Overview of a Successful Dry Eye Center of Excellence

Myths and realities from the management perspective

At our growing practice, which consists of 17 providers and 195 employees working in four offices, we long ago stopped asking whether we should establish ourselves as a dry eye center of excellence. We felt that if we were to remain committed to clinical leadership in our community, the answer had to be “yes.”

Dry eye is a ubiquitous disease that affects a patient’s quality of life and vision as well as our surgical outcomes. This is so important that we market dry eye care as much as we market cataract surgery in our practice — and the dry eye ads, particularly for clinical research, often bring in more patients.

When other practices consider this way of thinking about dry eye care, three objections tend to arise: 1) It will slow us down; 2) It will distract us from our surgical focus; and 3) The profit margins are low. Our practice is proof that these objections are myths and not reality.

Dry Eye Care Won’t Slow Down a Practice

Quality dry eye care adds elements to the exam and patient education, but none of it has to stress patient flow. Use of physician extenders speeds up the process. These key staff members may include a scribe, a physician assistant, an excellent optometrist, a mover who runs patients back and forth between rooms, the personnel at checkout, and an astute counselor who clearly describes the diagnoses and treatment choices to patients.

John Sheppard, MD, MMSc
Virginia Eye Consultants Norfolk, Va.

Dry Eye Care Enhances the Surgical Focus

Cataract surgery is known to add one severity step to a patient’s dry eye as classified by DEWS, and LASIK is known to add two steps¹ (Figure 1). Therefore, at our practice, we have zero tolerance for preoperative intraocular inflammation or posterior segment inflammation, and we find punctate keratopathy, particularly in the visual axis, as well as topographic aberrations intolerable.

Figure 1: Cataract surgery adds one severity step; LASIK adds two severity steps. Plan pre-op and post-op care accordingly.
Source: Behrens A, et al. Cornea. 2006;25:900-907.

In the multifocal IOL and refractive cataract surgery era, where our outcomes must be ultra satisfying, no surgeon should risk a patient with a bad outcome who says, “You gave me dry eye. I didn’t have it before my surgery.” We must be proactive.

Dry Eye Care Generates Revenue

In order to adequately treat dry eye and to maximize our surgical outcomes, we’re expanding our procedural services. Today, a wide variety of excellent practice-building treatments are available, including traditional punctal occlusion. In our practice in 2014, collagen and silicone punctal plugs and punctal cautery brought in six figures in collections and markedly improved the lives of our patients.

We use LipiFlow thermal pulsation therapy (TearScience) for our patients who have meibomian gland dysfunction/evaporative dry eye. We motivate our patients and our practitioners to recommend this at every opportunity because of the dramatic, sometimes life-changing, results we achieve. We’ve been able to continuously decrease our fee, thanks in part to recent pricing reductions from TearScience. We can easily gross more than $100,000 per year for our practice by offering this treatment.

Using the Prokera biologic corneal bandage (Bio-Tissue) to control the inflammatory process and accelerate healing on the ocular surface in a variety of dry eye-related conditions and to accelerate preparation for surgery, we can add more than $300,000 to our collections.

In addition, we recommend nutritional supplements to our patients, including HydroEye (ScienceBased Health), as part of our retail sales segment. We also sell other adjunct therapies, such as lid wipes, lid compresses, and humidifying masks, through MyEyeStore.com and at the checkout counter in our four clinics. By offering these retail products to our patients, we can earn an additional $300,000-plus yearly. Our combined revenue derived from dry eye therapeutics tops $1 million each year.

Furthermore, we’ve found that dry eye treatments, whether insurance-based or cash-based, are often a better use of physician time in terms of the dollars per minute they generate. For example, on this measure, Prokera Slim outperforms cataract surgery with monofocal IOL implantation ($120 vs. $40), and LipiFlow outperforms LASIK ($180 vs. $150 OU). These efficiencies are highly dependent on a well-trained technical and counseling staff.

Diagnostic testing for dry eye is an expanding area. We can perform a variety of tests, including imaging, which I consider complementary. For example, in our practice, we utilize tear osmolarity testing (TearLab) for a host of indications — new dry eye patients, all surgical patients, punctal plug decision analysis, lipid or aqueous prioritization, monitoring treatment effectiveness, neurotrophic assessment, post-LASIK hyperesthesia syndrome, contact lens decision analysis — which legitimately generates high six-figure billings annually. Other diagnostic tests we use contribute to vital decisions for each patient and limit erroneous therapeutic recommendations.

The tests that generate important annual revenue for our practice from our 17 providers follows:

• InflammaDry (RPS)

• TearLab Osmolarity test

• LipiView interferometry (TearScience)

• LipiView Dynamic Meibomian Imaging (TearScience)

• Doctor’s Allergy Formula (Bausch + Lomb)

Taken together, the dry eye-related diagnostic testing and imaging we perform in our practice results in significant revenues. Combining that with our dry eye therapeutics revenue, we are generating more than $3 million toward better patient care, the equivalent of three providers, yet superior decision making saves society an estimated $1 million per year. These fiscal bottom-line benefits come logically by making the correct diagnosis the first time around and prescribing the appropriate therapy, thereby saving tremendously on unnecessary topical prescriptions, oral prescriptions, over-the-counter medications, unpredictable refractive and cataract surgical outcomes, and unnecessary time and travel costs with fewer patient visits to providers to clean up previously empirical therapeutic decisions. Everyone wins.

Everyone Benefits from Dry Eye Care

No one loses when a practice commits to providing quality dry eye care. Patients win because their needs are identified and taken care of; insurers win because diagnosis is accurate and therapy is correctly targeted the first time; doctors win because their own practice grows; and the entire practice wins because income is diversified.

We look forward to continuing on our positive dry eye trajectory with the eventual help of several new therapies that are on the horizon. These include a multidose vial of cyclosporine (Restasis, Allergan), the secretagogue clinical candidate tavilermide (Allergan), electrostimulation (Allergan), lifitegrast (Shire), and the antibacterial, antiviral topical surface treatment (Shire) that has the potential to revolutionize the way we treat dry eye and secondary infections. ■

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