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Ophthalmologists continue to be concerned about decreasing reimbursement for cataract surgery and the increasing nonreimbursed costs of utilizing new technology. I believe, however, that the future for lens and implant surgery is rosy.

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In this part two episode of the EyePod podcast, Colin Carr answers some Q&A with 

 executive editor David Hutton, diving into commercial real estate and your healthcare practice. From representation to knowing the market, Carr shares his knowledge on ensuring you as a healthcare provider can have the best deal possible — and grow your networth — through your real estate.

This transcript has been ligthly edited for clarity.

How can healthcare providers win against landlords and commercial real estate?

The best way to level the playing field or win in the commercial real estate negotiation is to make sure that you are adequately prepared for the negotiation. And to do that, you want to start with the proper timing. If you have a lease expiring in two years, and you start negotiating with your current landlord, and they know that no matter what you say, you're on the hook for the next two years, and you have to make that payment, they're not going to give you some some some favorable deal or involuntarily cut your lease rate for no reason. Conversely, if your lease is expiring in one month, and you haven't started the process yet, they're going to assume that you are out of time you missed your window to relocate. And they're gonna hit you as hard as they can with the highest lease rate, the lowest concessions possible. So step number one is you got to time it properly. If you're too early, it shows you don't know what you're doing; if you're too late, it shows that you you fell asleep at the wheel, you don't know what you're doing. So step one is you need to time it properly.

Step two is you need to hire representation that can help level the playing field. You're working against typically a professional landlord who negotiates for a living. When you go into that transaction, as a doctor or healthcare provider or an office administrator, they're going to assume that you don't know what you're doing. No matter how clinically savvy you are, no matter how academically intelligent you are, it's not what you do on a daily basis. And so they're gonna assume that you don't know the ins and the outs, they're not going to treat you the same way. Now, let me be clear about this one, I'm not saying they're going to be a jerk to you, they can still very well be respectful to you treat you with dignity, but they're going to show you terms or assume that you don't know you're doing. And they're going to be pushing you towards a deal that someone who's represented would not accept. And so timing it properly is important, hiring representation is important.

And then we cover this on the former version of our interview, which is they need to go to the market, they need to look at multiple properties, they need to negotiate with multiple landlords or sellers, and they need to know all their options. If they don't, and they pick just one property, they're at the mercy of that one landlord, that one seller, and they're not going to see the best terms. If that landlord knows that you're out there looking at multiple properties, and they're competing for your tenancy or your business, they're going to bring more favorable terms to the table. And that's going to help you win in the negotiation.

What do these landlords know about negotiating that the healthcare providers really don't know?

Well, to start with, the landlord knows that it's going to cost them more money if the tenant moves out of a space or doesn't do the deal and it says vacant, then if the tenant actually has to move. And this is a really interesting dynamic. A lot of doctors will say what, hey, I don't I don't want to move, or it'll cost me my move. True. But it'll cost the landlord more money if you vacate that space and they have to sit vacant for six months, 12 months, a year, and then give the next tenant, a building allowance, free rent to build up, free rent once they move in, pay all the fees of the deal. The landlord knows it's actually going to hurt them more than it hurts the tenant if they have to relocate or find different properties. So when you as a tenant know that the landlord wants you to stay in the property more than you want to stay in the property, it changes the dynamics of the negotiation.

The landlord also knows that if a doctor is not represented, they're probably not serious about getting the best terms possible. If the doctor is talking to the landlord directly, they probably don't have a savvy agent helping advise them to protect their interests, they're probably just winging it. And again, that is the wrong approach.

It's kind of like this, if you went to court, and you got a judge in front of you, and the other side has has their own counsel and you're just winging it, you're not going to have the same level of respect. They're gonna assume that you you obviously don't care, or you're not taking this seriously, because if you did, you would have someone on your side protecting you or helping in the process, same thing. IRS says, "Hey, we're gonna audit you." If you don't get to get a tax advisor involved or a tax attorney, you probably don't care what the outcome is and just you know, winging it may or may not work for you — it's probably not gonna work out for you the way that you want to.

When it comes down to the lease, in advance of a sale or transaction, what should a healthcare provider know to be prepared?

So if you're gonna sell your practice, or you're going to transition out of your practice, you want to know, if you own the real estate, what the real estate's worth, and what a fair market lease would be if you decide to keep the real estate and lease it back to that practice, or if you're going to sell the real estate with the practice, you need to know what that real estate is worth.

A lot of healthcare providers will let a practice broker do that valuation, that practice broker may or may not know the value of real estate. So it's important to get a third party person who only does real estate to tell you what the real estate's worth, if you're going to sell or lease it. Conversely, if you are leasing the real estate yourself from a third party landlord, you need to know do you have a good lease or a bad lease. If you go to sell your practice, and you've got a bad lease, that's going to impact the value of your practice; if you have a phenomenal lease, that's going to also impact the value of your practice.

And so what's very common is people time up when their leases expiring — or about to expire — with when they want to sell their practice. And if there's the ability to renegotiate that lease, and let's say reduce the lease rate by a few dollars per square foot, or get the landlord to put money into the space to renovate, that's going to make your practice more desirable from a sale perspective, and that might actually free up more cash flow to give you a higher level of earnings to give you a higher multiplier when you sell the practice. And so if you have a lease that you can renegotiate it, and you can renegotiate it before you sell the practice, you might be able to increase your your earnings or your spread, or your profitability and make your practice sales price higher by a significant amount of money.

If you're if you're saving on a multiplier of EBITA, or another valuation of profitability, if you increase your profitability per year by 20, 30, $40,000, because of a better lease, and then you renovated the space as well, you might be able to sell that practice for an extra 100, $200,000 depending on how it's valued. So make sure you're not losing money because you don't understand your current lease value or your current property sale value.

How can a healthcare provider actually use commercial real estate to make money for them, maybe increase their net worth by seven figures?

So if you are in a market that has options available for you to either purchase commercial real estate, or for you to buy a piece of land and develop your own property, and you look at the fact that you're going to make a payment one way or the other, you're either going to lease for the next 20, 30 years, or maybe you have 10 years left or what have you, or you're going to purchase and you're gonna make a mortgage payment.

If every month you stroke a check or push a button online, and you're either paying a landlord or paying a mortgage company, if every month you're paying down principal and an ownership scenario by 3,000 a month, 5,000 a month, 8,000 a month, whatever it is, and then you also have the benefits of things like appreciation, huge tax deductions, like depreciation, etc. And an ownership scenario, it's very easy to pick up 30, $40,000 per year in tax deductions, it's very easy to pick up 30, 40, $50,000 per year, in principle, pay down and then pick up even more money and appreciation. And you start adding those costs up over over a 10, 15 year, 20 year period of time. And it's very easy to get to a million to $3 million of net benefit to yourself, you get combination of of increased value principle, pay down tax deductions, and then you go to sell that practice and the property, you get 10 years from now, 20 years from now, it's very common for that real estate to be worth well over a million dollars, it's very common for you to pay it off over a 15, 20 year period of time.

Residential people, you know, pull the equity out constantly, you get little equity, you pull it out, you do these 30year, 35 year notes; commercial real estate, you're doing 15, 20 year notes, and you're not refinancing very often. So if after 20 years of owning a building, it's paid off free and clear, it's worth a million half, $2 million, and you picked up you know a million dollars in tax deductions, real estate is a very tangible and easy way to change your financial perspective by again by hundreds of 1000s at the minimum, but typically you're changing it by a million, $2 million.

Some healthcare providers may think it's okay to go in with their lawyer is that a good idea?

It is a good idea to have a lawyer to review the legal documents, it is not a good idea to have a lawyer negotiate economic terms for you.

It's the same thing we were talking about. You know, you have an attorney that specializes in reviewing contracts, reviewing legal documents, the landlord knows they don't know the market; they're not a market expert, they're not beating the streets every day talking to landlords, sellers, owners, listing brokers. And so they're just basically guessing. They're going to try to get an online database, guess the values, and so when you have an attorney negotiating economic terms, there's a couple things working against you.

Number one is the doctor, healthcare provider, you're paying somebody 300, $405 per hour to do what an agent or advisor would do for you for free. So number one, you're paying someone when you shouldn't be paying them.

Number two, they're not an expert in that area, and the landlord knows that as well. So you're back to the idea of doing something without the expertise that you need. And then ultimately, again, are they going to spend a 30, 40, 50 hours of time to get the deal done the way it's supposed to be done? Not unless they charge you $30,000. So, do you want to pay someone $30,000 in attorneys fees to do what an agent would do for you for free? And then it gives you much better terms and results? The answer's no.

You'd rather go with an advisor, who will do it for you for free, who's going to help you capitalize on the deal. Now, you do need the attorney to review the legal contract. And you should never have a real estate broker offering to give you legal advice, or offering to help you tweak language or draft language. Real estate agents should not practice law. And attorneys should not practice real estate. They're separate parties; you need both. And if they're both good, they'll only operate in their lane. If you asked me to be your attorney, I'm not going to be your attorney. If you ask a good attorney to be a real estate agent, they're gonna say that's not what I do. You need both but not either or.

When it comes down to it, how do you choose the best commercial real estate agent?

The best way to choose is to is to do some research. You can talk to, you know, people in your community that you respect; if you've got a good CPA, ask them who they know that specializes in healthcare real estate on the tenant-buyer side. Ask your equipment suppliers, ask your technology provider, ask your lender, ask people that you trust that you've been working with for a while, who do they respect? Who do they think would be a good fit. And a lot of times you'll start hearing the same names, you'll start hearing, hey, this person or this company does a great job. And then you start there, you put out an inquiry, get them on the phone, get them in person, and then you just ask them questions like, you know, what's your experience working with healthcare providers? What's your experience working in this part of the market? Do you do more work tenant-buyer side for healthcare providers? Or do you do more work on a landlord and seller side for third party landlords and sellers? And you start getting a feel for who's got the right game plan, who you trust, and it's no different than anything else in life, you're going to know very quickly: I trust this person, or I don't trust them; I believe this person has my interest in mind, or I don't, I think they have the expertise or I don't believe they do. And so if you get up there and talk to a few people, you'll know very quickly, this is the person I want to work with, or it's not. And if it's not, then go on to the next person, there's too much on the line for you to settle in this transaction. If you don't trust the person, find somebody else, search online, do your research, do you do your due diligence, but don't lose 100, $200,000 because you weren't willing to take 30 minutes to research people and talk them on the phone or meet them in person.

Again, it's this idea, "Well, you know, I don't have time," and my response would be, "So you don't have 30 minutes or 45 minutes or an hour, and you're willing to lose $100,000 because of that?" Like if I offered to pay you $100,000 for half an hour of your time, I think you find a way to make time for that $100,000 check. It's the same amount of money, believe it or not, you just have to do your due diligence.

How much does it cost to hire this expert commercial real estate agent?

Well, that's the beauty. That's what I've alluded to a little bit here at some of the previous answers. It doesn't cost a healthcare provider anything to hire a commercial real estate agent. And that's because commissions and commercial real estate are paid, just like they are in residential. And that's why the landlord or the seller — so if you're going to sell your house in residential, you hire a listing agent as your advisor, your agent, and you would have a commission agreement for that transaction. And it would be built for two people; it'd be built for your agent, and it would be built for the buyer's agent. And if the buyer shows up without an agent, that listing agent gets a double commission.

So this is not a for-sale-by-owner scenario. This is where a lot of healthcare providers get confused. They think, well, if I don't hire an agent, I'm going to save money. And the reality is you're not the one paying the commission. So there's no money for you to save in this because you didn't determine the commission structure and you're not paying it. If you own the property and you wanted to sell it yourself or lease yourself, sure, you could save one half of the commission. But in a scenario, if you're a doctor or healthcare provider, and you're a tenant or a buyer, that commission is being paid by the landlord or the seller, it's going to get paid either a double commission to the listing agent, or it'll be slipped from the listing agent and then your agent, your representative. So there's no money to be saved by not hiring an agent. So the question is, well, why would I hire someone? And the answer is because you're too busy to hire someone, you don't know how the games played, or you just you just get frustrated and say "I'm just going to sign whenever they put in front of me."

Again, all those are bad game plans. But long story short, it's free to hire an agent as a tenant or a buyer's agent, you should always have representation, and they're going to take a fee out of the owners proceeds or the listing agent's portion, so it's not going to cost you as a doctor or healthcare provider anything.

Do you have a website people can visit, f they want to get more information about you?

I do, yep. Best way to get a hold of us is our website. It's 

. Upper right hand corner of our website, you can click the "Find an agent," we have agents across the country, we operate at every state across the country, you can click to get a free lease or purchase evaluation if you want to know how your lease compares to the current market, if you want to know what it would cost to own and what your options are in your immediate area. We'll do all those things upfront for you, as well just to give you initial information to help you make this decision.

And then ultimately, we also have hundreds of educational resources. We have a glossary, FAQ, we've got hundreds of videos.

If you want to get educated on healthcare real estate, we have more information than you could ever possibly get through. But we will help get you educated so that you can make the best decision possible for your practice, for your future and for your financials.

On this part two episode with Colin Carr, founder and CEO of CARR, we hear more about commercial real estate dos and don'ts when managing the space of your practice. Tune in now for the Q&A with Ophthalmology Times® executive editor, David Hutton.

Commercial real estate and your practice, part two with Colin Carr

Colin Carr, founder and CEO of CARR, chats with 

 executive editor David Hutton in this part one episode of the EyePod.

This transcript has been lightly edited for clarity.

Welcome to EyePod, a podcast series from 

. I'm David Hutton, your host for today's episode. I'm joined today by Colin Carr, the founder and CEO of CARR. 

CARR's team of healthcare real estate agents span coast-to-coast, and the company is a leading provider of commercial real estate services for healthcare professionals. Colin has been involved in commercial real estate since 2000, and has personally completed more than 1,000 transactions. He's here to share his expertise with us today. Thanks for joining us.

First off, how much is really on the line in healthcare real estate negotiation?

It's a great question. And most people would dramatically underestimate the answer. But the answer is there's several $100,000 that are on the line in a traditional commercial real estate transaction. So I mean, break down the numbers, let's say you've got a space, that's three or 4000 square feet, if you are overpaying by three or $4 per square foot, you take 3000 square feet, times $3 per square foot higher rent than you maybe could have paid or should have been paying if you were properly represented, and you had a really aggressive negotiation. And so 3000 square feet times $3 per square foot is $9,000 per year, and excess rent that you could have potentially avoided paying. Take that over a 10 year period of time and all of a sudden you've got $90,000. Look at other concepts like what are your annual increases, if you're paying a 4% annual increase, instead of three and a half percent, or three or two and a half percent, here comes another 20, $30,000 in additional rent that you could have avoided paying. And then you get into other questions like free rent allowances, renovation allowances, or tenant-proven allowances. And you could add up to a couple $100,000s very quickly in a standard negotiation.

What are the top mistakes that healthcare providers make with their office space?

So well, let me start with just maybe the top three or four. The first mistake that healthcare providers make with the real estate, is they try to take the do-it-yourself approach. They either think they're gonna save money by not working with someone, or they don't know where to go find a good advocate or advisor, or good agent, or they just, they all of sudden get a phone call from their landlord or from the property manager, asking them if they want to renew their lease, and they all of a sudden start scrambling and they start the process all by themselves. And the problem with that is several fold.

Number one, when you're dealing with a commercial real estate transaction, that is gonna be worth hundreds of 1000s of dollars or even millions of dollars over a 7-10 year period of time. There's a lot on the line. And if the landlord thinks that you don't know what you're doing, or if you're not qualified, or if you don't have time, they're going to use that against you. They're going to take advantage of you in the transaction. And here's the reality: if Chipotle shows up to do a deal, they're going to have a professional agent right presenting them. If Starbucks shows up, they're going to have an agent. If Charles Schwab or Lockheed Martin, or Visa or any large company shows up to do a deal, they're going to have professional representation. And so when a healthcare provider who maybe does two or three real estate deals in their entire career from the commercial perspective, shows up against the landlord that landlords going to assume they don't know what they're doing, they don't have the expertise, they don't have the time. And the landlords would give them a dramatically inferior deal. And we can break that thing down 10 different ways. But the bottom line is the do-it-yourself approach is going to cost the doctor, or the office manager, 40 to 50 hours of their time, they're going to probably lose 100, $200,000 in the negotiation, they're going to open themselves up to a bunch of pitfalls and complications that they shouldn't have been exposed to, and at the end of the day, they're not going to have any peace of mind that they got the best terms possible. So it is a lose, lose, lose scenario. So I'd say that the do-it-yourself approach, that's the top mistake that healthcare providers make.

Second mistake that we see them making is that they only choose one property to pursue. Maybe they drive by a property and they fall in love with it. Or maybe they've been in the same property for 10-20 years. And they go to do either a new deal or renewal, and they don't negotiate with any other landlords or sellers. That is a huge mistake in commercial real estate, because you have no basis to compare the terms that you negotiate on the one property to the market. And so this is where commercial real estate differs dramatically from residential real estate.

In residential real estate, you might go look at, you know, X number of houses, or you're looking at properties online, you know, via Zillow, or Redfin, or Trulia, what have you. And then when you find the property you like, you submit an offer and a contract, and if the seller says yes and signs, then you're under contract right away. In commercial real estate, there's too many variables to submit a binding offer, if it's a lease; if it's a purchase, yes, you can submit an offer, but typically, even then, you're still negotiating on what's called a non binding letter of intent, an LOI, or an RFP or request for proposal. So in commercial real estate, the top companies in the world, they'll go look at their options. And they'll negotiate on three, four or five properties simultaneously. Like they might look at 20 properties, whittle it down to the top four or five, and then they start trading paper with four or five different landlords. And they might go three or four rounds of negotiations before they finally get to the place where they're ready to choose which property they're going to move forward with.

And the benefit of doing that is they're not wondering if the terms of each property are competitive or aggressive, because they have a benchmark of three or four other landlords that they're all asking for the same, the same concessions are the same terms from so they know, unequivocally, this is either a good deal, this is an average deal, this is a terrible deal, this is a phenomenal deal, because they have all these things to compare it to. It'd be no different than shopping for an item if you went to four different stores and got four different prices. And if you couldn't negotiate it, you would wonder if you got the best deal possible.

Unfortunately, a lot of healthcare providers will just take one property, submit offers and get so far down the road, and they have no clue if it's a good deal or a bad deal. They might be able to compare the deal compared to where they started the negotiation where they finished the negotiation, but they could have started in a really bad place and not known it; they might have thought they're starting at a decend place, and then they end lower, they think they got a great deal. And they could still be overpaying by $200,000 over a 10 year period. And that happens all the time.

How do you decide when it's better to purchase or lease the property?

The best way to decide that is to let the numbers tell you which property, or which option, to choose. And this goes back to what I was just mentioning, if you only look at options to lease or only look at option to purchase, you don't have the ability to compare a purchase versus a lease. If you take the approach that I just gave you, which is you hire accurate representation, that advisor goes to the market and looks at all the properties that meet your top requirements, and then they whittle it down to the top maybe eight properties that best fit your requirements, you tour those properties and then you pick the top three or four to negotiate with. If you've got options, the lease and options the purchase in the running, then the numbers will start telling you very quickly which one makes more sense.

Now, if you like one property better, that's probably what you're going to choose if you love the option to purchase, and the option to lease is not that nice of a building. That's an easy question or scenario. But let's just say the option to lease is every bit as good as the option to purchase. Both are phenomenal locations. Both are beautiful properties and buildings. And you would be happy to either one, the way you decide that are the numbers: What's the downpayment? You know, how much how much money do you have to inject into the deal to get the financing that you want? What is the actual cost of the property after you pay down the principal, how much tax deductions and how much depreciation you get in an ownership versus a lease, and you could end up paying more for the property per month in a mortgage payment, but end up paying less per month or per quarter on taxes significantly. So you maybe pay your lender more, but you pay the government less.

And it actually, you could have a scenario where maybe it costs $10,000 a month to own, $6,000 A month the lease, but once you factor in principle paid on a tax deductions, the effective cost of owning could actually be less to own, even though you're paying a higher amount per month upfront. Once you factor in those benefits, it can be a lower effective cost of owning. And so the best way that you get there is to run a very detailed purchase versus lease analysis or to have your agent do that for you. And then that'll tell you quickly, "Hey, this property makes more sense economically, or financially than the other property does." The numbers speak very loudly.

Everybody likes to save money, how can health care providers save say $100,000 or more on their next lease renewal?

So lease renewals are the number one transaction where healthcare providers lose money, right? Healthcare providers are very good at losing money in a lot of different types of deals, which is not a compliment by the way, but lease renewals are the number one transaction where healthcare providers leave money on the table.

And here's why: A lot of healthcare providers, they're in a space that maybe been there for 5,10, 15 years, and they go into the transaction thinking "I don't want to move," or "I don't have time to move," and the landlords are going to assume that that's true, regardless. Okay, so a landlord's going to go into a deal and say, "This person, he or she probably doesn't have the time, they probably don't want to deal with the inconvenience, they probably haven't hired an expert agent to show them the market. They are in healthcare, which means they want to help people, they're not in aggressive negotiations for a living, so they don't like to be uncomfortable. And if I make it uncomfortable for them, or I don't cooperate within the way they want to, they'll probably just do whatever I say that I need them to do the probably just sign the deal at the end the day, they'll push back a little bit, but I won't get them to leave over it." And so a lot of landlords go into the transaction thinking, "If I charge them a little higher lease rate, they're probably not going to move because of it; if I give them lower concessions, they're probably not going to move over that." And so they just start kind of chipping away at these deals. And ultimately, the deal is so much further in favor of the landlord than the tenant than you could possibly imagine.

So that's me setting the table to say, if you want to save money in a lease renewal as a healthcare provider, you got to go to the market, you've got to look at what your other options are. And you've got to be willing to relocate. I didn't say you have to relocate, but you have to be willing to.

If you showed up at a car dealership and said, "I have to buy that car right there, no matter what the price is, I will pay it," you're not going to get a good price in the car, like this is terrible negotiation strategy right there. And we laugh at that, but that's literally what doctors are telling landlords: I don't have time to move, I don't want to move. It's too inconvenient, I don't have the money. I don't even know where to start. What will you give me? And the answer is you're gonna get a terrible deal.

And so if you want to save money on a lease renewal, you hire an expert agent to represent you, they go to the market and find all your top options: top options to lease, top option to purchase, looking at different square footages, different types of properties, office versus retail, what have you, standalone, multi-tenant, they look at all your options, they whittle it down to the top top five, seven properties. And then you start negotiating simultaneously with three or four of those people.

Once you know what terms you can accomplish, if you were to relocate or go somewhere else, you then have the basis to negotiate against your current landlord, because you know what a competitive deal is in the market. You know if you were to move, what it would cost you, or what you would be offered. And so when you negotiate with your current landlord, you're not going to be taken advantage of, you're not going to pay your current landlord $30 a square foot, if the other top three properties in immediate area are $25 a square foot, you're not going to overpay like that. If your current landlord says "hey, there's no free rent, there's no tenant improvement allowance." And yet, you can get a huge free rent package and a huge tenant proven allowance right next door down the street. You know your current landlord's not offering you a competitive market deal. And so you use other properties to leverage against your current landlord or your current your current property manager. And that ensures that you don't overpay.

And at the end of the day, when the landlord knows that you are serious that you're not going to be taken advantage of, they'll treat you like a respectable company. A landlord is not going to go to Starbucks and assume they don't know the market. They're not going to go to Amazon and assume they don't know the market. They're going to assume these guys are savvy, they've done the research. If I don't come with competitive terms, I'm going to lose the chance even to do business with them. So they come with aggressive terms, competitive terms, you know, fair terms, and the difference between that type of a proposal versus you know, "hey, landlord, send me an offer. What would you do if I was willing to stay there?" That's 100, $200,000 like that.

Thank you for joining us on this episode of EyePod, be sure to tune back in for part two with Colin Carr.

Colin Carr, founder and CEO of CARR, chats with Ophthalmology Times' David Hutton in this part one episode of the EyePod. Carr hits on some hot real estate topics in the healthcare industry, including top mistakes healthcare providers make with their office space, how to decide whether you're going to purchase or lease, and how healthcare providers can save $100k or more on their next lease renewal.

Tips, tricks, what to dos and what not to dos on how you can save money as a healthcare provider on your commercial real estate (Part 1)


Peter J. Polack, MD, FACS, and Zora Harrison, COO at Ocala Eye in North Central Florida, share the protocols and technology their practice implemented throughout the pandemic that has enabled them to safely and efficiently treat their patients.

COVID-19: Year in the life of ophthalmology practice

Find out how one eye care practice has found success in adapting their services to ensure staff/patient safety throughout the pandemic. 

Adjusting ophthalmology practice to a pandemic 

The partnership will integrate Ocuco’s optical software solution, Acuitas 3, with Nextech’s Ophthalmic Platform. 

Nextech and Ocuco partner to deliver seamless end-to-end eyecare platform

To create lasting change, ophthalmology must embrace the impact of sponsorship and advocacy—empowering the next generation of leaders with not just knowledge, but the opportunities to excel.

Beyond mentoring: The power of sponsorship and advocacy in ophthalmology

A retrospective study showed that the gender of the ophthalmologist influenced the amount of communication with the patient, and that the pandemic had an impact. 

How COVID-19 shifted ophthalmologist-patient communication

According to data presented this week at the 128th annual meeting of the American Academy of Ophthalmology, being held in Chicago, about three-quarters of medication volume remains in multiuse eye drop bottles tossed in the garbage well before FDA-regulated expiration dates.

AAO 2024: One simple change to boost sustainability in eye clinics: Stop discarding eye drops before they expire

Physicians can use media training, public relations to combat medical misinformation

Envision Summit 2025: Managing add-ons in a busy retina clinic

At the Envision Summit 2025 in San Juan, Puerto Rico, Ollya Fromal, MD, gave advice on how retina specialists can manage add-ons in their busy retina clinics.

Editor's note: The below transcript has been lightly edited for clarity.

Hi, I'm Ollya Fromal. I'm a vitreoretinal surgeon at The Retina Institute in St Louis, Missouri. And I'm here in beautiful San Juan at the Envision Summit. I gave a presentation this morning on how to manage add-ons in your busy retina clinics. So we talked about how to systematically approach new patients, trying to stay focused and concise while you're doing that, but also keeping an open mind as you walk through your differential diagnosis. We reviewed some key clinical and exam findings of the must-not-miss retina cases, and talked about the diagnostic dilemmas and then some initial management. So the cases that we reviewed was bilateral CMV retinitis, acute taxoplasmosis. We talked about how to examine children and adults. There was a case of solar retinopathy with a 11-year-old who was using dad's [inaudible] to view the solar eclipse, which did not have enough support and protection to protect from the harmful solar radiation. And we also talked about how to incorporate procedures into the busy retina clinic. So something that our surgeons need to always keep in mind as far as time management and how to work with the referring providers and not let those urgent cases derail your clinic flow.

Envision Summit 2025: How to use the new G2211 code

At the Envision Summit 2025 in San Juan, Puerto Rico, Lana Rifkin, MD, gave clinicians advice on how, and when it may be most appropriate to use the new G2211 code.

My name is Lana Rifkin, and I am a uveitis specialist in Boston, Massachusetts. I'm the director of the uveitis service at Ophthalmic Consultants of Boston. My session this year was, it's Friday afternoon–what uveitis walks in. I had a fabulous panel with really excellent speakers. We focused on how to evaluate and manage typical cases of uveitis that may walk into your clinic at any given moment.

My talk was actually not clinical, but on billing. My talk was the new G2211 billing code, how to use it appropriately. Because I think that in addition to the great clinical care that we provide, it's very important for us as ophthalmologists, and especially us as women, to know how to bill appropriately for the work that we do. The G2211 code is a new code that was introduced about a year ago. It's a complex code designed to encompass and reimburse for the very complex care that we provide for our patients in longitudinal format. So this applies to patients that are ongoing, that they're with us for the long haul. That we serve as the focal point of their care. Especially in uveitis, we see a lot of patients who have other complicated, systemic diseases, but we're the focal point as the eye disease drives their care. So this code recognizes the time and the mental capacity that it takes to organize all that, to communicate to the patient, with their families, with their other caregivers and other physicians. All of that takes time and effort, and this code recognizes that and reimburses a little bit for our time.

So the advice that I would have is don't be afraid of it. This code is not just designed for primary care physicians, but it is designed for those of us who do provide longitudinal care. Again, with the complexity of the disease processes and the patients that we see, it's very important to know how to bill it, when to bill it, when it's appropriate. So the main advice I have is don't be afraid. Learn the parameters. You can use it with any E&M code. It cannot be used with eye codes, but with any E&M code, even level fours and level fives. Even if you're billing a higher E&M code, it doesn't mean that you cannot bill this additional complex code.

Also extremely important is documentation. If you didn't document it, it didn't happen. But if you know that you are providing longitudinal care, that you are communicating with the patient, explaining the vision threatening nature of their disease. If you're communicating with other physicians and you document it, then it is absolutely appropriate to be billing the G2211 complex code.

John W. Kitchens, MD, video

. The FLORetina conference was recently held in Florence. At that event, Dr John Kitchens made a presentation titled "Efficiencies In and Out of the OR." Thanks for joining me. First, what inspired you to focus on efficiencies, both inside and outside the operating room in your practice, and what are some of the specific challenges you aim to address through these improvements?

 Yeah, David, you know, this has been a talk that I've thought about for a long time. It really comes from a couple of different origins. First and foremost, I'm in a large retina-only practice in Lexington, Kentucky, and I'm fortunate to have 10 partners who are all very like minded and very efficiency focused. And so I find that all the time, I'm getting suggestions from one partner or something that our scribes will recommend that one of the doctors does differently that makes things more efficient. And so I feel like we have this cross-pollination in our group that's always looking for ways that we can be more efficient and do things better, more patient-centric, and, frankly, more efficiently. The second thing is, every time I've been to a conference or whatnot, I find that the things that interest me the most - and the things that I talk to my friends and colleagues about the most-are are the little pearls and tricks that you can use to make things work better. And I'm constantly finding things that are unique from other doctors that make them more efficient, or sharing things that we do that make other practices more efficient. And this actually crosses borders. And a great example of that is about 3 or 4 months ago, we had some doctors come in from Oslo, Norway, and they came and watched us work at some of our satellite clinics. Believe it or not, in Norway, they don't have satellite clinics. They were actually able to see how we ran a satellite. They thought it was very unique. And they're now taking this back, and they're going to implement it in their country. So, it's just really neat to be able to cross-pollinate ideas and best practices from each other in the US and internationally.

 Could you elaborate on some of the strategies or tools you've implemented, and how have they impacted patient outcomes?

 Yeah, so a variety of different things, both in the clinic and in the operating room. I think the biggest difference maker for us in the clinic is utilizing scribes. Now, a lot of practices use scribes, but our scribes function in a way that's almost like an assistant to the physician, in that they're all very, very well-trained. They've been doing this for years. They're not just inputting data, but they're actually looking at the scans, pulling up the scans, talking to the patients as they bring them back to the exam room, and getting a little bit of insight. And it's not uncommon for my scribes to come and say, "Oh, we have Mrs. Jenkins here. She went 10 weeks in her injection interval. She feels like she's worse. Her scans look a little bit worse. We might want to think about taking her back to 8 weeks." Then, I'm able to actually delve into that chart, look, confirm what they're saying, and then decide if that is the course of action you want to make, and it's a team approach. And they, once again, also do the documentation. They help with the billing and other things like that. But I find that they always have really great insight and recommendations and make my day and my flow go a lot easier. A few other things that don't necessarily involve the scribes ... love injection-only visits. These are visits where we don't bill a patient for an exam. We don't dilate the patient. They come in, and we know they're going to get a shot. We follow their OCT, and we determine their interval based off what we see with their OCT, visual acuity, subjective complaints. I love to dictate. I feel like it's a lost art. Dictating notes on patients is really important, and it personalizes that visit to the referring doctor and then also sending a copy to the patient … great way to document, really gets my thoughts on paper in my own voice.And then a few other things. We do a lot of laser indirect for our PRP. It's all different than what's done in Europe, where they do more slit-lamp-based laser. Laser indirect seems to be a little bit faster. We’re starting to use chlorhexidine for our cleaning agent for injections instead of betadine. That seems to eliminate some of the follow-up calls with ocular irritation, corneal epithelial defects, and whatnot. We're not seeing a significant increase in endophthalmitis since using chlorhexidine, so that's also reassuring.When we look at in the operating room, we're constantly looking at ways to do things better, and these are just little pearls, techniques such as, you know you're doing a membrane peeling, and you have some ILM or epiretinal membrane on your forceps, just being able to swipe that off inside the eye with your light pipe. Not having to externalize your instruments where you wipe them on an instrument wipe, where you could then introduce fibers into the eye. You're not coming in and out of the eye quite as much, utilizing when the BIOM or wide-angle viewing system happens to inadvertently touch the cornea. In the past, we've pulled that out of the eye. I have my OR technician clean the BIOM underside. In reality, if you have a clean, gloved finger, you can swipe that and squeegee that lens off and get 90% of your view restored very, very quickly by yourself, not having to have that person, you know, go and actually do a full cleaning procedure. So just a lot of little things that we do.The last one actually kind of a bridging of the OR and the clinic is how we manage our post-op patients. You know, one of my partners, Tom Stone, who's been in this practice that I'm in for more than 20 years now, he's always been a very progressive-thinking, thoughtful guy, and, you know, about 5 or 6 years ago, he said, "Why do we use steroid drops? We're not really dealing with the anterior segment. We're not really inducing a lot of cystoid macular edema. Why don't we just try antibiotic ointment twice a day for a week?" And so, 5 years ago, we cut out all of our steroid drops, all of our dilating drops for our retina surgical patients, with the exception of patients that have an IOL placed or something that could induce a CME situation. We saw no increased rates of cystoid macular edema, no increased rates of infection. Patients are on antibiotic ointment twice a day for one week after the surgery, then they stop the antibiotic ointment. And we've had great results with this. The patients get 1 tube of ointment, and that suffices for the entirety of that week. And then we don't get a lot of calls. The referring doctors don't get a lot of calls for drop refills and confusion around drops and whatnot. And it's been absolutely great, and we published those results at ARVO a few years back.

 How do these processes influence the overall patient experience and clinic workflow, and what kind of feedback are you getting from the patients?

 Yeah, so I think anything that decreases the complexity for our patients is a benefit without compromising care. For instance, the antibiotic ointment — it's very easy to just recommend antibiotic ointment twice a day for a week, without having to talk about a taper. The patient doesn't have to deal with a copay, or as many copays, for getting drops and figuring out how to use them, so we get great responses on that. Occasionally, we'll hear from our referring doctors and from patients who might have had care elsewhere. They say, “Gosh, what do you do that's better so that we don't have to take those drops for a whole month?” I do think it's appreciated, and I think it shows that there's always this continual endeavor to not just accept the status quo, but actually look to be innovative.When we improve our clinic efficiency, I think it helps across the board for our clinics. You know, when you get upwards of 60 to 70 patients in a day, it's really hard to maintain that personalized feel and touch for patients, where you actually get a chance to talk to them about other things in their life — things you might have learned over the course of their treatment about their families and how things are going — and have time to answer all of their questions. So anything you can do to improve that efficiency helps. Patients don't wait as long. If a patient doesn't wait as long, they don't expect you to be in the room as long. They're more willing to say, “Hey, it’s a quick visit, but we're getting in and out really quick, so we appreciate that.” And then mostly, it just frees up time for those longer conversations that we do have to have with some patients.

 And what role do technology and team dynamics play in achieving these efficiencies?

 Yeah, so I'll tell you that we couldn't do it without the technology that we have. You know, more and more, retina is moving from a specialty that was focused on really the ability to examine the retina to the ability to strategize around best practices and the best ways to take care of patients, as well as ways to best educate patients. Now that we have OCT technology that we get on almost every patient, we're able to see the retina as well as the greatest retina specialists of the past. We're actually able to get a digital cross-section of the retina at every visit and look at the retina the way Don Gass used to be able to see it with a contact lens on the eye.With ultra-wide field imaging, we can now see 90% of the retina. So when a patient comes in with diabetic retinopathy or flashes and floaters, we can do an ultra-wide field image, capture 90% of the back of the eye, and make sure everything looks good. Then we can focus in, in a more targeted way, on areas that might concern us or perform a depressed examination in the patient with flashes and floaters. Furthermore, you have documentation right then and there of how that patient looks, so you can compare their condition going forward.So, technology is a huge piece. The second piece you mentioned is cooperation and teamwork amongst all of us. It's not just the doctors who are recommending some of these improvements in efficiency and discovering these methods; our scribes play a really active role in that as well. Even our workup team members will come and say, "Hey, I think we should do this differently," or "Hey, let's see these patients at the first part of the schedule and these other patients later." So it truly is a team environment, where everybody's experience, thoughts, and ideas matter, and we take all of those into consideration when making changes and adopting new practices.

At the FLORetina Conference in Florence, Italy, John W. Kitchens, of Retina Associates of Kentucky, highlighted strategies to enhance efficiency in retina practices, addressing challenges like staff shortages and rising patient volumes. He emphasized streamlined workflows, advanced diagnostic tools, and enhanced patient communication to optimize care and improve outcomes.

Practice Management

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