Responding to the Big Squeeze

How to plan for increasing patient volume and decreasing reimbursements.

Aging patients and more frequent office visits guarantee that retina specialists will be increasingly busy for the foreseeable future.

“It's not like you can treat these patients and release them,” says Phil Rosenfeld, MD, PhD, professor of ophthalmology at Bascom Palmer Eye Institute in Miami, Fla. “With practices getting busier and busier, the trend is not sustainable.”

Historically, Dr. Rosenfeld notes, retina specialists have spent most of their time examining patients and monitoring disease progression with imaging modalities, such as fluorescein angiography and OCT. Now, physicians treat with anti-VEGF therapy using “as-needed” or “treat-and-extend” regimens, while still trying to continue the traditional approach, which combines ophthalmic examination plus imaging tests.

“At this point, and into the foreseeable future, we need to re-engineer our approaches,” Dr. Rosenfeld notes.

In this review, practitioners reveal the novel approaches they're taking to improve patient management and treatment with anti-VEGF therapy.

MORE PATIENTS PER UNIT OF TIME

“The simple reality is that the number of patients with treatable retina disorders is rapidly increasing. To meet their needs, we'll have to see more patients per unit of time,” notes Andrew N. Antoszyk, MD, of the vitreoretinal service, Charlotte Eye Ear Nose and Throat Associates in Charlotte, N.C.

Dr. Antoszyk recommends physicians review their schedules for the day and determine which patients need ophthalmic imaging, such as OCT and/or fluorescein angiography. His practice created OCT protocols for patients with AMD, diabetic retinopathy and retinovascular occlusions. Imaging is obtained after the technician has completed work-ups and dilation. Ophthalmic photographers are instructed to contact the physician to review OCT scans that “show intraretinal or subretinal fluid or fluid under the pigment epithelium to determine the need for angiographic studies.”

“Our goal is to avoid having a patient return for supplemental tests,” he explains. “If this isn't possible, a patient can return for ancillary tests on examination days, when the patient load isn't as great or when the physician is in surgery. This latter option is feasible in larger practices as long as a physician is present in the office, particularly when performing invasive procedures such as fluorescein angiography.”

EXPANDING TREATMENT OPTIONS

David S. Boyer, MD, who practices with the Retina-Vitreous Associates Medical Group in Los Angeles and is clinical professor at the Keck School of Medicine of the University of Southern California in Los Angeles, says physicians should keep their minds open to all therapeutic options.

For example, he notes, research shows that monthly follow-up, even when treating as needed (PRN), is important when administering anti-VEGF therapy to AMD patients with neovascularization involving the central fovea and a central retinal thickness (CRT) of at least 300 µm, as measured by OCT.¹

However, Dr. Boyer also relies on proven treat-and-extend approaches for appropriate patients.² He is comfortable maintaining this approach until the 24-month CATT results are available. Based on the 12-month results of the CATT trial, PRN and monthly administration of bevacizumab (Avastin, Genentech) and ranibizumab (Lucentis, Genentech) were equivalent.³ Monthly ranibizumab was equivalent to PRN ranibizumab, but the comparison between PRN bevacizumab and monthly bevacizumab was inconclusive.

“The problem with PRN is the need for monthly follow-up in all cases,” he notes. “It presents an unmanageable log jam and potentially prevents patients from receiving care. Treat-and-extend lets us reduce the number of treatments and follow-up appointments. Plus, you and the patient know that a treatment will be administered when the patient visits, improving efficiency and offering more care opportunities for others.”

Dr. Boyer believes better studies of treat-and-extend will support new practice patterns in the future.

FEWER EXAMS FOR MONTHLY PATIENTS

Dr. Rosenfeld, whose pioneering research led to today's mainstream use of off-label bevacizumab, is on the vanguard of more progressive approaches.

“As we get busier and identify patients who need chronic therapy, we have to ask ourselves if we really need to examine the patient every time he or she needs an injection,” he says. “Perhaps we can examine stable patients less often (maybe every 3 or 6 months), even if they need frequent injections. I've already begun doing this for patients who appear stable but need an injection every 4 to 6 weeks. Once the treatment pattern has been established, it is perfectly reasonable to bypass the exam for a 3- to 6-month period and rely on OCT imaging or possibly even avoid OCT imaging altogether.

“Our only option is to do this when the circumstances are right or stop taking new patients,” says Dr. Rosenfeld. “Once you've optimized efficiency and reduced the amount of time you spend with patients, your only alternative is to see fewer new patients. The last thing we want to do is compromise patient care.”

OPTIMIZING EFFICIENCY

Dr. Rosenfeld says his large practice has optimized efficiency by bringing imaging to the patients in the clinic, instead of relying on a central imaging area. The use of highly trained technicians and nurses who specialize in imaging and injections has also expedited procedures. “Without them, we wouldn't be able to handle the high volume,” he says.

Meanwhile, at the beginning of his day, Dr. Antoszyk evaluates his schedule to determine how his staff will move patients, refining a chess match against inefficiency.

“We have no choice,” he says. “Patients are aging and living longer, the frequency of treatments isn't dropping in the foreseeable future and reimbursements are going to decrease as expenses increase.”

Dante Pieramici, MD, a partner at California Retina Consultants, a seven-physician group with 10 offices in eight cities within a 2-hour radius of Santa Barbara, Calif., says his group, like most, has more than doubled in size because of increased patient care during the past 10 years. Anti-VEGF therapy for AMD and management of patients with diabetes-related disease have driven much of the recent growth. However, he recommends resisting the temptation to expand until it's absolutely necessary.

“The possibility of future reduced volume is always a concern for us,” he says. “We've gotten busier, but we have to be conservative in our growth. We only grow when completely stretched. If your group is growing very rapidly, I think you could be at risk in the next 5 to 10 years, when new therapies may significantly reduce the treatment burden. While this will be good for doctors and patients, you need to make sure you aren't overextended.”

CONSIDERING FUTURE TREATMENTS

Dr. Pieramici says physicians should keep an eye on drug companies' R&D pipelines. “For example, other treatments will be coming out that may affect how we treat patients with diabetes,” he notes. “Microplasmin from ThromboGenics is going through the FDA approval process. It could be used to reduce abnormal vitreous traction and induce vitreous separation, playing a preventive role in the early stages of diabetic retinopathy and, ultimately, reducing the need for injections and laser.”

He also sees emerging treatments for dry AMD, such as complement inhibitors, now in clinical trials, to reduce disease progression and open a new avenue of therapy for patients.⁴

“Addressing the needs of 80% of the population with AMD is significant,” he says. “Some of these treatments under investigation are administered topically, some orally, and others via intravitreal injection. The complement inhibitors would block the innate inflammatory system. A number of lines of evidence suggest a pathophysiologic role of the complement system in AMD. Administering and monitoring these therapies could have a significant impact on our practices.”

EFFICIENCY TIPS

As Dr. Pieramici and his colleagues gear up for the future, they're instructing their staff members to do more than just vision testing and pressure checks. “Staff members are setting up injections, moving patients from room to room more efficiently, and helping with patient education,” he says. Dr. Pieramici's practice is also using space more efficiently by having injection-only rooms and, similar to Dr. Antoszyk's practice, having technicians conduct OCT and other testing when the physician isn't in the office.

“This frees up the OCT and staff on busy clinic days,” says Dr. Pieramici.

Meanwhile, like many of his colleagues, Dr. Boyer is fine-tuning a fast track lane for AMD patients who come in for treatment every 4 to 8 weeks. “We should really be interested in any changes in medications or condition,” he points out. “We should check pressures, obviously, and proceed with OCT and, if we know we're going to treat, start numbing the patient early in the visit so the visits are shorter.”

Effective education of staff and patients will also be more important in the years ahead.

“Strive to deliver consistent, concise and easily understood patient education with the use of all materials and staff available,” says Dr. Pieramici. “This material includes educational pamphlets from the AAO, ASRS, pharmaceutical companies, and custom material developed by your practice. Better-informed staff members and patients avoid slow-downs that arise when you have to repeat the concepts over and over. A well-trained staff can initiate the education process as patients progress through the clinic.”

MANAGING REFERRAL SOURCES

To reduce the overall burden on your practice, Dr. Pieramici also recommends sending patients back to referring physicians when appropriate. His practice conducts outreach activities, such as dinner meetings with general ophthalmologists and optometrists, to educate them on appropriate referrals.

“We're relying on primary care providers more to monitor stable non-neovascular AMD,” he says. “We have some very good observers out there who are equipped with OCT technology. We obviously don't want doctors sitting on severe disease, but we also don't want them sending patients without pathology.”

Dr. Rosenfeld says ophthalmology residents at Bascom Palmer already administer intravitreal injections and follow patients with AMD. “As time goes on, I see more general ophthalmologists becoming competent and comfortable administering these injections,” he says, adding that this change will reduce the strain on retina practices.

Dr. Boyer expects self-monitoring to increase, bringing patients to the office for earlier treatment. “Right now, we have the ForeseeHome AMD Monitor for home use,” he notes. “Other software programs that are in development will be precise and easy for patients to use. These tools will be most helpful when we're using the PRN treatment model.”

CONTINUALLY ADAPTING

As technology changes and patient volume continues to increase, the future will present more challenges and opportunities. Most retina specialists agree that they will succeed only by adapting and continually investigating new approaches. ■

References

1. Lalwani GA, Rosenfeld PJ, Fung AE, et al. A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO Study. Am J Ophthalmol. 2009;148(1):43-58.
2. Oubraham H, Cohen SY, Samimi S, et al. Inject and extend dosing versus dosing as needed: a comparative retrospective study of ranibizumab inexudative age-related macular degeneration. Retina. 2011;31(1):26-30.
3. CATT Research Group, Martin DF, Maguire MG, Ying GS, Grunwald JE, Fine SL, Jaffe GJ. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011;364(20):1897-1908.
4. Khandhadia S, Cipriani V, Yates JR, Lotery AJ. Age-related macular degeneration and the complement system. Immunobiology. E-pub ahead of print: July 23, 2011.

Michael Colucciello, MD, consults with a patient while retina staff look on. Staff members shown left to right are William Whitcraft, COA; Jennifer Morris, COA; and Michael Gulli.

The key to efficiency in the future will be carefully managing each step of an examination and screening, working closely with your staff. Here, Dr. Colucciello (far right) is shown with his practice's team of retinal technicians, all of whom are cross-trained to conduct patient work-ups prior to physician examinations, fundus photography, angiography, retinal scanning and intravitreal injection preparations.

Closely coordinating clinical care with front office staff on billing and scheduling will be critical in the years ahead. Here, Dr. Colucciello (far right) takes a moment with the managers at South Jersey Eye Physicians.

Injections have increased by more than 300% in some practices. Here, Dr. Colucciello evaluates a patient after administering an anti-VEGF injection.

Improving Efficiency

By Michael Colucciello, MD

By some estimates, we'll need to prepare for a future that includes an increased incidence of 200,000 cases of neovascular AMD every year.¹ That number translates into 80 new cases, many requiring monthly care, especially in the beginning, when frequent anti-VEGF therapy is needed to stabilize vision, for each retinal physician every 12 months. Increased incidence of diabetic retinopathy will also become a more significant factor, adding 25 to 30% more patients to our appointment books.²

With tighter control of blood sugar, thanks to insulin pumps and other advanced techniques, we hope that macular retinopathy will be less of an issue. But that will only help to some degree.

Because AMD is a largely inherited disease, the baseline cases will increase unabated. Better management of environmental factors, such as smoking, and use of antioxidants, lutein, zinc and omega-3 fatty acids, can be helpful — but only by so much.^3-6

As the lone retina specialist in a nine-ophthalmologist group with four offices in South Jersey, I've seen my patient volume increase by 30% during the past 10 years. I see no signs of let-up, either. Sound familiar?

Here are four steps to help you cope with the crushing demand.

1. Better educate your staff. Make sure staff members know what types of questions will arise and what types of testing will be needed in different situations. By increasing efficiencies in the office, we can increase patient flow.

2. Embrace electronic medical records (EMR) and delegate more. The more familiar your technicians become with EMR, the more efficient you will become. By using a scribe, you can spend more time with patients rather than with charting. Physician extenders can also communicate effectively, freeing up your time.

3. Perform manpower and time studies. Look at how efficiently you use your rooms. Consider patient flow, how you use diagnostic equipment, where you deploy monitors. Time patient visits: from the time patients check in until they leave. Not much data is needed to discern trends. For example, you'll learn how much time you need for a consult, follow-up, injection or laser treatment. You can adjust your 10-to-20 minute slots accordingly. Staff members become more efficient when they know you've made this aspect of your practice a priority.

4. Extend your review area. Creating multiple stations — in the laser room and in other rooms so the patient doesn't have to go back to a central testing station — will be the norm in the future.

References

1. Friedman DS, O'Colmain BJ, Muñoz B, et al. Eye Diseases Prevalence Research Group. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. 2004;122(4):564-572.
2. Saaddine JB, Honeycutt AA, Narayan KM, Zhang X, Klein R, Boyle JP. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005-2050. Arch Ophthalmol. 2008;126(12):1740-1747.
3. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001;119(10):1417-1436.
4. Seddon J, Reynolds R, Maller J, Fagerness JA, Daly MJ, Rosner B. Prediction model for prevalence and incidence of advanced age-related macular degeneration based on genetic, demographic, and environmental variables. Invest Ophthalmol Vis Sci. 2009;50(5):2044-2053.
5. Seddon JM, Reynolds R, Yu Y, Daly MJ. Risk models for progression to advanced age-related macular degeneration using demographic, environmental, genetic, and ocular factors. Ophthalmology. Epub ahead of print: Sept. 27, 2011.
6. Gale CR, Hall NF, Phillips DI, Martyn CN. Lutein and zeaxanthin status and risk of age-related macular degeneration. Invest Ophthalmol Vis Sci. 2003;44(6):2461-2465.

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Dr. Colucciello is a partner at South Jersey Eye Physicians and a clinical associate at the University of Pennsylvania/Scheie Eye Institute.

Strategies for the Future of Retina Practice

Here is how to prepare for loss of leverage, domination by large group practices, and more.

By John B. Pinto

Despite a generally favorable position on the balance sheet, retina specialists are vulnerable in their service span because more general ophthalmologists are performing intravitreal injections for retinal disease. A second dimension of vulnerability has been created by the expansion of large, multi-specialty practices. The overall effect is loss of independence and leverage.

There are more markets where retina has to join the large multispecialty practice to have access to patients. I recommend taking preventive steps to remain viable in response to what has evolved into a 20-year consolidation trend that is now only accelerating.

Learn to recognize opportunities and threats. If you're getting 50% of your business from a 30-doctor group, you're just one hiring event away from seeing your business closed. It would be better to join a group than try to hold out on your own. Here are four other measures you can take to prepare for the future:

Anticipate reimbursement cuts. Just as the federal government requires banks to stress-test themselves to see if they can function under adverse macroeconomic conditions, it's appropriate to stress test your practice. Project a revenue reduction of 10 to 20% and determine if the cut would put you under or just make you more uncomfortable. If it would put you under, take appropriate cost-cutting and revenue preservation measures to ensure that you can endure this type of shrinkage.

Evaluate your community. Like most of your colleagues, you're no doubt beleaguered by the challenges of current practice. But make sure you still pay attention to referral sources. Determine the impact of accountable care organizations on your practice. Some variation of this model will come to play in many markets.

Optimize basic business performance. Focus on cost appropriateness and the efficiency of billing systems. Be careful not to purchase new capital equipment that won't have a near-term financial AND clinical benefit. Think twice about taking on new office space.

Plan for incremental loss. The reality is that abrupt, double-digit Medicare cuts, if they were to occur, would be so disruptive that it would affect not just ophthalmology but a wide swath of ambulatory care. This would not be politically acceptable. As a result, rather than seeing the statutorily mandated cuts of more than 20%, we're much more likely to see single-digit cuts, if any, in the coming year. These small, incremental cuts give us time to figure out what to do next. But it will need to be figured out. In retina, a one dollar reduction of revenue typically translates to a one dollar reduction in profit. A 3% fee cut, under Medicare, given usual cost structures, would typically result in a reduction by twice that percentile amount in take-home pay for the retina specialist.

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John B. Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. John is the country's most-published author on ophthalmology management topics. He is the author of John Pinto's Little Green Book of Ophthalmology, Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees, The Women of Ophthalmology and Legal Issues in Ophthalmology: A Review for Surgeons and Administrators. He can be reached at 619-223-2233, via e-mail at pintoinc@aol.com or found on the web at www.pintoinc.com.