What's The Biggest Problem In Ophthalmology?
Check out the perspectives and ideas from four generations of actively practicing ophthalmologists and thought leaders in their field.
TRADITIONALIST
Dr. Steven Siepser - As I see what's facing the physicians now is that we're terribly under paid, it's awful. I was figuring out that in reality, we now are paid 5% in real dollars. For a cataract surgery compared to 1984, very simple, we got near $2,000 in 1984, in 1984 dollars. Back then, with 1984 dollars, if you did five cases, you could buy a car. Cars were, you know, $3,000, $5,000, $8,000 dollars. Now nice cars are $80,000 and we're getting $500 for a cataract… and with that profit margin, it must take us 200 cataracts to buy a car. It's a problem now throughout medicine and I always find one of my favorite thoughts is someone once said, “I don't need politicians, I don't need actors and actresses, and I don't need professional athletes. What I need is doctors, teachers, and nurses.”
BABY BOOMERS
Dr. Ming Wang - I think the biggest problem that we're facing as an industry, as a practice, and from the perspective of practicing ophthalmologists, is that there are so many forces that drag us away from our central focus. The central focus is our responsibility to our patients. By different forces, I mean for example, the financial forces - the cost of running a practice, there are forces that need to do marketing to attract patients, the forces of malpractice - the legal aspect of medicine, the forces of reduction in reimbursement from the government and the forces of increasing technology and the cost and attention as we need it, and also the increasing expectations from our patients. So, I think the biggest challenge is how can we, as ophthalmologists in the center, when surrounded by these different forces taking us away from the center, still manage to keep our focus in the center, which is the focus on the patient.
Now I'll give you one example. With the technology becoming available, it is increasing that the doctors are practicing technology-based medicine rather than a human-based medicine. For example, at Wang Vision Institute, I am the surgeon and Dr. Joshua Frankel is the surgeon and we have three optometrists, Dr. David Zimmerman, Dr. Marianne Johnson, and Dr. Julianne Koch, and I interact with our younger doctors almost on a daily basis. The most frequent teaching point for me is always to ask this question after the young doctor presents all the technologies, “What does this patient want? What is the perception of the patient, his perception, or of his or her problem?”
We are speaking in the language of the listener. Are we focusing on the most important mission in medicine? Yeah, making money is generally the business, but more important is treating a disease. There's actually something more important than treating a disease. Most young doctors ask, what is that? Could anything be more important than the technology and surgery to treat the disease? Yes. There's something even more important that makes someone happy and manifests. You actually listen to the patients. At the end of the day, it’s not what you think is most important as the surgeon, but what the patient feels is the most important.
Dr. Cynthia Matossian - Well, we have, I think a bunch of problems facing our industry and the biggest one in my opinion, is the disconnect between the cost of doing the business of ophthalmology and the reimbursement that we're getting in return. Right now to operate a state of the art cutting edge ophthalmology practice requires a lot of pieces of equipment. The lifespan of the pieces of equipment is getting shorter and shorter, meaning that there are newer versions that you have to constantly upgrade to or new pieces of equipment that are coming in, that we have never had before. The cost of staff is increasing because you need more educated staff to operate these more sophisticated pieces of equipment. It's not just checking vision anymore and writing a Snellen visual acuity in a chart anymore. And unfortunately on the flip side, the reimbursement is going down and it's hard to make that balance. So, you have to be inventive and creative and include cash paying procedures to profit and to become successful.
Dr. Nelson Preschel - I'll tell you what my problems with ophthalmology are right now. I spend too much time dealing with compliance, with paperwork. Honestly, not being a doctor. Another problem that I have is insurance companies dictating how I practice ophthalmology. It's been years since I was allowed to prescribe brand medication to my patients. In the recent months, I had to do a procedure that I was, you know, it was my second choice to do because the insurance company did not cover amniotic membrane of ocular surface reconstruction and my patient didn't do as well as I wanted after the procedure. I hate that someone else is dictating how I practice ophthalmology.
Dr. Larry Patterson - On the positive side, there's a limited number of ophthalmologists and far more people who are going to need our services. One of the biggest challenges we're facing is figuring out how to see all the people that need to be seen. I think probably the biggest problem would be optometric incursion into the surgical area. It was one thing for us to allow optometrists to do medical care and, within certain parameters, I think that's fine; but you have to draw a line in the sand with surgery. Otherwise there really becomes almost no difference between optometrists and ophthalmologists, and there was no reason to go to medical school and residency for ophthalmology. I think that's something ophthalmologists really need to wake up to and be willing to spend their time and money to fight that. I think ophthalmologists, a lot of them, are caught in a catch 22. They know optometrists shouldn't be doing surgery, but on the other hand, they get referrals from optometrists. If they're not careful they're going to find themselves getting bitten in the butt for not paying attention to what they're allowing to happen.
GENERATION X
Dr. Laura Periman - I think it's the corporatization of medicine is the biggest problem facing ophthalmology today, and by that, I mean, the erosions of practicing with autonomy in the context of big box groups, private equity acquisitions. Also, the health insurance companies and their arbitrary and capricious, artificial, time-wasting, unnecessary, non-medical denials, and prior authorizations and appeals.
Dr. Himani Goyal - I think honestly, it's just finding a balance of where you put technology in your life, and in our practice, and having it kind of meet our traditional ways that we were kind of taught in residency. Being able to take the stuff that we learned in residency and maybe stick to some of the basics that we learned, but build on them and then kind of find a balance where we're like, okay. It's okay if I don't know this exact technology, there's just so many things that you can do, but finding that balance, because there's just so much information. How do you actually process all of it and be able to use all of it? You kind of have to pick your niche. I think the biggest challenge, honestly, is kind of filtering out where you really want to focus, really finding that balance and then creating your own specialty, or expertise, within our own specialty. Like even as a cornea specialist, I feel like I'm different from my cornea colleagues. I think the hardest part is really just finding where all of that stuff finds a balance for each one of us, and knowing that it's okay. It's okay that I don't do exactly the same things and there's going to be things that my colleagues do that I don't, and vice versa.
MILLIENNIALS
Dr. Anna Lehmann - I think one of the hardest things is the expectations of patients. As technology develops so rapidly, our patients expect absolute perfection in every single outcome. I think that's something that causes most of us to be, in some way, perfectionists. That's something that's hard to deal with because at the end of the day, you can't be perfect. So, meeting that expectation or figuring out how to communicate with people so that they understand that's not a realistic expectation, is something that we're going to have to deal with. I think another thing though is all of the red tape like EMR and insurance. That's something that I certainly didn't fully understand until I got into private practice. There is a lot behind the scenes that is not just you and the patient in the exam room, or you and the patient on the operating table that has to do with how you're able to practice and what you're able to do.
Dr. Michael Patterson - I don't know how it's debatable at this point, it's the private equity market capitalizing on people that are weak at the time that makes them need to sell immediately. This is a dangerous time for all parties involved, including the private equity groups, make no mistake about it. They're in a tough deal. They need to make money, they need to turn capital quick. Guys that are older, it doesn't matter how you look at that, whether they're 40, 50, 60, 70, or 80, they want an exit plan. Legacy building is a powerful thing right now, but a lot of people don't care about their legacy. So a quick way to not care about it is to take a big payout and, and go on.
I don't look at anyone bad for doing that. I mean, I'm grateful to have a CEO that wouldn't let that happen even if anybody wanted it to, but I see this as being absolutely catastrophic long-term, for the patients mostly.
I saw a patient today from Mexico, just today, that has no money, no insurance and I put bilateral injections into her eyes to save her vision over the next six months. And I just don't see how, if you're just crunching numbers, how you're going to be able to do that. Eventually, you have to say to yourself, this is more than just making money and I feel passionately about this in my area. I'm in a rural area. We're in the middle of nowhere, and a lot of people think they're rural and they're in a suburb of Memphis, but we're rural. I feel passionate about our team and our leaders and the goals of our practice to really change people’s lives in the rural communities, and we can't do that if we sell out.
This is tough for so many levels. If you look at residents that are coming out, they don't want to join those practices because they don't know what their buy-in is. Then the senior partners, understandably, value their practice very high. Most people think they are a lot better than they are, no matter what side of the argument you're on. So it's tough, it's a tough deal going forward. I think there's no question. The insurance companies might make it to where it's tough if you're not a huge group, they could, they could say that you're costing too much money and that's dangerous. That's a very dangerous way to practice medicine.
