Quick and easy bottom-line boosters

How our practice bridges the reimbursement gap with new revenue streams.

By Cynthia Matossian, MD, FACS

About the Author
	Cynthia Matossian, MD FACS, is the founder of Matossian Eye Associates, an integrated ophthalmology-optometry practice with three offices in Pennsylvania and New Jersey. Her e-mail is cmatossian@matossianeye.com.

We all know that the practice of medicine is becoming more difficult — largely because of the growing gap between what we are reimbursed for our services and our overhead. I speak nationally, and, lately I have been hearing a louder rumble from my colleagues about this problem. Physicians are concerned about the trend they are seeing — reimbursement cuts, and higher insurance deductions and co-pays making patients think twice about coming to the doctor for other than serious issues. These hurdles make the practice of medicine more challenging.

PHOTO BY JAY WILEY

Clearly, we have to find ways to counterbalance these trends. While physicians are becoming more aware of the need to practice medicine a different way because of the changed landscape, often they aren't sure what to do. New technologies and services usually cost a hefty sum and require burdensome training for staff — and what if they don't work or the return on investment turns out to be poor?

Please consider some of my suggestions; they've really helped in my own practice. You won't get rich from any one of these offerings, but each one helps bridge the gap. Moreover, anyone can implement these very quickly without great investment in inventory or staff training.

THE DRY EYE DEFENSE

Dry eye disease is almost ubiquitous, so any practice would do well to offer patients products that may relieve the gritty feeling in their eyes. While there are plenty of artificial tears and omega-3 supplements in any supermarket, drugstore or on online sites, patients often become confused once they wander store aisles searching for the right product — what's the difference between brand A and brand B? What is the optimal dosage? By making available the products you believe could make a difference in the ocular health of your patients, you are providing both clarity and convenience. Here are the ones I've chosen to carry in our office for sale to our patients. Patients can purchase these items as they check out.

Hot and cold masks

We offer two masks: hot and cold. We suggest the hot mask for our dry eye patients when we recommend hot compresses. The commonly used method, a washcloth soaked in hot water, is less expensive, but of course, it doesn't stay warm long enough to do the job.

The heat mask is more effective. You put it on a dinner plate and heat it in a microwave. If you follow the manufacturer's instructions, it delivers the appropriate, correct temperature for up to five minutes. It beats the washcloth by a mile. The cold mask is for patients who have ocular allergies or migraine headaches. While it's not as big a seller as the heat mask, it helps some patients.

Omega-3 supplements

Omega-3 eases dry eye symptoms, among its other benefits. When I recommended it in the past, the dozens of brands patients encountered on store shelves often confused them. We were bombarded with calls. I soon realized that I was not being very helpful to my patients if I could not more precisely direct them to a product or two. So I researched available options and went with PRN (Physician Recommended Nutraceutical).

In addition to the pharmaceutical grade quality of PRN's product and the samples (So rare these days!) the company provides, my patients and I appreciate PRN's health-coach model the most. For a surgeon to spend 10-15 minutes discussing the ins and outs of omega-3s with patients can be cost-prohibitive and inefficient, yet they deserve answers to all their questions. We direct our patients to PRN's health coaches via a toll-free number.

These trained health coaches address the patient's questions, including those about how the supplement interacts with the patient's current medication regimen, how the product compares to the less expensive brands that can cause fish gas or fish burp, which often makes patients stop using them — whatever the patient's concerns may be. Instead of me going into all this, I tell the patient “With your permission, a PRN health coach will call you within two or three business days. List any questions you have — they are the experts and they will go over your questions with you.” This way, I duck out of that potentially time-consuming discussion and the patient talks to someone who is far more current about omega-3s.

The health coaches do not engage in hard-sell tactics. We've done mystery shopping with PRN to make sure patients aren't pressured. I do tell patients that I personally use the product, but the decision to buy through PRN is completely up to them. If the patient is interested, PRN has various models to choose from — a three-, six- or 12-month supply. Of course, the more you buy, the less you pay per bottle. This direct ship method obviates keeping any omega-3 inventory in the office.

Artificial tears

I carry these because so many patients ask which brand they should use. We offer preservative-free Retain MGD (OcuSoft Inc., Rosenberg, Texas). This ophthalmic emulsion is sold in a set of 30 individual vials. Each vial is good for a 24-hour period; each holds approximately eight to 10 drops. Patients use them throughout the day, although they cannot easily carry an open vial with them.

IPL therapy

PHOTO BY JAY WILEY

We personalize the IPL maintenance schedule to each patient.

Intense pulsed light therapy is a treatment for meibomian gland dysfunction/ocular surface disease. We have a paradigm for our dry eye patients: Omega-3s, cyclosporine, and if they fail that combination or are unable to tolerate it, then — because we do not want to keep patients on steroids indefinitely for a chronic disease — the next step is IPL.

We administer an IPL treatment once a month for four months. The physician performs this procedure. Thereafter, the maintenance schedule is personalized to each patient and usually involves a treatment every six to 12 months. The patient pays for one treatment at a time, making it financially easier than one big expense.

Letting patients know

While many of these items do not make for visually appealing displays, manufacturers can often provide attractive signage to place around the waiting room. We also use EyeMaginations (EyeMaginations, Baltimore) to educate our patients about the therapies we offer. While the patient is dilating and waiting for the physician, our staff selects a topic-appropriate video based on the patients pre-existing diagnoses.

We've created play lists, a string of two or three related videos, depending on the patient's condition. Each is only a minute long, so they won't put the patients to sleep. While EyeMaginations introduces concepts, the burden remains on the physician to educate the patient about the therapeutic regimen he or she chooses for the patient.

BECOME A MINI-PHARMACY

EyeScripts Dispensing (Lake Villa, 1ll.) is a point-of-care dispensing system designed by ophthalmologists specifically for ophthalmologists, and it can help your practice grow its revenue. Let's say we prescribe Zirgan (ganciclovir ophthalmic gel, Bausch + Lomb, Rochester, N.Y.) or Tobradex (tobramycin, dexamethasone ointment, Alcon, Fort Worth, Texas). The patients will have the option to purchase it directly from our office as they check out. We act as a mini pharmacy, in effect. This service performs three functions:

• Patient safety and convenience. It allows us to ensure patients are getting the correct medication the physician has prescribed and that the pharmacist is not substituting something else — either in the same class or, potentially, not even in the same class. This service also provides a one-stop-shop convenience, eliminating the need for the patient to go to the pharmacy.

• Redeem the coupons. Sometimes pharmacies do not honor promotional coupons drug companies offer for their products, or the patients forget to bring them to the pharmacy. We make sure whatever promotional material the companies have left with us are attached to the prescription to help the patient pay the least possible amount for that medication.

• Additional revenue. The practice makes a small markup — not a lot. Again, you're not going to get rich. EyeScripts does not require any additional staffing or housing of inventory. You need only one small locker with a lock. Fortunately, ophthalmic medications come in small bottles and tubes, so they don't require much space. Not every state permits the sale of medication in physician offices. You'll need to check your state regulations.

WHEN DISEASE IS NOT AN ISSUE

What about patients who don't have any form of eye disease — your healthy, run-of-the-mill patients who just need their annual eye exam or refraction for their contact lenses or glasses? After all, they comprise a significant portion of any general ophthalmology practice. Fear not; I can tell you about some relatively easy ways to provide often overlooked but necessary services while also increasing revenues from this group.

Charging for refraction

Don't feel pressured to underwrite refractions: Medicare never pays for refractions. When I ask colleagues about their refraction fees, the spectrum is dramatic: Some never charge and others charge very high fees. Set your fees wisely.

To keep patients current with their refraction, we have a calendar built into our EMR for annual refractions. I find that if you do not track it, patients may return for, say, a glaucoma or a diabetes check, and you may not remember that it has been a year since their last refraction.

View of retina without dilation

The OptoMap Retinal Exam (Optos, Marlborough, Mass.) provides an ultra-widefield view of the retina — out to 200°—without dilating patients. For the younger, healthier patients, the Optomap is a convenience many are willing to pay for.

Let's say a 16-year-old athlete who has a refractive error of −2.00 D presents for her annual contact lens check. Patients like this don't want to be dilated since they may not be able to do homework afterwards or go to sports practice. In these cases we offer the OptoMap. If we see pathology, obviously we dilate them, but otherwise it's an option for which patients are willing to pay out of pocket.

REMEMBER CONTACT LENSES

Sell contacts from your Web site

We used to have patients call our practice during office hours to tell us they needed to re-order their contact lenses; the front desk would take a message, the message would go to the contact lens technician. A day or two would go by before that tech reached the patient to confirm the information. By that time, the patient was practically out of contact lenses and was frustrated to learn that the contacts hadn't yet been ordered. This is the sort of situation that drove many of our contact lens wearers to try 1-800-Contacts. To avoid this cycle, we now offer contact lens sales through our Web site. If the patient knows his or her power — and only if the person is an established patient — he or she can order contacts directly from our Web site, 24/7. This has helped us retain our contact lens patients.

Our Web designer had to interface with the contact lens vendor to make it appear as a seamless transaction to our patients. It looks like they are ordering directly from Matossian Eye — whereas, in effect, their order goes directly to our contact lens vendor. The vendor receives the order and ships the contacts. Again, you will not make huge profits on contact lens orders, but you are keeping the patient in your practice.

Lubricating drops for contact lenses

PHOTO BY JAY WILEY

Patients gain convenience and avoid confusion in store aisles when you offer the products you recommend for them.

Because many patients were asking about lubricating drops for their contact lenses, we now sell Retain CMC (Ocusoft Inc, Rosenberg, Texas). This product works as a lubricating drop with most contact lens brands and is available for our patients as they check out.

DON'T LET THEM GET AWAY

We all know the cost of bringing a new patient to the practice is much higher than bringing an established patient back. A successful patient recall system can be problematic to execute. We've found Brevium Patient Reactivation software (Brevium Inc., Mountain, Utah) to be helpful in bringing back our “lost” patients.

Each night, the software automatically searches every patient history in the practice database to find lost patients in a two-step process. First, it searches ignored recalls to find those who either missed or never scheduled an appointment after the practice reached out to them. Second, the software analyzes claims data to identify patients based on their disease state: glaucoma, cataract, diabetes, AMD or other. The software does not require EMR and it interfaces with most practice management systems.

You choose the search parameters for the software: For instance, patients who have not been back to the practice for two years or more. The software brings up the names of those patients; we assign a front-desk person to call them and the name pops up on the screen with all attempts to contact the patient clearly documented. The reporting is excellent: You know the number of calls each person assigned to this made per hour, the number of appointments each person made and then the number of kept appointments. This way, you can easily track outcomes. You pay Brevium according to the number of appointments kept.

Make your own luck

There isn't a gold mine on the eye-care horizon. The suggestions I have shared with you are easy to implement. You have to do what you can to diversify your revenue stream because while you may be practicing fantastic ophthalmology, the gap between what we are reimbursed and the costs of operating a medical practice is growing. Hopefully these ideas can help you bridge that gap so you can continue to give your patients outstanding quality care. OM