With the US having the worst health outcomes among developed countries, despite having the highest per capita spending, signifies the poor state of its healthcare system. With Medicare continuing to cut physicians' pay, being a physician, especially if they own a healthcare delivery facility such as a clinic or medical center, is becoming more financially unsustainable.
As the US healthcare economics continues to worsen, Dr. Oday Alsheikh, Medical Director of TLC San Antonio and an ophthalmologist with subspecialty training in cornea transplants and refractive surgery, is introducing a new way to more effectively and efficiently deliver much-needed eye surgery services to the people who need it.
For most of his career, Dr. Alsheikh has been passionate about healthcare economics and its impact on patients, physicians, hospital systems, and local communities. He focuses on quality improvement and the successful delivery of rapid change to better meet the demands of patients, local communities, and national and societal needs.
According to Dr. Alsheikh, the American Academy of Ophthalmology, the world's largest association of eye physicians and surgeons, has decided that physicians under its regulation do not need to get a second board certification for subspecialty training. This means that ophthalmologists can practice various subspecialties, as long as they have the requisite training and are comfortable with their surgical outcomes, the scope of their practice is limited more by self-regulation, regulation from surgical centers and hospitals, and the potential of malpractice lawsuits.
Dr. Alsheikh underwent fellowship training for cornea surgery, but after he went into private practice, he decided to pick up a second subspecialty in glaucoma. Around 10 years later, Dr. Alsheikh is now known as one of the best glaucoma surgeons in the city of San Antonio, doing around 150 major procedures each year, in a cost-effective manner.
Unfortunately, glaucoma is a relatively poorly paid subspecialty of ophthalmology due to limited Medicare reimbursements, estimated at around $1,200 per surgery, including 90 days of postoperative care. This results in glaucoma being a "healthcare desert", which refers to a specific condition or geographical area where there is a lack of medical care due to physicians being unwilling to practice.
Older glaucoma surgeries have much more post-operative visits but are significantly less expensive and are also more effective, while current new glaucoma surgeries are focused on quicker recovery and shortened number of post-operative visits. Recently, there has been tremendous investment in glaucoma surgeries and a general shift towards minimally invasive glaucoma surgery.
According to Dr. Alsheikh, this is a much-needed revolution in managing glaucoma. However, it ignores the needs of patients with severe vision loss due to glaucoma, where eye pressure needs to be the lowest possible.
"In this situation, older is better," he says. The surgery is a trapdoor bypass, called a Trabeculectomy, which is a very delicate surgery that requires a lot of post-op visits. Physicians usually opt for implantable shunts, which require fewer post-op visits. According to Dr. Alsheikh, due to the economics of the operation, most freshly graduated glaucoma specialists do not know how to perform a Trabeculectomy. While shunts have a higher failure rate, cost more, and have a higher rate of infections, it has quickly become the preferred surgery for glaucoma.
"We have seen a three-fold increase in patients seeking glaucoma care since the pandemic – much higher than the increased rate of patients seeking cataract surgery," Dr. Alsheikh says. "Patients with insurance that pays below Medicare rates can have a very difficult time finding a surgeon."
With severe glaucoma being a "healthcare desert", there is also a concurrent demographic shift in reimbursement economics. Many Baby Boomer doctors are now retiring, so there are not enough specialists entering the glaucoma field. Specialists, especially the new graduates, are being offered very high incomes right out of fellowship, and it doesn't match what can actually be produced in the clinic, causing practices to lose money and creating real issues for employers. Additionally, employers and physicians consciously and unconsciously make decisions that have larger societal impacts. Dr. Alsheikh believes that it is very important to prevent glaucoma from getting worse, and innovation plays a huge role in this. At the same time, advanced glaucoma needs more attention. Currently, those patients are left to fend for themselves due to a lack of insight into healthcare economics. This is probably true for many more conditions such as heart disease, cancer, and neurodegenerative diseases like dementia.
"In response, I refined a quality improvement system where I've been able to control the costs and I am able to take care of the less fortunate, even at $1,000 a case, because I was able to cut the surgical time significantly and simplify the post-op care," he says.
Ever since he combined practicing cornea and glaucoma surgery, Dr. Alsheikh noticed that patient satisfaction improved while costs went down, and his outcomes were actually superior to many of the famous academic centers around the country.
Dr. Alsheikh was able to create this quality improvement infrastructure by leveraging his understanding of cost into care and lowering his expenses. While his expenses still remain high by normal standards, he is still able to maintain profitability via volume. This cannot be replicated without training, so Dr. Alsheikh applies the lean framework of production to medical practice.
The lean methodology, which was developed by Toyota Motor Company, enabled it to rise and become one of the most dominant automakers in the world. It is composed of various concepts aimed at improving efficiency and increasing value for the customer while eliminating waste.
Dr. Alsheikh believes in a reevaluation of healthcare standards, bringing them up-to-date with the present-day economic realities.
"Practice owners, insurance companies, hospitals, medical boards, and society as a whole need to look at healthcare from a different angle," Dr. Alsheikh says. "Overspecialization only results in waste and losses. We need to weigh the benefits of doing one task well repeatedly versus multitasking, guided by proper risk analysis, investment in new technology, personnel training, and changing the culture of organizations."
