Practice Management

3 Challenges & the Solutions Helping Support Our 24% Per-Patient Revenue Increase

By Shane Foster, OD

Dr. Foster examining a patient. Dr. Foster has implemented solutions to address the challenges of OD recruitment, inflation and expanding scope of practice.

August 10, 2022

The challenges–and opportunities–for independent ODs are great.

I took over full ownership of our practice, Athens Eye Care, in 2019, when I bought out my retiring partners (who had been in practice for 37 years).

Just a few months later, COVID hit. We were forced to reduce our doctor days due to COVID safety procedures and precautions and also due to staffing issues. We went from 12.25 doctor days per week in 2019, to nine doctor days per week in late 2020 through 2021 (a reduction of 26 percent).

However, we were able to work smarter, not harder, and we only saw a reduction in revenue of about 5-10 percent. This is mostly due to a 24 percent increase in revenue per patient (or revenue per exam) in 2021 compared to 2019. We no longer work Saturdays, and we only work a half day on Fridays. This shorter schedule has boosted morale in both doctors and staff and has led to a great increase in productivity and job satisfaction.

We felt like we had really hit our stride, but then the skyrocketing consumer price index made us pivot and reassess our business once again. Here are some ways I am trying to combat inflation in my practice while also focusing on enriching the future of independent optometry.

Challenge: Continue to profit from increased per-patient revenue.
The cost of goods is going up for all businesses, including optometry practices. Meanwhile, reimbursements from commercial medical insurers are relatively stagnant, Medicare reimbursements are actively being cut and vision plans have not increased their reimbursements in more than two decades.

We are focusing on several strategies to combat the rising cost of doing business:
1. Leaning into programs from our optometric alliance, Vision Source, that help us save on cost of goods.

  1. Utilizing Essilor Experts to help streamline our ophthalmic lens portfolio and adjust optical pricing to focus on lens bundles and options that not only provide the highest-quality patient experience, but also maximize reimbursements from vision-care plans.
  2. Buying from the contact-lens vendors that offer us the lowest cost of goods and provide rebates for our loyalty and growth. We also focus on doing business with contact-lens companies that provide excellent patient rebates because those allow our patients to get the highest-quality products at the absolute best prices, while allowing us to make a great profit.
  3. Maintaining a “lean and mean” staff. We have fewer, but more engaged and productive, staff members than we had prior to the pandemic.

Staff members are highly engaged in our vendor-savings programs. For example, they have gone through training with Essilor Experts to learn the importance of offering quality eyewear solutions to patients and how that can also help the practice financially. Our doctors have also educated the staff on the importance of utilizing our preferred contact-lens vendors when applicable, and they all know our doctors’ “go-to” lens choices. After the initial training on these programs, which takes no more than a few hours, it becomes automatic for our staff members. They build good habits and they don’t have to spend much time thinking about it.

The greatest thing about the programs we are implementing in our practice is that they are patient-focused. Our motto is, “What’s good for the patient is good for the practice.” By offering the best-in-class ophthalmic lens and contact-lens technologies, our patients have a premium experience in their vision and ocular health. It just so happens that this philosophy also allows the practice to achieve the best profitability.

Dr. Foster with Ohio state representative Jay Edwards. Dr. Foster, his associates and support staff all volunteer to lobby for expanded scope of practice.

Expanding Scope of Practice
Challenge: Provide expanded services to serve patients and continue growing per-patient revenue.
As a legislated profession, optometrists are bound by the scope of practice rules set forth by each state legislature. As some states push forward with advanced procedures, others have lagged behind in their ability to prescribe oral medications or treat glaucoma. This wide difference in scope of practice makes it difficult to define what optometrists do, and can be confusing to our patients.

States with a more restrictive scope of practice may find it difficult to attract the freshest young minds graduating from optometry school because all colleges of optometry are teaching these expanded procedures, and students are eager to practice at the highest level of their education. Going to a state with a restricted scope may be viewed as taking a step backward before their career has even started.

Expanding scope of practice is expensive because it requires us to lobby legislators and other government officials to educate them on the need for the kind of eyecare we want to provide. It also requires significant manpower – from state association employees, lobbyists, grassroots volunteers, etc.

I have taken courses to become more educated in expanded procedures. I have shadowed optometrists in other states who perform these procedures regularly. I have discussed with my staff why the expanded scope is important to our patients’ access to care, since we live in a rural area and many of our patients must wait 4-5 months to even get evaluated for a YAG capsulotomy.

I have been on the board of the Ohio Optometric Association for the past eight years, and this year I serve as President of the Board of Trustees. I have volunteered significant time to furthering optometry in the state of Ohio, and scope expansion has always been an item on the agenda. I have formed relationships with my state legislators over the years so they now feel comfortable calling or texting to discuss matters affecting optometry, or healthcare in general. All of my fellow board members, past presidents and other association volunteers have done the same.

My associates are active volunteers in our state association as well, serving on committees and in local leadership. Even my support staff members have become involved, going to the statehouse to advocate for our patients, and writing letters to our state legislators to help generate support for our issues.

Membership in the American Optometric Association and our state affiliates comes at a cost, but I see it as an absolute necessity to keep our profession strong and well represented. (My combined state and AOA membership is only about $150 per month).

The benefit to patients in access to care is the main argument, and driving force, for optometric scope expansion. But expanded scope of practice also comes with substantial benefits to practices. These procedures offer higher reimbursement rates than some of the standard procedures we are doing today. Expanded scope also allows us to keep our patients close to home in our own practices rather than referring them to another practitioner. This helps promote patient retention.

However, there are also added costs to expanding scope of practice, such as investment in instrumentation. Doctors will need to train staff to assist in these procedures and will need equipment to perform sterilization of instruments. Adding these procedures to a practice also will likely increase the cost of professional liability insurance coverage.

Overall, though, expanded scope would have a positive impact on practice profitability if doctors code and bill properly and if insurers continue to reimburse at reasonable rates that are equivalent to those that our ophthalmology colleagues receive.

Nurturing the Next Generation of ODs to Work in Independent Practices
Challenge: Keep practices staffed adequately to provide great care that also creates a higher per-patient revenue.
Maintaining a steady flow of new graduates, who are interested in pursuing independent optometry and becoming private practice owners, is a huge challenge facing our industry, and practice owners individually. The rising cost of education and the meteoric rise of private equity in optometry means that independent ODs have an uphill battle in recruiting good applicants and retaining great talent.

My practice is a clinical extern site for fourth-year optometry students from The Ohio State University College of Optometry. Hosting these students in their final year of education gives us the opportunity to show them the benefits of independent optometry. I discuss the business of optometry and show them what is involved in the administrative side of private practice (financial reports, staffing issues, etc.). They are able to observe the benefits of being your own boss or being an associate in a private practice, including great latitude in autonomy, and flexibility in scheduling for prioritization of family responsibilities, community involvement and other professional development and volunteer opportunities.

We also have high school students who are interested in a career in optometry shadow in our practice. We give them a glimpse into our profession and get them excited about pursuing optometry when they go to college. We are fortunate to have a major university in our town, Ohio University. For the past 25 years, our practice has been employing pre-optometry students from Ohio University part time so they can get hands-on experience in an optometry office. We also host the pre-optometry club in our office, so they can observe and ask questions of our doctors.

Hiring a student part-time has employment costs, but these students are such high achievers and so motivated to learn that they are often the most economical hires you can make for your practice. Becoming an extern site for a school or college of optometry means you will have a new provider rotating through your office every few months. There is an investment of time in these students to get them up to speed, so they can perform more independently.

However, we have found that the students bring so much value and productivity to our practice. It allows us to add a few more patients to our schedules and/or get more administrative tasks done throughout the day. The vast majority of patients love working with the students and getting to know them, and it sets our practice apart from others because we have been entrusted to educate the next generation of ODs.

In addition, the students look up to our staff to help guide them when they have questions. This provides our staff with a sense of authority and leadership. They enjoy training these students as well.

By shepherding young minds interested in this profession, and helping to train the next generation of optometrists, my hope is that many of them will decide to pursue a career in private practice and that one or more of them will want to join me and I can pass the torch to them to carry on the legacy of my practice.

By Shane Foster, OD, is the owner of Athens Eye Care in Athens, Ohio, and Hocking Hills Eye Care in Logan, Ohio, which was named one of CooperVision’s Best Practices. To contact Dr. Foster:


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