Stop Selling the Widget: How Optometry Builds a More Valuable Practice

If you spend enough time talking with optometrists about reimbursement, the conversation eventually comes down to the same frustration: somebody isn’t paying us enough. 

Sometimes it is a medical payer. Sometimes it is a new policy that changes the economics of a product or service that had previously been cash pay. Whatever the catalyst, the frustration is understandable. Nobody enjoys watching the economics of something they have built suddenly change.

But I think we may occasionally be asking the wrong question. Instead of asking, “How much money can I make from this product?” Perhaps we should be asking, “What clinical services does this patient actually need, and how do I build a system to provide them?” 

That may sound like a subtle distinction, but I don’t think it is. In fact, I think it gets to the heart of building sustainable medical optometry practices.

The Myopia Management Problem Isn’t Really About Myopia

Let’s use myopia management as an example. On one hand, we want patients to have access to evidence-based treatment. On the other hand, when a payer begins covering a product that had previously generated a strong cash-pay margin, many practices immediately worry about what that will do to profitability.

I understand the concern. I would generally prefer to determine the value of what I provide rather than have somebody else determine it for me. But if we truly believe progressive myopia is important, then broader patient access to myopia management is a good thing. Removing a financial barrier for families is a good thing. The fact that a payer recognizes enough value in myopia management to provide a benefit for it is also, broadly speaking, a good thing.

The complication comes when most of the financial value of the service has been attached to the product itself. I tend to call that product the “widget.” 

The widget could be a specialty contact lens, an ophthalmic lens, a pharmaceutical or a device. Over time, the particular widget will change. So will reimbursement, formularies and technology.

If the practice depends heavily on the margin attached to that widget, every one of those changes becomes a financial threat.

That tells me we need to pay more attention to the professional services surrounding it.

Your Expertise Is More Valuable Than the Widget

Optometrists tend to have little trouble assigning value to a physical product. A sophisticated pair of ophthalmic lenses costs money. The patient can hold the glasses in their hand, so the value feels tangible. 

Professional expertise can be harder for doctors to value in the same way. I have heard doctors hesitate over the value of an encounter because it took five or ten minutes. But consider what had to happen for that visit to take only five minutes. 

You spent four years in optometry school, completed thousands of patient encounters, attended hundreds of hours of continuing education, and spent years developing the clinical judgment necessary to recognize the problem quickly. 

An experienced clinician may evaluate an acute problem, recognize the likely diagnosis quickly, and establish a treatment plan in a relatively short visit.

The patient still benefits from all the experience that made that speed possible. Efficiency does not reduce the value of clinical judgment. 

Separate the Professional Service from the Product

This becomes particularly important in myopia management. 

If I diagnose a child with progressive myopia and prescribe an appropriate myopia-management lens, I do not stop being the doctor once the glasses are dispensed. I still have to determine whether the treatment is working. 

I may need to monitor visual acuity, refraction, and axial length. I need to evaluate adherence. I need to decide what constitutes acceptable progression and, most importantly, what I will do if the child is not responding as I expected.

Do I change the treatment? Do I add another treatment? Do I change the follow-up frequency? 

Those decisions are where much of the professional value lives.

Problems arise when a global fee assumes the product margin will subsidize every professional service around it. That structure may work for years. Then a payer changes reimbursement and the math suddenly stops working. A more durable approach starts by defining the care the patient will need over time.

Who should provide each part? How much physician involvement is required? How should the professional services be valued? Build those answers into the model from the beginning.

Build Myopia Management Like You Build Glaucoma Management

Now, let’s consider how we manage glaucoma. When I diagnose glaucoma, I do not typically sell somebody a “glaucoma package” that includes their medication and every encounter I might have with them over the next year. I diagnose the disease, establish the appropriate testing, initiate treatment, determine the appropriate follow-up interval, and then modify the plan based upon how the patient responds.

Why should the fundamental thought process be dramatically different for progressive myopia? 

The coding and payer rules may be different, of course. A medical payer may not recognize a refractive diagnosis such as myopia for a particular service, which may leave the patient responsible for that care. That does not mean the clinical service suddenly has no value. It means we need to understand who is responsible for paying for it and communicate that clearly.

I have discussed this before in the context of atropine follow-up for myopia management. The appropriate diagnosis and payer responsibility can vary depending on the patient’s documented condition and findings.

Our job is to document the condition we are actually managing and understand how the service should appropriately be billed.

That approach holds up far better than building the program around the assumption that today’s product margin will still exist five years from now.

The Comprehensive Exam Should Be an Entry Point, Not an Event

For many practices, the comprehensive eye examination is treated as an event. The patient comes in, we perform the examination, we prescribe glasses or contact lenses, and then we hope to see the patient again in 12 or 24 months. If that is our model, we have essentially created one opportunity to establish the relationship and generate value.

I prefer to think of the comprehensive examination as an entry point. 

During that visit, we may uncover myopia progression or glaucoma risk. We may identify dry eye disease, macular degeneration, ocular allergy, or another condition that requires follow-up. When that happens, the routine exam has done exactly what it should do: it has identified a patient need.

Does the practice have a reliable system for addressing that need? 

That has been central to how I teach practice development: capture, care, and manage. 

Detect the problem, diagnose it, communicate why follow-up matters, establish the appropriate clinical protocol, and then manage the patient longitudinally. The pillar model then takes that concept further by creating the intake questions, clinical protocol, patient education, billing and coding structure, and staff training necessary to deliver that care consistently.

When we build our practices around that process, something important happens. 

Taking better care of the patient also takes better care of the practice.

Longitudinal Care Has Value

Even CMS has increasingly recognized the resources involved in longitudinal care. 

The introduction of HCPCS code G2211 was intended to recognize some of the additional resource costs associated with clinicians who serve as the continuing focal point for care or provide ongoing management of a patient’s serious or complex condition. Its use has specific requirements, including its relationship to office/outpatient E/M services, but the broader concept is worth recognizing: there is legitimate healthcare value associated with an ongoing clinical relationship.

That is exactly how I want optometrists thinking. Instead of measuring the day by asking, “What did I sell today?” I would rather ask, “How many patients did I appropriately diagnose, treat, and manage today?” Those two questions can produce very different practices, even when the doctors involved are seeing exactly the same types of patients.

It also changes where we get the proverbial dopamine hit. 

Product sales create immediate feedback. You sold the glasses and can see the transaction. Medical care does not always work that way. You may provide excellent care today and not see the reimbursement for weeks. 

But if the clinical process, documentation, and billing are correct, the economics eventually follow the care. That is a healthier foundation for a practice than constantly chasing the next high-margin product.

Protect the Doctor’s Time

This also forces us to reconsider how we structure our schedules. 

A follow-up visit does not automatically need 30 minutes because our scheduling template happens to be built in 30-minute blocks. Instead, ask what information we actually need, what our staff can collect, what testing needs to occur, how much physician time is necessary, and what clinical decision we are making.

If the answer requires five or ten minutes of physician time, build the process around that reality. That is not assembly-line medicine.

It is efficient medicine, and efficiency becomes much easier when everyone in the practice works to the fullest extent of their knowledge, education, and training.

I do not want a doctor spending time measuring a PD or making a routine frame adjustment when a well-trained optician can handle that work more efficiently.

The same principle applies throughout the practice.

Team members should work to the fullest extent of their knowledge, education, and training, which protects physician time for the parts of care that actually require physician judgment.

The Same Principles Apply to AMD Management

This is where the myopia discussion becomes much bigger than myopia. Replace “myopia” with age-related macular degeneration, and almost every practice-development principle remains intact. The technology changes, the patient changes, and the clinical protocol changes, but the process of building the service does not.

For AMD, we need to determine: 

• What questions identify patients at risk
• What clinical findings trigger additional evaluation
• What diagnostic technology we need
• How we stratify risk and when the patient should return
• What treatments or interventions should be discussed
• When referral is appropriate
• How we educate the patient
• What the staff is responsible for, and 
• How the professional services should be documented, coded, and billed.

That is how you build an AMD pillar. It is also why we built the <<< AMD Implementation Workshop around implementation. *link to: AMD Workshop Page >>>

The framework is the same one we use to build other clinical pillars: intake forms, clinical protocols, patient education, billing and coding, and staff training. 

Knowledge is important, but knowledge without implementation tends to stay in a notebook from the last CE meeting. Knowledge attached to a repeatable system can actually change patient care.

Incremental Improvement Beats Reinventing Your Practice

Please know: improving your practice does not usually mean complete reinvention. Maybe your fees don’t need to increase by $200 overnight, or you don’t need to figure out how to see 50 patients tomorrow. 

Maybe instead, you learn how to appropriately accommodate two additional medical encounters within the schedule you already have.

If a practice generates approximately $450 per OD hour, two additional appropriately coded medical patients can meaningfully affect revenue per OD hour without requiring the doctor to dramatically increase total clinical time.

That is the kind of practical improvement that matters: compliance updates, billing and coding strategies, and scheduling refinement that create incremental gains without asking the doctor to simply work harder.

“See more patients” has limited usefulness when the schedule is full, an associate is difficult to find, and the doctor has no interest in cramming another ten visits into the day.

I would rather look for opportunities within the practice you already have.

Can we find two opportunities? Can staff do more of the work that doesn’t require a doctor? Can we create appropriate short medical follow-ups? Can we make sure the services we already provide are documented and coded correctly? Those are much more realistic questions.

Accurate Coding Is Part of Valuing Your Expertise

Of course, none of this works if the documentation and coding are not correct. Interestingly, CMS’s own Comprehensive Error Rate Testing data provides perspective. In the 2023 data I reviewed, incorrect coding accounted for 141 of 182 identified office-visit errors.

Of those incorrect-coding errors, 123 were undercoding, compared with only 18 involving overcoding.

That does not mean we should hunt for ways to code higher. It means we should code accurately. Document what happened, understand the rules, and select the code supported by the work you performed. We should neither inflate our value nor apologize for it.

Billing and coding should be considered while the clinical service is being built.

Before launching a myopia, AMD, dry eye, or glaucoma pillar, think through the encounters and testing you expect the patient to need. Understand the documentation requirements and payer considerations associated with that care.

Doing that work upfront gives the practice the infrastructure to keep providing the service sustainably.

Build the System Around the Patient

Optometrists spend a lot of time talking about how other people value our profession.

We want payers to recognize our value. We want patients and legislators to understand the role optometry can play in healthcare.

We also have some responsibility for how we value our own work.

That does not mean charging patients ridiculous amounts of money or turning every encounter into a revenue opportunity. It means recognizing that our knowledge, clinical judgment, and longitudinal management have legitimate value. 

When we build systems around identifying patient needs, establishing appropriate clinical protocols, efficiently delivering care, accurately documenting and coding that care, and training our teams to execute those systems consistently, we stop depending upon any single product for the financial health of the practice.

The widget is not the practice; the care is the practice. 

The technology, pharmaceutical, contact lens, or pair of glasses may be an important part of delivering that care, but none of them replace the doctor who determines why the patient needs it, whether it is working, and what needs to happen next.

That same framework applies whether we are talking about myopia management, AMD, glaucoma, dry eye, or surgical co-management. If we can move the measure of success away from “I sold another widget today” and toward “I took really good care of that patient today,” we end up with a model that is better aligned with why most of us went into optometry in the first place. 

And, as it turns out, taking really good care of patients can also be a pretty good business model.

Want to Find the Next Opportunity Inside Your Practice?

That is the work we do inside Practice Performance Partners Pro Memberships. 

We look at the clinical and operational systems that shape a medical optometry practice—from scheduling and team utilization to billing, coding, and clinical pillars—and work through practical improvements you can actually implement.

You may already have more opportunity inside your current patient base and schedule than you realize.

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