In an analysis of 2 million patient encounters occurring in 40 states and 228 hospitals throughout a two-week period between March and April 2020, hospital care volume dropped by more than 50% compared with the same period in 2019.¹ Among outpatient encounters, cataract was the hardest hit, down 97%; glaucoma encounters dropped 88%. Overall, ophthalmology was the hardest hit medical specialty, with an estimated volume loss of 81%.

Though that decrease was temporary, it wasn’t without impact.

Reimbursed office visits and elective procedures are down. Practitioners are wrestling with reorganizing the physical environment of their offices and surgical centers to meet new requirements, while navigating the complexities of paying and retaining trained staff.

As practices and ASCs begin to fully reopen, ophthalmologists are aiming to raise volume back to pre-COVID-19 levels, but that may be challenging as infection rates change in the coming months. Even in counties that are fully “open,” the shared CDC guidelines will continue to add cleaning time and extra physical spacing, both of which reduce potential volumes.

As a result, we’re seeing trends emerge in how practitioners maximize per-patient revenues. The choices all fall firmly within a framework of providing better patient care, including, surgeons say, several underutilized measures whose time has come.

“If you start with ‘How can I make more money?’ you will lose,” explains Blake Williamson, MD, of Williamson Eye Center in Baton Rouge, LA. “Physicians should never be guided by that. Instead, look at your process from start to finish and ask, ‘With a limited number of patients, what can I do to grow my practice that will make my patients happiest?’ If you have not been offering patients the full suite of current technologies and innovations in the IOL, glaucoma, and dry eye spaces that can improve their outcomes and lifestyles, it’s time to do that now.”

Bridge the Toric IOL Gap

The consensus among doctors we talked to was that surgeons who have been on the fence about refractive cataract surgery for astigmatism, presbyopia, and other conditions should focus on boosting their adoption rates now—as it will improve patients’ vision and quality of life while adding revenue. Several doctors noted that toric IOLs, in particular, represent an aspect of patient care that has been deferred for too long.

“We began 2020 with a substantial cut in reimbursements for cataract surgery, so we were all talking about doing more advanced IOLs. Then COVID hit, and elective surgery was out of the question for about two months,” says Cynthia Matossian, MD, of Matossian Eye Associates in suburban Philadelphia. “We’ve all been adjusting to a new and changing ‘normal,’ with staffing challenges and volume restrictions. And now we’re ready to focus on advanced IOLs again, and I think toric IOLs are an excellent opportunity to help patients while offsetting financial challenges.

“About 22% of patients who present for cataract surgery have astigmatism of 1.5D or higher.² You’d think that would mean that 22% of patients get toric IOLs, but that number is actually only somewhere around 8%,”³ Dr. Matossian continues. “For surgeons who have not been offering toric IOLs, it’s time to focus on closing that gap.”

Through a hybrid in-office and telemedicine visit where patients choose from the IOL options recommended by their surgeons, patients at Eye Centers of York in York, PA, are now selecting more advanced cataract options on their own. “We really feared that the financial stress of the pandemic would decrease patient engagement in premium services, but we’ve seen the opposite,” says Eye Centers of York’s Denise M. Visco, MD.

Dr. Visco points out that the ASC administrators can play a vital role in increasing premium service revenues. “If the facility has a femtosecond laser and it stocks MIGS devices, but the adoption rates are not where they should be relative to your goals, then the administrator can reach out to physicians who are under-utilizing these resources and offer to schedule training,” she explains. “That can increase revenues from those resources charged to any doctor who uses the ASC.”

Mark King, practice administrator at Tyson Eye in Cape Coral, FL, has changed the workflow processes for surgical counseling, which has had a positive effect on premium services.

“The process is now more electronic and less focused on paper brochures. The perspective has changed a bit, too,” King notes. “Cataract patients have been dependent on glasses or contact lenses, but that dependence is worrisome when their eye doctor’s office is closed for a long period. Now we point out that premium cataract surgery can offer spectacle independence. That’s reassuring to them in the COVID-19 environment. And here in Florida, where hurricanes can cause office closures, the benefits of that independence won’t go away.”

Combine Telemedicine With Amplified Dry Eye Treatment

“I think it’s important to look toward advanced dry eye and ocular surface therapies right now, because patients with effective dry eye treatment regimens are amongst our happiest patients,” Dr. Williamson advises. “It’s a welcome relief for patients who are handling dry eye on their own in the context of myriad other stressors. And these technologies tend to be in the cash-pay model.”

Whether dry eye is the primary complaint or a problem that needs to be addressed before surgery, in-office procedures, such as Blephex (Lombart), iLUX (Alcon), intense pulsed light (IPL) therapy, LipiFlow (Johnson & Johnson Vision), TearCare (Sight Sciences) and others, have become an indispensable part of many treatment plans. Physicians say these cash procedures are generally well received by their patients, and the out-of-pocket payments are a good way to build revenue.

Dr. Matossian is sensitive to patients’ financial situations today, but she continues to actively discuss dry eye treatment options. When she diagnoses dry eye, she offers to perform a procedure the same day, adding to the revenue-per-patient encounter.

“I’ve been using telemedicine to stay connected with my dry eye patients,” she says. “Now that we have reopened our practice doors, our patients are starting to return for their scheduled in-office procedures, with safety protocols in place.”

Dr. Williamson is also using telemedicine for dry eye and other routine visits. In fact, he finds that telemedicine is convenient for patients with low-risk complaints, such as those needing medication refills, as well as patients who need post-op visits after cataract surgery.

“On post-op day 1, my cataract patients are virtually always doing well,” he says. “The only common thing we’re looking for is an IOP spike, and so we are meticulous about checking for physiologic IOP with a Barraquer tonometer before the patient is let off the table. Now, on post-op day 1, my scribe organizes patients into a virtual waiting room, and I simply click through the list and conduct virtual telemed exams to make sure everyone is seeing well, pain-free, and happy. If there is any pain or redness, or any concern whatsoever, the patient sees me in person that day.

“This has been a total game-changer for my team because my ODs and I no longer have to process 30 1-day post-ops through our clinic,” he explains. “This relieves the front desk and technicians, while also allowing for those appointment slots to be filled with other billable clinic visits instead of visits in the global period. Patients also love it because they can stay safe at home.”

Go Drop-Free

Dr. Matossian, like many other surgeons, has long been using a “drop-free” approach to cataract surgery, where drugs used in the OR, such as steroids Dextenza (Ocular Therapeutix) and Dexycu (EyePoint Pharmaceuticals) and the NSAID Omidria (Omeros), allow patients to use fewer postoperative drops. Since COVID-19 has changed routines for postoperative follow-up, more physicians are going drop-free.

“We have really moved toward a drop-free approach during COVID-19,” Dr. Visco says. “The pass-through rebate offers a modest boost in per-patient revenue. But perhaps more importantly, it creates a better patient experience. They don’t need to go to the pharmacy or call their doctor because they’re confused about the regimen. As a result, patients are happier with their surgeon, and their surgeons are happier with our ASC. We will definitely continue offering a drop-free approach post-coronavirus.”

“We know how confused patients can get using three different ophthalmic solutions, particularly when they’re tapering the steroid on the first eye,” Dr. Matossian says. “Once the second eye undergoes surgery, the medication schedules are no longer similar between the two eyes, leading to more errors and inadvertent noncompliance. An intracannicular insert or the placement of a spherule intraocularly that releases steroid gradually over 30 days will eliminate approximately 70 drops from the post-operative regimen. I feel better knowing my patients are getting their steroid every day in the right amount. The safety profile of these two products is very solid, which may make it possible to choose telemedicine for some of the postoperative visits within the global period. Drop-free surgery also decreases preauthorizations and patients call-backs, saving staff time.” [See page 16 for more on drop-free strategies.]

Expand Use of MIGS and Drug-Eluting Implants

The benefits of MIGS are well established, but surgeons continue to have varying levels of adoption. The doctors we spoke to take an aggressive approach, and agree that it’s more important than ever for others to follow their lead. Yes, adding a MIGS procedure to cataract surgery generates more revenue with little added time, but again, the benefit to patients is even more compelling.

“If a surgeon has been on the fence about using MIGS, using them more often, or trying new MIGS procedures, this is a good time to do it,” Dr. Williamson says. “Unfortunately, some patients with glaucoma, most of them seniors, are not seeing their doctors with the usual frequency during COVID-19, which means the noncompliance that is all too common for glaucoma medications can lead to permanent vision loss. We need to be looking at drug-eluting implants, such as Durysta (Allergan), or MIGS to serve these patients. After these interventions, most patients can use fewer drops or even stop drops entirely, improving their lifestyle and ocular surface health while controlling their IOP. Now more than ever, MIGS are the right thing to do, and they will increase your reimbursements as well.”

Spreading the Word About Safety

None of these opportunities to maximize revenues is a major change—they all fit very neatly, and easily, into existing patterns. But patients need to return to the practice and ASC to make this happen. In some areas, higher coronavirus infection rates mean greater restrictions, while other areas are nearly back on track, at least for the time being.

All the practices and ASCs mentioned here are educating referring doctors and patients about their COVID-19 protocols, cleaning and PPE procedures, and processes for safely moving patients through the environment. Use of social media images and videos give people the reassurance of actually seeing those protocols in place. The video of Dr. Williamson’s practice has more than 15,000 views on Facebook (facebook.com/WilliamsonEyeCenter ).

As Dr. Williamson puts it, “The best way to generate revenue is to simply get your patients back in the door. We’ve temporarily shifted from marketing outcomes to marketing safety—highlighting how we’re providing the safest eye exam available. Safety is the new currency with which you purchase patients’ belief and trust in you and your practice.” ■

REFERENCES

1. Strata Decision Technology. National Patient and Procedure Volume Tracker. Available at: stratadecision.com/National-Patient-and-Procedure-Volume-Tracker/ ; Last accessed June 8, 2020.
2. Ferrer-Blasco T, Montés-Micó R, Peixoto-de-Matos SC, González-Méijome JM, Cerviño A. Prevalence of corneal astigmatism before cataract surgery. J Cataract Refract Surg. 2009;35(1):70-75.
3. Blum, K. Not all patients get a toric IOL option. Ophthalmology Management 2017;21(12):48-51.