Dropping Managed Care Plans, Part 2<br>Evaluating chair costs, marginal costs and time management
March 16, 2005
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Before we evaluate specific vision or medical plans for acceptance (or continuation) in your practice, we should first evaluate your practice costs. Knowing how much it costs you to see
a patient is the first step in determining if a plan is profitable, and how profitable.
This evaluation is often referred to as chair cost – as in what is the cost incurred each time
a patient sits in the exam chair? You can calculate chair cost per patient or per hour; both
Chair cost calculation - the easy way
The basic premise is to divide your fixed costs by the number of patients you see in a given
time period, like one year. Similarly, you could divide the total fixed costs by the number
of hours your office was open during that time period. Fixed costs are considered to
be everything in your list of expenses, except your cost of goods sold. One easy way to figure
this is to take your true gross (collected revenue – not billed charges), and subtract all
cost of goods (frames, contacts and lab bills) and subtract the practice net (or all
doctors’ income). If your practice has typical expense ratios, you would subtract about 30%
for the COGS and 30% for the net, leaving 40% of your gross as fixed costs. If your
practice grosses $1 million, your fixed costs would be $400,000.
Counting the number of patients or the number of hours can be trickier than it seems.
Patient numbers are really the number of exams performed, but should that be full exams
only or all office visits? It could be either way, or you could use a formula that counts
an OV as a half point and comprehensive exams as a full point. The important thing is to
be consistent when you make comparisons. You might want to use a value that relates to the
plan you’re evaluating, such as, counting full exams only if you’re looking at a vision plan
that will be used primarily for full exams. The hourly calculation begs the question of
using all office hours or just hours when doctors are scheduled for patients.
If the million dollar gross practice above saw 4,000 patients, the chair cost would be $100
per patient ($400,000/4000). If it were open 2,000 hours, the hourly chair cost would be
$200 per hour.
Knowing the per patient cost in our example, we might deduce that if you accept a vision
plan that pays less than $100 for an exam, you’re losing money on each patient. The old joke
is that you can’t make up a per unit loss with volume! But it’s really not that simple.
In reality, when you consider participating with a managed care plan, you’re fixed costs
are already being met. The rent is already being paid and staff salaries are already covered.
A fair question might be, what would be the additional expenses involved in
seeing the patients that come from that plan? Those expenses may be zero, unless you have
to hire one more staff person. The rent would not increase and the electric bill will remain
the same with or without this vision plan. The analysis of a special group of expenses like
this is often called the marginal cost.
How full is the appointment book?
A key factor in your evaluation is how well booked you are with patients. This factor
goes hand-in-hand with your cost analysis. There is some truth in the common sense approach
that says a low-paying exam is better than no exam. A good analogy is in the airline
industry. If a commercial jet takes of with empty seats, those revenue opportunities are
lost forever. The airline would be better off discounting the tickets for those remaining
seats to $49 each, than having the seat be empty. In fact, that is exactly what airlines
do, through the use of sophisticated pricing models. Likewise, an appointment slot with an
empty exam chair is revenue that can never be recovered in your practice.
Beware of the inertia of managed care
There is danger in accepting too many managed care plans, however, just because the practice
is not fully busy. Your practice develops a momentum that can be hard to change. The
practice philosophy can be formed by the patients you see and by the fee levels that
are generated. Policies are built around managed care plans and frame inventory is based
upon plan coverage amounts. Staff training and staff attitude can shift. The
practice reputation begins to reflect a managed care approach, and before you know it, you are not the high fee / advanced service practice you once dreamt about.
Remember, building time into your schedule purely for administration, and not patient care,
is a good thing. Use that time for practice development and marketing that will build
the private-pay sector of your practice. We’ll focus on analyzing managed care plans next
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.