new physicians in, and just the daily operations of a practice.” 

According to Ms. Wohl, it’s important to look outside the practice for business guidance. This can include accountants, attorneys and consultants. “The best run and most financially successful practices look beyond themselves for business guidance. Advisors have the advantage of looking at a practice objectively and have experience helping to solve those same problems many times over, as opposed to owners and managers who are seeing an issue for the first time or only a couple of times,” she says.

Dr. Whitman adds that having good banking relations is also a must. “It’s a very sensitive banking time with the recent failures. I think regional banks are a great way to go,” he says. “They’re very interested in your business, and they look at physicians still as relatively safe bets. And, to me, that’s investing in your future and their future. They have a good banking client, and you have someone who will believe in you when you’re looking to open that next office and need to take out a loan.”

According to Dr. Durrie, private pay procedures are an area for growth. “In ophthalmology, we have the opportunity for growth in an area where you have patient-shared responsibility in that they’re paying for part of the procedure, for example, paying for premium lenses, refractive lens exchange, ICL, LASIK and other concierge-type services,” he adds. “All practices have the ability to move in that direction, and a lot of the practices that we have within the iOR family are looking to best practices from other practices and through our corporate networking to see if we can move to doing more private-pay procedures. Everyone is worried about continued cuts in insurance and Medicare reimbursements.”

He explains that the disease-based part of a practice will grow naturally due to the aging population. “We’re going to be doing significantly more cataracts, significantly more retina, and more glaucoma just because of the aging population and people living longer. We can be more efficient by possibly using optometry more within the office. We’ve had years of discussion about referrals from optometry, but I think most people are saying surgeons should spend more time in the operating room and bring in more optometric help to streamline patient care,” Dr. Durrie says.

Does Practice Size Matter?

When it comes to growth and taking advantage of opportunities, Dr. Berdahl says there are advantages and disadvantages to both large and small practices. “Large practices can’t make decisions quickly, and you have to fight really hard not make them sterile and depersonalized,” he says. “It’s natural to start focusing on spreadsheets more than people. Don’t let that happen. So, there are some real disadvantages to being big. But there are some advantages, too. You may have some more leverage with payers and suppliers, and you may be able to recruit better leadership talent. It’s difficult for the health system to become the leader in ophthalmology in any region. Maybe it’s because they’ve got other focuses, but ophthalmology is still a place where somebody can hang up a shingle. A small practice that’s highly focused can be the go-to practice in a region because it’s such focused and personal care. They can make decisions more nimbly and more swiftly, and oftentimes they don’t have the bureaucracy and the associated costs.”

However, true solo practices have unique challenges, according to Dr. Whitman. “It’s getting tougher and tougher for the true solo practices out there, and there are still a number of them. We see private equity growing because they are able to help larger practices. We’re not part of private equity at this point, but it’s something I would look at in the future. However, you can see private equity groups wanting to reach out to these solo practices who are having problems administratively. I mean, just the issues of human resources and negotiating with so many different payers is difficult for a solo practitioner. It used to be very different. Thirty years ago, Medicare was the main payer, and it was easy to deal with the private companies. Now, there are many options with many different rules. It’s difficult to have to swim in those waters. We’re a large practice, and we have an insurance office set up with a CFO that oversees it. We’re a large business in that sense, so we can deal with that. Private equity will take over practices and surgery centers and bring other practices in. It’s economy of scale—you use the surgery center, and they’re already doing the bookkeeping, so doing the bookkeeping for one more practice or 10 more practices isn’t necessarily a problem. It’s become much more difficult for a solo practice to do its thing, unless it’s one of those rare boutique practices that’s only doing non-insurance, but there aren’t very many of those around,” he says.

However, Dr. Durrie says that rural and smaller practices can still do well, especially in ophthalmology. “I’m a strong believer in physician-led opportunities, so when it comes to physician-owned practices merging together on a physician-led basis, I’m all in favor of that. I think there’s a lot of economy to scale on practices within a community working together, merging, or sharing resources. I worry a lot about the consolidation and the corporatization of health care in general, and I think we, as physicians, need to take on a leadership role in the health-care solutions for the future. We will always protect the patient better than any administrators or any corporate entities who are just trying to make money out of health care. We have a lot of rural practices that have been driving 45 minutes to a hospital, and they are now moving surgery into their office, and that sustains them for years down the road because they now have better control over the quality of care and they’re leading it,” he says.

Dr. Durrie is chairman of in-office surgery business iOR Partners. None of the other individuals interviewed in the article have a financial interest in any product mentioned, unless specifically noted.