Is Dropping a Vision Plan One of Your Resolutions for 2024?

Steve Alexander:  If, in general, a New Year’s resolution for you is to simplify your life, then you can think about which vision plan is causing you the most heartache and with its removal, which one will have the most positive impact.

Bethany Fishbein: Hi, I am Bethany Fishbein, CEO of The Power Practice, host of The Power Hour Optometry Podcast. And today, I am happy to welcome back to the podcast, Steve Alexander. He is the head of marketing and partnerships for Anagram.

And in preparation for the podcast, I cleared off my desk, one piece of paper, one window open. Steve, thank you so much for being here.

Steve Alexander: Thank you for having me, Bethany. My pleasure. I’m impressed that you got your desk that clear.

Bethany Fishbein: Well, I have like one of those L-shaped desks, so it may have been that I moved everything from one on to the other before you give me too much credit. But we’ll go with it for now. I’ll take the credit.

Steve Alexander: Alright!

Bethany Fishbein:  So interestingly, when we talked last time, we were talking about habits, and that conversation related to… Yeah, ADHD and living with that and kind of habits that make life work when sometimes your brain is really trying to not make it work or make it work otherwise. And so you were one of my first thoughts when it came to talking about making changes for the new year. As we head through December here into the new year, people start to think about New Year’s resolutions.

And we’re talking this month about professional New Year’s resolutions, things you want to do for your business. But talk first just about resolutions in general. I’m curious about your thoughts around that kind of habit change.

Steve Alexander: I think what’s interesting about resolutions in general and New Year’s resolutions specifically is they act as a kind of milestone psychologically. It’s very easy to say, ‘I’ll start my diet on Monday or ‘I’ll start working out next year or what have you. But the actual execution of that is a lot more difficult, and certainly keeping it consistent is difficult. But I think as we get closer to the end of the year, at least my mind tends to go like, What is 2024 going to look like? How am I going to treat 2024 differently than I’ve treated 2023 or something to that effect?

 And as I’m thinking about the changes that I’d like to make, it’s easy then to say, Okay, January 2nd, I’m going to do this differently. And then figuring out how to actually do that successfully is where the challenge is. But identifying that you’d like to make a change personally, professionally, in terms of relationships, whatever it is, that’s the most important step — identifying that you’d like to make a change. But I actually believe the most important step is the next one.

Bethany Fishbein: Which is?

Steve Alexander: It’s always the next one.

Bethany Fishbein: Whatever it is, it’s always the next one.

Steve Alexander:  That’s right.

Bethany Fishbein: Gotcha. Totally missed the depth of that.

Steve Alexander: Well, but it’s actually okay to kind of make it explicit. The first step is identifying that there’s a problem and setting out to solve it theoretically. But the next step, always the next step — is the most important one you can take.

Bethany Fishbein: One you can take. So just not even talking practice yet, and we’ll get there in a minute. For somebody who says, I want to make a change in life. I want to give up sugar. I want to start to exercise, whatever the thing is. Once you kind of get in your head that that’s what you want to do in an ideal world, what should that next step look like? Because you can’t just say, I want to make a change. You can’t just wake up on January 2nd, committed to giving up sugar if all you have in the house is frosted flakes.

Steve Alexander:  Exactly right. Yeah. So if we go back to our previous conversation about the building, the scaffolding, right? Being able to set yourself up to succeed in whatever you’re trying to accomplish, it is about making it easy, right? Making change as an individual is never easy, but it is much harder when you’ve made it much harder.

So if you want to give up sugar on January 2nd, then on January 1st, you should clear your house of all the temptations for sugar. In the same way, if you want to have a successful meeting in your practice or your business or whatever, you set an agenda so you know what you’d like to accomplish. It is about laying the groundwork to be successful and then executing on that. Yeah. That’s not to say that every plan is going to be a success right away, but having a plan is a great place to begin because in my mind, it is much easier to edit than it is to create. So create first and then edit as you learn more about what’s worked for you and what hasn’t.

Bethany Fishbein: I would also just throw in maybe an earlier step that we talk about a lot is figuring out, really understanding the reason underneath why you want this to begin with. And I know your area of expertise is in dropping insurance plans, so I’m going to use that as an example. But I think people can get caught up in wanting to do something because it’s cool or trendy, or people will look at you a certain way if you say you’re doing it. I don’t know if giving up sugar is quite a parallel there, but like people who say, you know, Oh, I do CrossFit. I didn’t.

Steve Alexander: Right.

Bethany Fishbein: You know, it’s people look at you a certain way. So I feel like in the optometric practice ownership world, some people want to drop insurance for the sake of dropping insurance to say they did it.

Steve Alexander: Right.

Bethany Fishbein: And that isn’t quite as successful or as compelling as somebody who is going to do that as an action to get somewhere else. You know what I mean?

Steve Alexander: Absolutely. Yeah. I think, in general, doing something because other people are doing it or doing something because it’s trendy, it’s a common human psychological want. There’s a desire to fit in. There’s a desire to be part of the cool, sort of in-group. How great to be part of an industry right now where, you know, the in-group are the ones dropping a vision plan. That’s great for us and for Anagram. And I think, for an industry as a whole, it’s a positive thing. But you’re right, it’s not the right fit for everybody. And it’s very unlikely to be successful if you’re doing it because it’s a trend as opposed to doing it because it makes sense for your individual situation.

Prior to making that decision, you’ve got to lay a little bit of the groundwork in understanding what it is about the vision plan you’d like to change. Whether it is a financial-based decision. It’s no secret that vision plan reimbursements haven’t gone up in 20 years for the most part. So is it a financial decision, understanding that my cost of doing business has gone up every single year and that cost has accelerated over the past couple of years where now it’s plainly untenable to accept those reimbursements, and I should step away from them for that reason? Is it a function of the quality of service that you’d like to provide?

One of the best things in my mind about working in this industry, getting to work with optometrists and ECPs who genuinely passionately care about their patients and care about the quality of services they provide. It’s something that is more difficult when somebody is dictating to you what an eye exam is and what it isn’t. Most of the vision plans will include the standard eye exam and refraction and maybe dilation, but retinal photos, visual fields, or certainly OCTs or the other diagnostic services that many ODs today consider a baseline part of their eye exam are not included in a vision plan world view of vision plan.

So, if you, as a practitioner, say, My standard of care is X, Y, Z, and the vision plan says, Actually, your standard of care is X only; Y and Z are not part of it, then you’ve got to make a decision about how you feel about that equation. In my mind, making it easier for a practice to make those decisions in a way that allows them to be financially successful while servicing their patients the way they want is really important.  And I think that’s the next step for this industry.

Bethany Fishbein:  I think, though, that sometimes there are situations where it’s not that easy of a decision or maybe even not the right decision for a practice. We’ve seen doctors get into trouble because their friend group or their Facebook group or their study group, or whatever, starts to adopt something and they say, ‘I’m going to do it too,’ without a plan of how and what’s going to replace it, and whether it’s the right timing.

I know what that plan looks like when I have that conversation with clients, but talk through your side of it a little bit. Are there ever situations where you’re getting interest from someone and saying, I don’t—I’m not saying it’s not the right time to use Anagram. I’m not talking about Anagram, but just by the nature of what you do, are you having this ‘Should I drop a plan’ conversation with people all the time?

Steve Alexander: Absolutely, yeah. In my capacity as a consultant, when a practice asks me about how to go about dropping plans in general, my suggestion is a bottom-up approach in terms of patient volume. If your practice is in network with most vision plans and one of them makes up 50% of your patient volume while another makes up 10%, don’t drop the one that represents half of your patient volume right away. Now, there’s an instinctive logic to that, but there’s also a practical logic that I can dive into.

What happens often is once a practice or practice owner gets this idea in their head, they want to rip it off like a bandaid. Ripping it off like a bandaid makes sense in many situations, but it may not make sense in this one. Once you drop a vision insurance plan, and your patients are accustomed to using that vision plan at your practice, you have to build into your conversations how to convert those patients from phone calls to patients. If you can’t make that case as the practice owner and then pass that information down to your front desk reception or whoever’s answering the phone, or to your opticians or technicians, then the patient will have a harder time making that transition. But if all of you are speaking in the same voice, it is much more likely to be successful.

Now, if you do that with a vision plan that represents 50% of your patient base, anytime your practice stumbles on the conversion side, it will be much more costly than if it happens with a plan representing 10% of your patient base. So, the bottom-up approach allows you to have some training wheels, have the staff understand, and learn how to have that conversation, get really good at it, and not to mention have a higher per-patient revenue for the ones that you convert. Then making a decision for the next vision plan becomes easier.

But practices that tear it off like a Band-Aid can run into issues if the training isn’t airtight, if the delivery of the message isn’t spot on every time. These issues create more fear every time rejections come in, making things a bit harder. And that’s irrespective of Anagram, right? It’s just the process of dropping a vision plan and then communicating to your patients what you’ve done.

Bethany Fishbein: That’s interesting. It makes total sense when you say it, and it’s something I’ve given similar advice on, but haven’t thought of it for that reason. I think about minimizing risk and how, a lot of times, it builds confidence that we can do this. If it’s 10% of your patients and you totally bomb it, worst case, you’ve lost 10 percent of your patients. It’s funny; I said similar but in different ways, and what you’re saying makes sense. I mean, the other side of it is that with a plan that only involves 10% of your patients, more often than not, the practice isn’t even going to feel that difference. Is that a good thing or a bad thing?

Steve Alexander: Well, what I would suggest is that this is super nuanced and can be really context-specific, but for a given practice, I think they won’t feel a negative impact by dropping that plan. So, if we take a given practice and I were to ask a practice owner, ‘Is there a vision plan that you take but don’t like taking?’ Most likely, the answer to that question is yes.

If a vision plan represents 10% of a practice’s patient volume, then they typically account for five to 6% of the practice’s top-line revenue. If that’s true, they usually represent 2% of the practice’s bottom-line revenue. If you drop that plan, you gain 10% of space on your appointment book and lose 2% of your bottom-line revenue. It’s immediately a fair trade, even if you don’t capture any of those patients again. If you capture about 30% of those patients, you’re going to lose 10% of your revenue, but overall, your revenue actually goes up, and your appointment book is much lighter. This allows you to do things like think about marketing, adding a specialty, training your staff, or doing some recruitment – all of those things that you don’t have time to do because you have to see four, five, six patients an hour.

Bethany Fishbein: That’s, I think, what makes it feel good on the positive side, right? Like people, practice owners can very easily see the “what if” on the negative side. What if none of those patients come in? What if we don’t convert any of them? What if my staff doesn’t like having that conversation and they quit? What if we lose whole families? What if people, my friends, come up to me? What if people think I’m greedy? Like, there’s all of that. But I think that one of the things that people forget to do, or neglect to do, is figure out what they’re going to do with the space that this insurance or these insurance patients are vacating in their lives.

So, I know, you know, we’re talking about New Year’s resolutions and habits. And I remember that was a strategy when people were quitting smoking. I think this is like one of my parents, and there is a little pencil, the appropriate size, that you were going to put in your mouth instead of a cigarette. Like, what were you going to do instead? And when people don’t think through that, I think they’re missing a huge piece of what’s going to either motivate them to do this or make them decide to hold back a little bit longer.

Steve Alexander: I think that’s exactly right. If we can take a step back and think about how the industry ended up in this situation in the first place, vision plans presented themselves initially way back when as a counterbalance to the influx of big retail in eye care. So, practices have gradually added more and more vision plans as they’ve proliferated and have had to adjust their models accordingly.

It used to be that you could see one to two patients an hour and be profitable. Then, you add a vision plan, and it’s maybe three or four patients an hour. Add another vision plan, and it’s four or five patients an hour, and so on. What practices don’t really think about or haven’t really thought about in broad strokes (I mean, certainly there are some practices that feel this), is that every time you add an additional vision plan, you have to add support to make that work.

As you lower your per-patient revenue and I always like to emphasize this, I don’t like to think about patients as revenue, but in order to continue serving patients, you have to be a profitable business so that aside, as you add vision plans and lower your per-patient revenue, you have to see more patients to stay profitable. To see more patients, you have to hire more staff. To hire more staff, you have to see more patients. It becomes a cycle, and practices need to carefully consider this aspect to maintain a balance between profitability and patient care.

Bethany Fishbein: A cycle where you’re just spinning your wheels, right? You’re increasing your costs to support a more productive… No. To be able to see more patients, you’re increasing costs. Like, you’re just building a team to churn the machine faster.

Steve Alexander: That’s right. Yeah. At a certain point, the tail is wagging the dog, right? You are not making those decisions because that’s where you’d like your practice to go. You’re making those decisions because you believe you have to do it. And that is a rough situation to be in. That’s how you end up with practices that are skating on razor-thin margins every step of the way.

Another implication of vision plans is that you have to raise the cost of your materials. Your frame prices have to be so high, your lens prices have to be so high, or you have to sell these particular lenses to stay profitable. And then when a patient comes in without a vision plan, if they’re a privately paid patient and you start quoting them your $350 frames and your $900 retail lenses, and they say it’s way too expensive (because it is), then you’re not making it accessible for the vast majority of people in America who can’t afford a $500 expense. Consequently, you can’t capture that patient because your pricing is structured in response to the vision plans, not in response to your actual market.

So, I think this is such a complex issue. Like most things, there are 15 different things to consider when you’re talking about it. But if, in general, a New Year’s resolution for you is to simplify your life, then you can think about which vision plan is causing you the most heartache and with its removal, which one will have the most positive impact.

Bethany Fishbein:  Okay. So what you just said, this is it. As I’ve been thinking about this, this is kind of the connector piece that I feel like I was missing. If your New Year’s resolution is to drop an insurance plan, it probably shouldn’t be because that in itself is not the point, right? It’s got to be for something. So the example that you just gave made that clear. If your resolution is to simplify your life, what other resolutions might dropping a vision plan help to serve?

Steve Alexander:  I think simplifying your work life is probably the one that sticks out to me the most, but it also aligns with wanting to be more in charge of your practice’s decisions. With a given vision plan, any vision plan, there are typically three constituents in the conversation: the practice, the patient, and the vision plan. So, you’ve always got to consider that third party, and it’s literally called the third party. But wouldn’t it be great if the decision-making process for taking care of the patient only involved you, the practice, and the patient?

I know it’s pie in the sky, right? It’s really ambitious to say that kind of thing, but that doesn’t mean it can’t be aimed for. So, I think simplifying your life, streamlining your process, allowing—if your goal in 2024 is to give every patient the best possible experience at your practice, then seeing fewer patients will make it more likely that you can deliver on that resolution.

But I think you’re right. I think dropping a vision plan as a resolution doesn’t make a ton of sense. Building a more effective business as a resolution does make sense, and dropping a vision plan is a step in that direction.

Bethany Fishbein: Because we see practices get in trouble sometimes where they’re doing it for the sake of doing it, and then they’ll, like, we’ll get the call somewhere along the line, maybe they’ve already done it, and it’s like, “you know, I dropped this plan, and now my business is down, I’m suffering, why did you drop the plan?” And the answer we get is something like, “well, isn’t that what we should be doing? Right?” So when is it not right for a practice? Is it always—right? Always, right? Like,

Steve Alexander: I think it can be pretty specific. There are some vision plans, for example, that do a really good job of reimbursing specialty contacts, right? If you’re a specialty contact practice and you see a lot of scleral patients or keratoconic patients or what have you, and many of them have a vision plan, dropping that vision plan without a method of keeping those patients as your patients is it is a mistake. It will come back to bite you sooner rather than later.

Bethany Fishbein: Because if your thought is, in 2024, I want to spend more of my day fitting scleral lenses on keratoconic patients and addressing dry eye, then a plan that gives great coverage for those makes it easier for you to do that.

Steve Alexander: That’s right. Yeah. It’s much easier to get a patient to pay whatever their co-pays are for that service as compared to $3,000 out of pocket. That is a big gap in coverage that this vision plan does provide. So if you’re in that specialty, that’s something you’ve really got to think about and do the math as well.

Because there are certainly patients who will pay out of pocket. And depending on your practice’s context, if you’re the only contact lens specialist in your market, odds are they will still come to you because that’s a service that they need. But the question that you then have to answer is, are you okay with charging those prices for a cash pay patient? If your answer to that question is no, then you’ve got to reevaluate what you want to do.

Bethany Fishbein:There’s some self-knowledge in here too.

Steve Alexander:  Absolutely.

Bethany Fishbein:One of the other examples that I think of when I consider, When is this not the right time? is when people are not good at or not willing to do—oh, yeah, other things to promote their practice. One of the things that vision plans are good at is fully passively marketing for your business. Because whatever percentage of people, when they need to go to a provider, they start with their plan website. For health insurance, vision, it doesn’t matter. And so you don’t have to do, spend, go anywhere to make that happen. You just sign up, and you’re on the list.

For someone who isn’t willing or just it’s not their strength and they’re not wanting to learn to do any other type of self-promotion of their practice, it can be very effective to just get on the plan. And the difference between what you would usually get and what the plan pays you is a marketing expense.

Steve Alexander: Right. It is worth considering, though, generally speaking, marketing expenses are what’s called the customer acquisition cost in marketing, usually only paid one time. It’s usually only paid until they become a customer of yours. With vision plans, you do pay it every single time they come in. And I think it actually begs an interesting question. Who does that patient belong to? If you, as the practitioner, believe that is a vision plan patient and you treat them accordingly, they probably are a vision plan patient. If you subsequently drop that vision plan, that patient is very likely to follow wherever that plan is in network.

So, something I’ve taken to saying is if you think dropping a vision plan will mean that none of those patients will come see you, you’re probably right. And that is something you really got to think about. Because in many cases, if you want to think about vision plans as a marketing expense, then it is incumbent on you, the practice, to turn them from a vision plan patient into your patient. The way you do that is by offering them services the way you’ve defined them. Whatever your eye exam looks like, whatever your optical treatments are, whatever level of service you’d like to offer to them, if they take advantage of those and this can be a little bit counterintuitive the more a patient spends at your practice, the more loyal they are to your practice.

Bethany Fishbein: I agree with that 100%.

Steve Alexander: Yeah. So if you’re thinking about your patients in those terms, a vision plan patient in your office today who says something like, “I only want what’s covered by my insurance,” which happens all the time and is a perfectly fine request for a patient to make, by the way, they don’t know what they’re missing by saying that. But if that’s what a patient is saying, and if that’s what a patient is doing, then that patient is absolutely that vision plan’s patient only. And if, and when you drop that plan, you are very likely to lose that patient. But that patient is not profitable for you right now. Not to say that they deserve anything less. They deserve the same level of quality of care that you’d like to provide them, but their value doesn’t match yours in terms of how much they care about the eye care, the eyewear services they receive.

So, but the patients who have that vision plan and do get the OCT or the retinal photos, and the ones that do get the annual supply of contacts through your practice, those are the ones that are supporting your practice. And those are the ones that are very likely to continue supporting your practice, as long as you make it easy for them to understand and use their benefits.

Bethany Fishbein: This idea is kind of what transcends timing, in my opinion. Sometimes people have a vision, they want a cold start or practice, and they don’t want to take any insurance plans. And you can do that. It takes a lot of effort, marketing, and, you know, really work to make that happen. I don’t think you can open, not do any of those things, not take the plans, and just expect that self-pay patients are going to show up.

But what you can do at any stage of where you are in the insurance game is to put effort into making those patients belong to your practice, instead of to the plan. Absolutely. So taking advantage of additional services, providing things that are outside the plan, and, you know, the patients ultimately need to have because you have them and it’s going to serve a need for them, providing a specific level of care and service and getting them a little bit spoiled and used to that. I think those are things that you can do in a practice when you, quote, have to still take a plan financially, or you just don’t have the patient base or whatever. And that sets you up for the decreased reliance on the plans that you ultimately need to take that leap. We were talking before we hit record that sometimes it’s not your choice when that happens.

Steve Alexander:  Absolutely. Yeah. Local employers have agreements with vision plans for a certain period of time. It’s really common for a big employer to go from one vision plan to another. There are circumstances where a practice is in network with one big plan but out of network with the other one. Then, their biggest local employer switches to the other one. What happens to your practice then? There’s a significant opportunity cost in not being prepared for those changes. It’s hard to quantify. But in my consulting and what I’m hoping to help practices identify is the more of your patients come from vision plans, the more of your patients view themselves as a vision plan patient, the more susceptible you are to these sorts of whims. That is, in the long term, very dangerous for your practice.

I think you brought up a really interesting point as well, being less reliant on those vision plans. And that can mean getting ready for dropping a plan and setting up the infrastructure to do so. But it can also mean building a cash pay specialty and creating the space for vision plans to be less necessary. So if you are interested in being a dry eye specialist or aesthetics or low vision or pediatrics or whatever interests you in eye care, and over the last 20 years, you’ve seen the scope of optometric practice increase by leaps and bounds. If you find a niche that you’d like to carve out and you devote the time to build that side of your business, suddenly that can be a big driver for your new patients.

If you get one myopia management patient or one ortho K patient or whatever specialty the case is, you can equate that to five or 10 in-network vision plan patients. And then the math starts to look a little bit different. If a vision plan makes up 70% of your patient volume, it’s really hard to think about dropping it. But if it makes up 20% of your patient volume, suddenly it’s not so scary.

Bethany Fishbein:  And what happens when you don’t? Because it is scary when a huge employer in your town switches to a plan that you’re not in network with. You start to get requests from your patients like, “Can’t you join that one? Can’t you join?” Which as a patient, that’s normal to ask, right? If I think all I have to do is ask you and then you’ll magically say, “yes,” and then I’ll pay less for what I want anyway. So the patient’s asking is not the problem. But we have seen situations where a doc will say, “Yeah, so I guess I have to get on this plan now because my entire township, my entire school district, this huge pharma company, like, you know, all of my patients.” So if they just do that, let’s walk down that path a little bit. What can that lead to?

Steve Alexander: Well, there are basically two options for a practice in that circumstance. One is to try to get credentialed with that vision plan and probably do so from a position of weakness. If that vision plan has just won a major contract in your area, they’re not going to be inclined to give you the best reimbursement because they know you want access to those patients, but that’s the path you can take. You can get credentialed with them and jump through whatever hoops they require, then lock into an agreement with them at the conclusion of it, and start seeing those patients on an in-network basis.

Option two is you don’t credential with them, and you hope some of the patients continue to come see you. When they buy glasses or come for the eye exam, you give them an itemized receipt and say, Here’s  your itemized receipt. You can fill out a form and get a reimbursement.

Option three is to stay out of network but use a service like anagram to make that process really easy. I like to emphasize here that when a patient calls and asks about a vision plan, especially when you’re not in network with them, they’re not asking if you’re in network or out of network. They don’t know really. What they’re telling you is, “I’d like to use my benefits at your practice.” Especially in the circumstance we’re describing here, is that they know your practice, they want to stay, and what they’re saying is, “I have these benefits from my employer, and I’d like to use them at your practice. Can you help me?” And it is then incumbent on you, the practice, to figure out the best way to help them. In all circumstances, giving your patient homework is a bad idea.

Bethany Fishbein: Yeah. I mean, it’s not the same thing, but I remember a contact lens rep once telling me about the percentage of people that actually send in a hundred dollar rebate. And I don’t remember the actual numbers, but they asked me what it was. And I was like, ” don’t know, 85.  And it was like less than-

Steve Alexander: 6%

Bethany Fishbein:  Yeah. The craziness.

Steve Alexander: Yeah. And it’s just a psychological thing. Yeah. Yeah. It’s a psychological thing. You know, there’s an example that I like to draw. I think it was in Portugal. Some time ago, they had a really low enrollment rate for organ donation, and they changed it from an opt-in situation to an opt-out situation, and the percentages stayed the same, right? It was 85% were not an organ donor when it was opt-in. And then they switched it to, 85% were organ donors when they made it an opt-out option. People don’t like doing whatever was.

Bethany Fishbein:  cause 85% is gonna do whatever was the easiest

Steve Alexander: That’s right. That’s right.

Bethany Fishbein: Wow. I thought it was like a big deal for a hundred dollars. You’re talking kidneys.

Steve Alexander: Yeah, and, but, and it’s just like those obstacles, and look, you’ve got to think about the situation we live in right now. It’s 2023. I don’t know when the last time you sent a physical letter was, but for me, I don’t know if I ever have voluntarily sent a physical letter. Um, so getting somebody to put something into an envelope, put a stamp on it, know what to do with an envelope when sending it is, honestly, it’s outdated. People don’t know what to do, so they’re not gonna.

Bethany Fishbein: Right, we could do a whole podcast episode on young staff members who don’t know where the stamp goes on the envelope and…

Steve Alexander:  right right

Bethany Fishbein: because it’s a thing like you’re right

Steve Alexander:  absolutely

Bethany Fishbein: People do not. They don’t do that. So I think part of that idea of readiness and talking about taking the steps that ultimately will, again, let you be less reliant on insurance. I think wherever you are in the process, there’s absolute value towards making it easy for patients to do business with you. One of the key examples we come across is having an appointment available soon when they want that. Yes. Because-

Steve Alexander:  Yeah, absolutely. When I was running practices, I would make it a habit to have an open appointment slot in the morning and in the afternoon up to three days from now. So today, we’re recording on a Monday, and I would have slots open for Friday morning and Friday afternoon, specifically for new patients. The reason I keep it open for new patients is they are very unlikely to wait any longer than they have to. An existing patient might give you a couple of weeks of leeway because they already know you, they want to stay with you, but a new patient probably won’t. So I would keep that available to them for this week and give them a morning and an afternoon available slot. If Wednesday rolls around and those slots are still available, I would call an existing patient from the following day and say, ‘Hey, can you come in on Friday?’ Most likely they will, and they’ll appreciate the service as well. They’ll like being able to come in a bit earlier.

I think something that gets lost in the shuffle is some of the hidden costs of being outwardly booked. If your practice is booked out three, four, five, six weeks, new patients might call and ask if they can come in. If they can’t get in until next year, they’re never going to call you back, unfortunately. But if you make it easy for them.

Bethany Fishbein: If you take the action of dropping an insurance plan, that’s already perceived as one reason why they might not choose your service. If they are tied to their insurance but like you, and they call one year and realize you are out of network with their plan, it’s like, well, they’re already kind of unsure about that. If the next appointment is five weeks away, they might make it, but in the meantime, they might also ask around, go on their neighborhood page, and ask for another recommendation. They can very easily be pulled to try something else because they’re in ‘I need an eye exam’ mode. If they call and find out you’re out of network, explaining how it works is crucial. For example, if they say, ‘Oh, we’re out of network,’ you can respond with, ‘Here’s how it works. I have an appointment today at two o’clock.’ This may turn the situation around as they might reply with, ‘Oh, I want an appointment today at two o’clock. That’s perfect.’ Suddenly, the scale tips back in your favor.

Steve Alexander: Absolutely right, yeah. I think it’s worth considering how society operates now; instant gratification is key, isn’t it? People aren’t really willing to wait for anything. When you order online and the shipping says five to six business days, you think, ‘I might be dead by then, who knows?’ People want it right now. If you put it off for several months, it doesn’t provide a good experience for the patient.

If the resolution for 2024 is to give your patients the best possible experience, then you want to make it possible for those who want to come in sooner to do so. There’s a similar issue, not related to vision insurances, where there’s a misconception about what patient service really is. It’s common for a patient to come in 15-20 minutes late to an appointment, and the thought is, ‘Well, they’re here now, and I’m going to go see them because they’re here now, and I want to provide good patient service or customer service.’ But what is not really thought about is what happens to the patient who is coming in on time in five minutes.

Bethany Fishbein:  Right.

Steve Alexander: And the knock on effect of that for the rest of your day.

Bethany Fishbein: And maybe you’re taking poor care or decreasing the experience for the other six on your schedule after that. Yeah, that’s right. You’re always kind of weighing it. So, Steve, if somebody has one of those resolutions, they want to gain control over their business, they want to spend time doing the things that they want to do. They want to simplify their business life. They want to take ownership of their decision-making, which I said already, and we’ll edit one of those out. How can they judge when it’s the right time to make dropping a plan part of that?


Steve Alexander: It’s a really good question. I hesitate to fall back on a quote, but there’s one that I love, and I believe it’s a Chinese proverb: ‘The best time to plant a tree is 20 years ago. The next best time is right now.’

I think it would be great if this were a situation that most practices were facing, but it is. What’s really important is that specific self-evaluation, as most practices will have an instinctive answer to which vision plan they would drop if they could. So, think about that, identify that plan, and then do a little bit of math. Pull a week’s worth of exams or appointments and identify how many of those involve this vision plan. This is an important percentage for you to understand.

For example, if you see a hundred patients in a given time period and 10 of them come from this vision plan, you can extrapolate that it’s about 10% of your patient base. Take 10 of those patients and work out how much revenue you generated at the top line for exam services, materials, etc. Consider what you wrote off, what the vision plan reimbursed you, and what it cost you to manufacture everything. This will give you a top-line and a bottom-line understanding of those patients in proportion to the rest of your business. Then, do the same comparison for a vision plan that you definitely don’t want to get rid of.

Once you see how big the gap is between those two things, and it will be significant, you can decide not just when the right time to drop that vision plan is, but how much it’s costing you to not drop that vision plan.

Bethany Fishbein: Because for every patient that you see that has this, instead of seeing somebody else, that’s right. You could do that. When does it make more sense to not see anyone at all?

Steve Alexander: That’s a good question. I think in a circumstance where a patient is strictly adhering to their vision plan requirements or allowances, it actually makes more sense not to see that patient. There’s a practice that I know of that started to grade its patients based on that. They would grade their patients based on whether or not they bought materials, and if they bought precisely the materials the practice had recommended and what the value to the practice is. After a patient went beneath a certain grade, they were no longer part of the recall process. So, that was a really clever way of still welcoming that patient but not necessarily prioritizing them.

In answer to your question, it is when you lose money seeing that patient. It is better not to see that patient from a financial standpoint.

Bethany Fishbein: This is always the argument though, like it’s not as if you have an empty space and you send your staff home, and then you don’t pay them for that hour. So the counter-argument is always, well, even $40 is better than nothing. So when is truly nothing better than $40?

Steve Alexander: Well, I’m not comparing it to nothing, right? So you’d have to think about what you’re going to do instead, like we had talked about. It’s not just that I’m not going to see that patient, and we’re all going to sit around twiddling our thumbs. The reality is that the patient is not there. So what are we doing instead? Are we marketing our practice? Are we going out to a local event when we have the available time? Are we thinking about what our specialty is going to be? Or are we evaluating our pricing or our product mix, or talking to a lab? There are so many things you could be doing to make your business better that often you don’t have time for because your appointment book is jam-packed. So, I think not seeing a patient is better than seeing a low-revenue patient when you are actually investing in your practice.

Bethany Fishbein:  And that’s a whole new year’s resolution in itself about using that time productively and deleting the silly games and time-sucking apps off your phone.

Steve Alexander:  That’s right. That’s right.

Bethany Fishbein:  Because that takes some discipline. Like if the next patient is ready, you know what you’re doing next: I’m just going to go into exam two and take care of that patient. Then I’m going to go into exam three, but there is some discipline and some good habits required to utilize that downtime productively.

Steve Alexander: Precisely. Yeah. I think things that don’t seem like they’re revenue-generating activities are actually. Many practices don’t devote time to staff development or coaching or partnership in that way. But if there’s a staff member who is not delivering or maybe could use some help doing A, B, and C, spending that time with them will pay dividends sooner rather than later.

Bethany Fishbein:  Yeah

Steve Alexander:  But if you never have the time to do that, then you’re always just going to skate by, or that employee might always just skate by.

Bethany Fishbein:  Yeah, absolutely. I mean, spending—like it’s a big example, right? Spending time with an associate doctor to help them more effectively recommend myopia management. There’s a lot of $40 that you can make back by investing a couple of hours in a person in your practice. Good point.

Steve Alexander:  Yeah, absolutely. Right.

And those things are often lost. But you know, like this whole conversation has been about, you can’t just decide to drop a vision plan because it’s trendy. I mean, you could, but it’s not a good idea. Doing something because everyone else is doing it is a bad reason. Along those same lines, doing something because you’ve always done it is also a bad reason.

Bethany Fishbein: So not dropping because you’re afraid of change is not great. Dropping just because you want change for the sake of change is also not great. Just like any good resolution, you need a plan and a goal to make it work.

Steve Alexander: Absolutely. Yeah.

Bethany Fishbein: You have your New Year’s resolutions picked out?

Steve Alexander: Yes

Bethany Fishbein: Do you do New Year’s resolutions?

Steve Alexander: I’m always trying to improve, so I’m a believer in the concept of Kaizen—relentless self-improvement. I’m always doing something to try to make myself better. I have a couple of various mantras that I follow, but for my New Year’s resolution right now, it is to try to get better, higher quality sleep. That is my goal.

Bethany Fishbein:  What are you tracking your sleep with to measure?

Steve Alexander: Nothing

Bethany Fishbein:  Oh, you can just tell.

Steve Alexander:  Well, I’m worried about turning it into another spreadsheet that I have to look into. So at the moment, I’m not trying to do it. But I know, at the very least, I’m kind of naturally a night owl. So I know when I turn off my computer, so I’m trying to move it to the PM instead of the AM. That’s going to be really nice.

Bethany Fishbein: That’s going to be really nice.

Interesting. It’s going to make your US travel a little bit more challenging. Right now, it’s probably… You’re still running on US time a little bit.

Steve Alexander: Yeah, yeah, a little bit. But you know, I know that there’s one thing that we can’t adapt our way out of, and that is the need for sleep. So I’d like to make that at least a goal to make it better. I can’t aim for perfect. I’m not going to aim for perfect because I will disappoint myself if that’s what I want to do. But I always just aim for better.

Bethany Fishbein: What else do you want to say, Steve, that we can work our way into this? Because I’m going to figure out after what we want this to sound like, and we were going in a bunch of different directions. You’re right, there are so many layers and nuances to this. It’s not as easy a decision or as straightforward a decision as it sometimes seems to be. And sometimes it’s way more straightforward than people are making it, both at the same time.

Steve Alexander:  Yeah, what I would say is, I think it’s important to recognize that change is coming to your practice, whether you want it to or not. It is up to you to direct that change in a positive way. So whether you want to admit it or not, time keeps going forward. Your patients keep changing; they’re always a little bit older every time you see them. There are new patients coming into the world, coming into your practice, and they have different expectations and desires, and they want more tech or they want to be communicated with differently.

Continuing down the path that you’re presently on is probably not a path to continued success. Now, we’re not talking about big changes or anything, but understanding what’s happening in the world around you and adapting accordingly. The days of being a generalist optometrist, like you said, is just opening your doors and seeing patients flooding in. That’s just not going to happen anymore.

So understanding that and taking steps to be successful for whatever changes are coming are vitally important to your continued success.

Bethany Fishbein:  Awesome. Steve, thank you once again for another-

Steve Alexander: My Pleasure

Bethany Fishbein: Interesting conversation. If someone is listening and they are committed to dropping plans, being part of the actions that will get them to their 2024 resolution, and they want Anagram to be part of that picture, how do they reach out to you, or how do they learn more about your company?

Steve Alexander:  Feel free to email me directly at Steve at anagram.care, or just go to the website anagram.care. And I would strongly recommend subscribing to our blog, SpyGlass.com. In that blog, we release an article every week about making these kinds of incremental changes to your practice. The idea behind each article is to give you something you can do differently that only costs you effort. Now, there is nothing that is free, right? Even if it doesn’t cost you monetarily, it costs you with effort and time. But the articles are designed to break down a given topic and make it easy for you to understand and hopefully implement change. Yeah, I would strongly recommend everybody subscribe to that and check out Anagram. We’re doing some cool stuff technologically.

Bethany Fishbein: Very cool. Steve, thank you so much.

Steve Alexander:  My pleasure. Thanks, Bethany. Sure, sure, sure, sure. Yeah. So I have an article that’s in draft mode on SpyGlass that is called ‘Stop Getting Your… Okay, I’m going to say it, and then you can delete this. There’s an article called ‘Stop Getting Your Fucking Advice on Facebook.’ And the reason behind that is not to cast aspersions at any group in particular. But the problem that I have with seeking advice on Facebook, in general, is there… And you’ve heard me talk about this several times, is most things are context-specific. So if somebody asks for, should I get this piece of equipment or should I bring in this frame line or whatever the question is without providing the practical context of your practice, of where you sit, and what life cycle your practice is in and what you’re trying to accomplish, any answer that you receive on those fora is wrong.

Bethany Fishbein: Is fora the plural of forum?

Steve Alexander:  Yes.

Bethany Fishbein: All right. I agree. And you can move over. I’ll step up onto your soapbox with you on that one because sometimes people will say to me,’How come you never answer questions on Facebook?’ And always, I don’t know enough about the practice to answer. When should you hire an associate? And people just answer, ‘Well, when you should hire an associate is completely  different than when somebody else should hire an associate. I think that should be a New Year’s resolution. Stop getting your effing advice on Facebook.

Steve Alexander:  I love that.

Bethany Fishbein: That one I can do. Very cool. All right, Steve, thank you for your time. I appreciate it. I appreciate you. And I hope you feel better. I think, are you feeling under the weather?

Steve Alexander: I feel fine, but my voice is getting a little bit hoarse. I’m not sure why, but I feel okay. Thank you.

Bethany Fishbein: All right. Be well.

Steve Alexander: Thank you. You too.

Bethany Fishbein:  And we will be in touch. Thank you.