Article Date: 12/1/2002

Practice Management
10 LESSONS O.D.s Can Learn From M.D.s
Increase your practice's efficiency and income with some tips from ophthalmologists.

Even if you subtract reimbursement for performing surgery and pro-rate for more primary eye care income, the starting salary for an ophthalmologist is anywhere from $100,000 to $150,000 greater than for an optometrist. Why is this? What do ophthalmologists do that allows them to make so much more? Let's explore some practices that we can learn from.

LESSON #1: Build the right staff.

You don't need to hire the most expensive secretary or technician, but you shouldn't hire the cheapest. Most ophthalmologists I know hire someone in the middle and make their responsibilities commensurate with the salary. Hiring the cheapest usually means that the person is delegated very little and also that there is higher turnover, which is detrimental to building a loyal patient base.

Patients should become familiar with you and your staff. They don't want to see a new face every time they visit your office. Ophthalmologists are notorious for spending little chair time with patients, yet patients return to them year after year. Why? Because the patients get attached to the doctor and the staff.

LESSON #2: Get the most out of ancillary staff.

In most optometrists' offices, the O.D. does almost everything. She delegates screening tasks such as basic history taking, air puff tonometry, contact lens insertion and removal (I&R) and lensometry to the technician.

In most ophthalmologists' offices, however, a technician performs the refraction. In many, he'll even check IOP and get the patient dilating. In some cases, the technicians handle the call backs for prescription refills. This may seem aggressive, but if O.D.s are going to increase patient flow, we must increase our use of of ancillary staff.

With the expansion of diagnostic and therapeutic laws, our roles as primary eyecare providers should change from one of information gatherer to information processor. Train technicians to perform the tests, and we can make decisions based on the information they gather.

By using staff this way, you can shave five or 10 minutes from each exam. This translates into a savings of 90 minutes at the end of the day -- you can either go home earlier or you can schedule another six patients, which more than pays for extra money you would have to pay this better-trained technician. The time issue is noteworthy because optometrists typically schedule two complete exams each hour, while most ophthalmologists schedule four or five.

As usual, marketing contributes heavily toward success. And it's an area in which ophthalmologists operate in a manner distinctly different from that of most optometrists.

LESSON #3: Create the right ambiance.

Many O.D.'s offices are so cluttered by frames and contact lens posters that they look more like a retail establishment than a professional doctor's office. Most ophthalmologists keep patient distractions to a minimum. Keep a few name brands accessible, but let patients focus on you. A patient can get brand name contact lenses or frames anywhere, but there's only one place where she can get your services.

LESSON #4: Obtain referrals.

Ophthalmologists are great at soliciting referrals from primary care doctors. O.D.s should adopt this practice.

Start by sending a letter or by calling local primary care doctors to explain your services. Mention that you're licensed to handle ocular disease, that you're willing to see emergencies (most ophthalmologists are booked months in advance), and that you'll send a letter back to them summarizing the results of each patient they send to you.

Many primary care doctors still don't know what we can do, so it is our job to educate them.

LESSON #5: Stress check-ups.

Ophthalmologists tend to stress the importance of yearly exams, emphasizing that even if the patient's vision is unchanged, he should still return to the office to have the health of his eyes checked regularly. If you don't emphasize this point during your exams, many of your patients won't return until they perceive a change in their vision.

LESSON #6: Let the patient decide.

The last aspect of marketing is presenting yourself as a professional, which means that you shouldn't prejudge a patient's willingness or ability to pay.

M.D.s make recommendations without considering the cost. This doesn't mean that you shouldn't be up front about costs; otherwise, you might have a lot of unhappy patients. But consider having one of your techs inform them about the bill.

A prime example among ophthalmologists is cataract surgery: Ophthalmologists don't tell the patient about the 20% Medicare deductible. Instead, they recommend the surgery and the billing person tells the patient about the costs. By distancing themselves from the cost, they maintain an aura of professionalism.

Apply the same principle to contact lenses. Recommend whatever lens you think is appropriate and let your technician review the finances before he performs the I+R. Thus you remove the perception that you are selling a product.

LESSON #7: Abandon the routine.

With the emergence of health plans and HMOs, few doctors don't accept insurance. What many optometrists don't know is that reimbursement rates differ for routine exams versus exams that have a medical diagnosis. Ophthalmologists are aware of this: Few people go through an ophthalmic exam that is labeled as routine.

For example, virtually every contact lens wearer will have a complaint of intermittent dryness or itching, or some degree of corneal neovascularization or sub-clinical superficial punctate keratitis (SPK). All four of these conditions -- dry eye syndrome (375.15), seasonal allergic conjunctivitis (372.05), corneal neovascularization (370.60) and SPK (370.21) -- warrant medical diagnosis instead of a routine exam. The same can be said of patients who have diabetes, early cataracts or those who have complaints of floaters caused by a posterior vitreous detachment.

Not many patients come in complaining about these conditions -- you usually have to ask them. Ask more specific questions such as, "Do you have any problems with your eyes getting red, irritated, itchy or burning with your contact lenses?" Or with your elderly patients, "Any problems with flashes of light, floaters, or nighttime glare?" Ask patients to come back for follow-up care once you've established a medical diagnosis. The follow up brings in additional revenue and underscores the health aspect of eye exams.

LESSON #8: Dilate every patient.

M.D.s dilate every patient as part of a comprehensive eye examination. Optometrists should do this too, for three reasons.

First, many insurances require dilation as part of a comprehensive eye exam. If you don't dilate, you can only bill for an intermediate exam, for which the reimbursement is lower.

Second, you could miss many medical diagnoses because of a failure to dilate.

Third, if we set this as the standard of care, then the public perception of us as providers of comprehensive eye exams increases. Don't offer patients a choice of two exams -- one with dilation and one without. Instead, include dilation in the fee structure of the exam. A patient choosing not to be dilated should be the exception, not the rule.

LESSON #9: Consider referring patients to other O.D.s.

Ophthalmologists commonly send patients to each other. Optometrists, on the other hand, tend to send patients to ophthalmologists instead of to other optometrists. This conveys the message that ophthalmologists are better. Send a patient to an ophthalmologist as a specialist, if a glaucoma or retina specialist is what they truly need.

But consider referring your patients to an another optometrist to confirm a keratoconus diagnosis or for glaucoma management. Even though we can't legally call ourselves specialists, many optometrists practice to the full extent of their state's laws and are capable of managing all aspects of those diseases. Refer patients to the other optometrist with the explanation that, "The doctor I'm referring you to has more experience with this condition than I do."

Sending a patient to an ophthalmologist inevitably leads to a discussion that an optometrist is not a medical doctor. It erodes the patient's confidence in an optometrist for anything except for glasses and contact lenses.

And keep track of ophthalmologists who "steal" patients from you. The patient should return to you for continued primary eyecare.

LESSON #10: Keep up with technology.

Obviously, as primary eyecare providers, we must keep up with the latest information -- but we must extend that philosophy to medical equipment as well. Corneal topographers, pachymeters, and nerve fiber analyzers are all relatively new medical equipment that you'll find in almost any ophthalmologist's office. We can't say the same for many optometrists.

Such equipment increases revenue in terms of reimbursement, but it also instills a level of confidence in your patients. Once they see that you keep up with medical technology, they'll trust you and will return to your office.

Better yet, by sharing their positive opinion of you and your practice with friends and family, they may generate more patients for you. It's true that you have to have the patient volume in place to afford such equipment, but the technology is well worth the investment.

Hopefully you can incorporate some of these changes into your practice, and maybe one day we can narrow the gap between our incomes and that of ophthalmologists.

Dr. Gupta practices full-scope primary care optometry in Stamford, Conn. You can reach him at


Optometric Management, Issue: December 2002