DECADE OF GROWTH IN PRIVATE PRACTICE

Manfred Tetz MD vividly recalls the day in May 2003 he opened his private practice in Berlin. 'I saw one patient that day. It is quite different these days.' Today, Eye Centre Spreebogen is staffed by two full-time ophthalmologists in addition to Prof Tetz. There are also three part-time colleagues for specialised work such as retina and strabismus, and a few affiliated surgeons who use the clinic's facilities for private patients. The practice sees a full range of patients, from cataract and refractive to glaucoma and retina. Payment for services comes from a variety of sources: Germany's public and private insurance systems as well as domestic and international self-pay patients for noncovered services. Despite an uneven economy, practice volume has grown steadily at about 10 per cent annually, says Prof Tetz, who recently joined the ESCRS Practice Development Committee. He believes his success is primarily the result of recommendations from previous patients. 'My philosophy on growth has always been organic, based on good quality service. We did a survey on what is most important to patients in terms of choosing a practice, and number one is word-of-mouth recommendations. It is very interesting, but not surprising. When I see a colleague in another medical field, it is usually based on a recommendation of someone I know,' Prof Tetz says.

A good website also helps, Prof Tetz adds. He believes that the most effective site provides easy access to information about eye conditions, procedures and the practice, but isn't too complicated. 'The more educated patients will not go by the fanciest website with whistles and bells; they want a clean website that provides basic information and doesn't drown them with too much information. It is a narrow line to walk between informative and innovative but not getting into overkill.' But the best website in the world isn't much good without satisfied patients, Prof Tetz says. 'The old rules still hold. Good quality service and a good reputation attract new business.'

Full service spurs growth Prof Tetz believes that offering a full range of ophthalmic services has helped keep his clinic growing. 'My approach to developing the business is to provide all segments of surgical, medical, and diagnostic ophthalmology, and not do a monoculture of laser, refractive laser or cataract. These monocultures may be very redeeming for a time, but they are very sensitive to changes in the legal system, changes in coverage by health insurance companies, and changes in the economy.' Some surgeons who 'retired' to refractive corneal surgery did well for a few years, but were forced to go back to general ophthalmology when the economy deteriorated, Dr Tetz notes. 'Making the switch back from refractive surgery is more difficult than maintaining a full-service practice.' In his own practice, laser refractive surgery has been a steady, but relatively small, business, Prof Tetz says. His growth area is lens-based refractive surgery, including toric, multifocal and phakic IOLs, which have steadily grown in both absolute and proportional terms in recent years. These lenses got a boost in January, when a new law allowing surgeons to charge publicly insured patients extra for premium lenses took effect in Germany. Previously, regulations varied from state to state, but in general this was prohibited, and cataract services had to be paid entirely by insurance or entirely out-of-pocket, Prof Tetz notes.

Overall, private practice is growing in Germany, in part because many new technologies, including diagnostics such as HRT and OCT, are not covered by public insurers, who still cover about 90 per cent of patients, Prof Tetz says. He believes that Germany is moving toward a system in which public insurers provide basic coverage, but advanced services increasingly will be paid out-of-pocket. 'In Italy, Spain and Greece it is common knowledge that you needed to pay privately if you wanted better service, but in Germany we try to regulate everything as much as possible. Private practice always existed here, but the rules are getting more permissive. It is very hard to get more money into the public system and it cannot cover all of the innovations in medicine and ophthalmology,' Prof Tetz says. Flexibility required Of course, selfpay patients generally demand more for their hard-earned euro. 'I think private practice is going to grow, but a lot of my colleagues do not like the extra time and effort of dealing with the patient. There is no way to do good refractive if you don't spend extra time pre- and post-surgery, and extra chair time and extra follow up. If you are not willing to do it, you will not succeed,' Prof Tetz says.

To accommodate the greater demands of private pay patients, Prof Tetz sees them in a separate location, or at different times if two locations aren't possible. He also separates surgical and non-surgical patients. 'The worst thing for a patient who is going for an operation and hasn't slept is to come into a waiting room with 30 people, and wonder when they will be called.' Staff also must be trained to be more flexible in dealing with private patients, and to provide information on services and new technologies, Prof Tetz notes. This requires good 'soft skills' of practice leaders to help shape the culture of the practice into a service-oriented team. Willingness to change operations – and even partners – as practice needs change is also key for surgeons, Prof Tetz adds. Over time, he has brought in a clinic manager and outsourced private billing and other administrative functions to allow his staff to focus more on patient service. 'When I first started, I hired a team of good people and thought we would stay together until we died. The first thing I had to learn is there is always fluctuation on a team. Adapting to circumstances requires refreshing elements of the team, and it is quite natural,' Prof Tetz says. 'You have to change steadily to remain stable. It is not guaranteed that things will get better if they change, but if you want things to get better, you have to change.'