California Retina Consultants is a six-surgeon practice with seven locations scattered across the central California coastal region, from Santa Barbara on the Pacific coast to as far inland as Bakersfield. The practice is positioned as an academic clinical practice, which allows us to offer state-of-the-art treatments to our patients before they become generally available.

This article, like others in the Practices in Transition series, explores how this practice model has worked for us and what we have learned in the process of growing and changing to fit the times.

ACADEMIC CLINICAL PRACTICE
I took over a solo practice in Santa Barbara from a retiring physician 17 years ago, and since that time the practice has slowly brought on new physicians, not only with the goal of increasing geographic scope, but also to position ourselves to become an academic clinical practice. Our reputation as a practice that participates in clinical trials of new therapies allows us to attract patients who are interested in cutting-edge treatments, to help those patients, and at the same time to help advance the field in an academic fashion.

Our practice has been able to develop good synergistic relationships with the entities that sponsor clinical trials: The sponsors have access to large numbers of potential clinical trial subjects because of our large patient volume, and the practice benefits because it has access to new medicines before they receive Food and Drug Administration (FDA) approval. Our focus on research is also intellectually stimulating for the practice physicians because we know we are on the front line of new therapies.

At the outset of involvement in clinical trials, navigation of contract and other matters can be tricky, and we have learned some lessons along the way. First, it is important to pay attention to the indemnification clauses in contracts for clinical trial participation. Most malpractice insurance does not allow the insured to indemnify a third party, and most clinical trial sponsors want to be indemnified. This means you will likely have to indemnify the sponsor yourself, without your carrier's support, if you sign the contract as it is presented to you. Often these clauses must be negotiated to minimize your liability. It is important for those of us in private practice to protect ourselves by limiting our liability in the clinical trial setting.

Also, one should be aware that some insurance carriers do not cover non-FDA-approved drugs unless there is a specific rider or amendment to the practice's policy.

The bottom line is this: Be careful what you sign.

ECONOMIC PROFILES
There is a large difference in the socioeconomic profiles of the populations in Santa Barbara and the surrounding communities where we have branch office locations. Santa Barbara is a small town with controlled growth; there has been almost no population change in the past 17 years. It is an affluent community, with high standards of medical care. Therefore we do not see as many patients with uncontrolled diabetes and end-stage diabetic retinal complications there as we do in some of the other cities we serve. The severity of diabetes seems to be inversely correlated with the socioeconomic standards of the community or with the patients' access to health care.

Conversely, we see more age-related macular degeneration (AMD) in Santa Barbara than in some of the other communities. The different disease mixes in our coverage areas helps to make practice interesting.

PATIENT EDUCATION AND EXPECTATIONS
The advent of the Internet and the resulting increase in patient self-education has been a double-edged sword for physicians. The Internet allows patients to find information about their diseases - but sometimes it provides them with information about diseases they do not have. The physician then spends extra chair time convincing patients that this or that disease is not their particular problem, and this treatment they read about is not the right one for them.

In general, however, the rise in patient education has been helpful, and it has increased patient expectations in some regards. In fact, the advent of efficacious treatments for wet AMD has changed both patients' and physicians' expectations in the past few years, as we have experienced the revolution in pharmacologic treatment for wet AMD. The ability to maintain or improve vision in patients with wet AMD using vascular endothelial growth factor (VEGF) inhibitors has been the biggest change in retina practice in the past decade. Patient expectations are higher, as are ours, with respect to visual outcome, although this has brought about a treatment burden that is still sometimes a challenge.

INCREASED PATIENT VOLUME
One of the results of the introduction of anti-VEGF agents with frequent dosing schedules has been a tremendous increase in patient volume. We have incorporated some changes in our practice to accommodate this. Although we are constrained in regard to size until leases run out or we build expansions, we have been able to squeeze an injection room into each office. Here the patient can be prepped for an injection and wait for the numbing medicine to take effect without disrupting the flow of the exam rooms.

Nevertheless, even with these additional rooms, we still face significant challenges with regard to patient flow and the large number of injections that must be given. Adaptation is necessary to become more efficient and handle these changes in an efficient fashion. We have added technicians to facilitate the additional procedure demand, and this has allowed us to be more efficient, but of course it has also increased our overhead.

DIGITAL IMAGE MANAGEMENT
Generally we make the decision to treat wet AMD with an anti-VEGF injection based on the patient's optical coherence tomography (OCT) evaluation at each visit, rather than giving routine monthly injections as was done in the clinical trials. We use the treat-and-extend method, in which we try to keep the retina dry with the longest possible interval between injections. In order to do this, we must check the OCT at each visit. Consequently I like to have access to the patient's OCT images as I evaluate him or her, right before I decide whether to do the injection and determine the interval of follow-up.

To help manage the increased patient volume, we have adopted a digital image management system. An Eyeroute (Topcon) (previously called Anka (McLean, VA)) digital imaging system is networked to computers in every exam room. When the physician walks in to see the patient, a dual-monitor computer shows the most recent and previous OCT images on the screens. Often patients can tell the status of their eyes even before the physician is in the room because they are used to seeing the OCT images and having them explained.

The same goes for fluorescein angiography; we used to have to develop the film and take time to interpret it. Now we and the patient are able to see the results immediately.

It is helpful to show these images to the patient directly and explain them. Patients feel much more in the loop and involved with their treatment. Using the Eyeroute system for handling all of our fluorescein and OCT digital images for the past 7 years has facilitated a more efficient practice. At this point, I cannot imagine practicing without it or a similar system.

We have not yet made the jump into electronic medical records (EMR), however. Eventually, I am sure EMR will also make us more efficient, but we have not adopted a system because we have not found one that will work for us off the shelf. Existing systems would take a lot of tweaking to be even as efficient as we are with paper charts, let alone more efficient. Eventually we will have to move to EMR, but we are waiting for a system more specific to retina practice before we change.

BUSINESS TIPS
In growing from a solo to a six-surgeon practice, we have by necessity learned a lot about the business of retina. Residency does not prepare one for the world of billing and coding, for example. It is good to have a physician who is adept at it, but a good administrator who can explain things in a way you can understand can also be helpful.

When we have introduced new technologies, such as photodynamic therapy (PDT) and then more recently Lucentis (ranibizumab, Genentech), we have devoted a full-time equivalent billing person to managing the accounts receivable and billing for that technology. This paid off handsomely with PDT because we were paid for the early treatments when many people were having problems with payment.

It is important to pay attention to accounts receivable. I glance over a printout of the accounts receivable for Lucentis to make sure there are no areas where carriers are not paying. We have also made use of the foundations and other services that Genentech supports to cover part of the cost of the drug that insurance does not pay. This has allowed us to do a good job of collecting the full amount for Lucentis.

For our physicians, we have started a cash-balance defined benefit plan in addition to the 401(k) program that we have had for years. The defined benefit plan allows the physician to put significantly more pretax money away for retirement than a 401(k). Income taxes are bound to go up in coming years, and I would encourage physicians to investigate this type of instrument. Anyone who would like more information on these plans is welcome to contact me.

CHANGES IN PATIENT CARE
In addition to the changes in our practice over the past 17 years, it has been most gratifying to see improvements in the care we can offer to our patients. The ability to sustain vision in people with wet AMD for years is astounding, compared with what we could offer patients before the advent of anti-VEGF agents. Our practice was one of the pioneers of intravitreal off-label use of Avastin (bevacizumab, Genentech) in 2005. We now have patients who have been treated for almost 5 years with outstanding outcomes.

During this time surgery has also become more efficient with smaller-gauge instrumentation, shorter surgery times, less invasive techniques, and faster recovery. Those are all positives for the patient, the surgeon, and the facility.

All in all, the practice has come a long way from 17 years ago, when it was just me and four employees. Our slow, controlled growth to six physicians, seven locations, and many more employees has allowed us to offer cutting-edge care to more patients over a greater geographical area. We look forward to many more years offering state-of-the-art patient care in our practice on the California coast.

Robert L. Avery, MD, is the founder of California Retina Consultants in Santa Barbara. He is Associate Medical Editor of Retina Today. Dr. Avery reports that he is a paid consultant to Genentech. He can be reached at avery1@jhu.edu.