Article

Giving birth to a dry eye clinic

DED mavens — two established, one en route — provide pearls, expose pitfalls and show how it’s done.

DRY EYE DISEASE SPECIAL SERIES: CLINICS

Giving birth to a dry eye clinic

DED mavens — two established, one en route — provide pearls, expose pitfalls and show how it’s done.

By Patti Barkey, COE, Sheetal Shah, MD, and Zachary Smith, MHSA

INTRODUCTION

By Patti Barkey

I truly dislike the term dry eye center of excellence; it was created as a marketing term and stuck. Every office should be treating their patients’ dry eye disease, just like they treat their glaucoma, cataracts or detached retinas. Using the word excellence makes it sound as if treatment is optional and difficult to obtain. Excellence isn’t about the center’s appearance; it is achieved in the patient experiences and outcomes.

Frank Bowden, MD, of Bowden Eye & Associates in Jacksonville, Fla., showing a patient her LipiView test results.

Establishing quality dry eye care involves a commitment to learning about the disease state and acquiring the tools necessary to provide a thorough diagnostic and treatment process.

We’ve been helping practices learn about dry eye disease for the past four years, since the FDA approved the first diagnostic tool. Before that, the only medication designed for dry eye was Restasis (cyclosporine ophthalmic emulsion, Allergan).

There were multiple artificial tears on the market but there was a failure in the education of both provider and patient as to how the products should be properly used. Not every artificial tear tackles the specific patient issue. Trial and error lead to frustration.

But since LipiFlow, the dry eye diagnostic and therapeutic floodgates opened, as did the doors to our dry eye education center — Donald Korb, OD, was our spark. Today we have products that can get to the root of the problem: Patients can’t be cured, but they can certainly become more comfortable.

Many practices struggle with asking patients to pay for therapeutic services that aren’t covered by insurance. We find that we enable the patients to make an informed decision by simply educating them about the benefits of an out-of-pocket product or service.

Patients today are educated and do their research. Order the appropriate treatment plan then let them spend their money as they see fit.

It is okay for practices to make the decision not to offer dry eye care. But they shouldn’t pretend the disease doesn’t deserve recognition.

Do what others do: You can recognize that patients have DED, and then diagnose. You can get good at diagnosing, and then refer.

What you can’t do is dabble.

Because for many of these patients, no one has ever taken proper care of them. It’s important to remember that.

OVERVIEW

Dry eye services could help many of your patients and boost your practice’s bottom line simply because so many Americans suffer from this condition.

If your practice does not put much emphasis on diagnosing and treating dry eye, a medically important condition, it’s likely only a matter of time before your patients begin asking for more options or self-educating and asking for specific treatments, especially in these times of substantial direct-to-consumer advertising by pharmaceutical and medical equipment companies. If you take into account the considerations discussed here — physician engagement, communication, training, staffing, treatment protocols — and plan carefully to address your patients’ needs, the chances of arriving at a win-win solution for your patients and your practice will be greatly enhanced.

Given the prevalence of dry eye symptoms — at least 50% in comprehensive practices — the need is great to establish a systematic way to address dry eye disease. Creating a dry eye practice is an investment of finances, time and personnel. To do it right, start with existing resources to create a system that works for your practice. The rest will fall into place.

Physician engagement

Physicians and/or practice administrators may have difficulty developing a new service line if all stakeholders — physicians especially — are not engaged in the process. It’s not uncommon for a physician or practice administrator to attempt to drive things on his own, regardless of engagement from other physicians or key players in the practice.

So, a critical observation to make is whether all stakeholders are engaged or if you are getting buy-in. When a minority introduces significant changes or additions and then tries to get the others on board, consider this buy-in, which produces inconsistent results.

Conversely, when all parties are actively involved in the process of developing a new service line, what you have is engagement, which is more likely to produce coordinated efforts and successful results.

Communication

Like air, communication is essential. It will circumvent problems like “my docs won’t buy in” or “my techs won’t like adding to their work-ups.” Let staff be part of the center-building process by spreading the news about the new plans. Involve your technicians in the implementation process by sharing suggestions and listening to their opinions. These support staff know their workflow better than anyone, so they can offer solutions that will work. Distribute a weekly memo to all staff on the project’s progress.

Sample of procedures, charges, Bowden Eye
Feb. 2014 — Sept. 2015 No. of services Codes Charges Insurance payments Patient responsibility
Allergy testing 60 95004 - GA $600 $377.86 no out-of-pocket
InflammaDry 4 (2 bilateral) 83516-GA $104 $61.56 no out-of-pocket
Office visits 7 92014
92012
99214
$580 ($290 x 2)
$882 ($294 x 3)
$480 ($240 x 2)
Total: $1,942
$489.52 ($244.76 x 2)
$760.50 ($253.50 x 3)
$431.84 ($215.92 x 2)
Total: $1,681.26
no out-of-pocket
TearLab Osmolarity Test 14 83861QW,RT,GA
83861QW,LT,GA
$540 $531.90 no out-of-pocket
Procedures/treatments 9 MGP, LipiFlow, LipiView, BlephEx $3,125 0 $3,125
Products 27 Inventoried $915 0 $915
PROKERA 1 65778LT, GA
V2790LT, GA
$1,660 $1,317.08 no out-of-pocket
TOTALS     $8,886 $4,023.66 $4,040

At the physician level, have monthly provider meetings and make sure the providers have a shared commitment to patient care. Develop the dry eye standard of care with the provider team — more on this later — and agree on what roles each will play in this segment of patient care. Be consistent with the standards agreed upon, and don’t waffle. Establishing consistency and expectations with your entire team is vital.

Administrators should hold regular training meetings with all staff and assign someone the task of auditing records for consistency. The audits should be used for teaching.

Every staff member should be involved in the patient education process. Additional patient education approaches, like videos, prepared by your clinic or borrowed from appropriate vendors can help patients understand all the information given to them.

What you’ll find throughout this process is that, while having the right technologies and the right processes in place are important to success, it’s the human component that makes or breaks it.

Training and staffing

A leader or point person is imperative to a successful dry eye clinic. Depending on the structure of your clinic, this person may be an ophthalmologist, optometrist, a counselor or a lead technician. The point person needs to take ownership of the dry eye clinic. He or she is responsible for the flow, education, creation of an algorithm and all associated training.

Dry eye care is a team effort. Often practices hesitate to offer dedicated dry eye care because managing this disease can be tedious and cumbersome. Having a team alleviates this problem. Investing time into properly educating and training the staff is vital to success.

Most vendors offer training in their respective areas. Many will come to your practice, analyze your volume/flow and make useful suggestions. They will also train your staff at no cost. You can obtain valuable educational materials from the vendors, such as post-treatment instruction sheets, dry eye disease education sheets, brochures, dry eye questionnaires and so on. They also can share observations on how other successful dry eye practices are run and can offer relevant advice. Just a note of caution: Some may want to counsel you on other vendors’ products.

A dry eye algorithm

By Sheetal Shah, MD

A dry eye algorithm has screening tests, diagnostic tests and treatment options.

Screening allows identification of dry eye and scheduling dry eye evaluations. Conducting multiple tests over several office visits is often required for an accurate diagnosis.

Screening tests

Identify dry eye disease and schedule dry eye evaluations:

    • SPEED Questionnaire: Score > 6 (Bowden treats at 1).

    • TearLab Osmolarity System: Increased osmolarity indicates inflammation in the tear film.

    • InflammaDry: Positively identifies elevated MMP-9 marker in tear film.

Diagnostic tests

    • LipiView Tear Film Interferometer determines lipid layer thickness in the tear film and gives a probability for MGD. Also, the new Dynamic Meibomian Gland Imaging shows the degree of damage to meibomian glands. In my practice, this is the best tool we have to educate patients on MGD.

    • Diagnostic Expression of meibomian glands using the Korb Meibomian Gland Evaluator (TearScience) is an important way to determine how many glands are secreting oil during a natural blink. In patients that have non-obvious meibomian gland obstruction, diagnostic expression is the only way to detect MGD.

Treatments

    • LipiFlow

    • BlephEx

    • Intense Pulsed Light treatment

    • PROKERA

Pharmaceuticals

    • Loteprednol

    • Cyclosporine

    • Lifitegrast

Dry eye products are a great revenue generator and save patients the hassle of finding the recommended items in retail stores, as well as enhancing compliance and success. Some of the popular products are different types of artificial tears (Oasis, Retaine MGD), eyelid cleaning products, dry eye vitamins, moisture goggles and heat masks.

Ms. Barkey’s recommendations to sell

    • Nutraceuticals such as HydroEye (ScienceBased Health)

    • Moisture compress or mask, such as Bruder or D.E.R.M.

    • Tears such as Oasis or Ocusoft Retaine MGD

    • Retaine PM

Educating your colleagues is another important step. Develop a system for other ophthalmologists and optometrists in your practice to refer to the dry eye clinic. It can be a box that is checked off on the checkout sheet or a simple statement such as “refer to dry eye clinic.”

One principal concern when trying to build a dry eye service line is how your staffing model may need to change to accommodate new functions and increased volume. In Zachary Smith’s practice, the program was implemented gradually, so staff adapted easily, adjusting technician schedules rather than having to hire new staff.

In Dr. Shah’s dry eye center, these positions are described or considered as follows:

    • Technicians perform diagnostic tests, provide patient education and answer preliminary patient questions.

    • A dry eye counselor is a viable option.

    • A financial counselor should be on hand to help with questions about payment.

    • Support staff includes schedulers, answering service, insurance verification.

Treatment protocol

The dry eye center needs constancy and consistency in all areas. It needs an algorithm covering screening tests, diagnostic tests and treatment options. There should be protocols covering frequency of visits, products and prescriptions based on the patient’s type of dry eye disease. Therapeutics and procedures should be clearly defined as to when it is effective to recommend and proceed.

Once the dry eye team comes up with a plan, share it with staff for feedback on flow, diagnostics performance, scheduling and assigning responsibilities. Make sure you take feedback seriously. Lack of consistency with plan standards will most often be the issue that arises. When that happens it will confuse everyone and set you back in all areas.

As Zachary Smith and Evergreen Eye center implemented new technologies, they realized their physicians had different practice patterns. Knowing that standardization often lends itself to consistent clinical outcomes and efficiency, their physicians met many times to compare notes, discuss best practices and develop a standardized dry eye protocol. Throughout this process, they also consulted with a well-known dry eye specialist.

The inevitable overhead issues

By Zachary Smith, MHSA

When evaluating the impact of a dry eye clinic on your practice’s bottom line, you should distinguish between average and marginal costs, especially when evaluating staffing costs. While average cost is certainly easier to ascertain, marginal cost is more accurate and gives you better insight into the clinic’s true impact.

Here’s the difference:

You calculate the average cost by including projected revenue from the new services, reduced by your current overhead. If, for example, you project collections of $200,000 annually from dry eye services, and if your practice overhead (independent of employed physician salaries) is 65%, then your cost to provide these services is $130,000. If an employed physician provides 100% of these services, whose compensation is 35% of collections ($70,000), then the practice’s profit is potentially $0 based on average cost.

However, marginal cost highlights additional costs the practice will incur rather than reallocating overhead costs it is already paying. In other words, to generate that $200,000 in revenue, you may only spend around $45,000 for an additional technician (about $18/hour, plus taxes and benefits) and $40,000 for supplies. Add in your employed physician compensation of $70,000 and the practice still nets around $45,000 based on marginal cost.

Having a physician-endorsed standardized protocol results in easier staff training, more consistent patient education and increased use of new technologies.

Steps to building a dry eye clinic

By Sheetal Shah, MD

STEP 1: Decide what type of dry eye care to offer.

Identify a need and make a decision to have proper dry eye management in your practice. Start by asking, “Is dry eye disease a problem here?” The answer is usually “yes” for most comprehensive practices. Once identified, the next step is to decide whether you want to provide complete dry eye care (screening, diagnostic tests and treatments) or part of it (screening tests, diagnostic tests or both) and refer to a full spectrum, dry eye practice for the rest (treatments).

STEP 2: Appoint one person to take charge.

A leader or point person is imperative to a successful dry eye clinic.

STEP 3: Create a patient base.

This is accomplished both internally and externally. Most patients are already established within your practice. One way to identify them so you can streamline them into the dry eye clinic is to search by dry eye diagnostic codes (H04.123 or H02.01). Once identified, a notification (e-mail/letter) can be sent to these patients outlining the new services being offered.

To reach patients outside of your practice, you will need resources in terms of advertising, and your practice’s website is a great place to start. Include videos and a written description of dry eye tests and treatments. In addition, visiting surrounding practices and informing them of your dry eye care model is helpful. You can host patient and physician seminars on your new dry eye protocol. Often vendors can assist by sharing their experience and providing resources.

STEP 4: Decide on which diagnostic tests and treatments to offer.

Tests and treatments will depend on your level of investment, as will the scope of your dry eye care. Review diagnostics.

You can start out with a slit lamp, a BioGlo strip and 1% lissamine green, and add on with advanced diagnostics and treatments as business grows.

STEP 5: Create a team; educate and train.

The members of your team are already in your practice. Again, they need to be educated on your dry eye care model. Hiring a dedicated dry eye counselor is up to you. Your current technicians, office managers, front desk staff and financial person can be trained to perform these tasks. Do not forget to educate patients.

Another matter to consider: Your clinical personnel may require training to support your physicians as they administer new treatments. Evergreen Eye Center trained its staff on each new process or piece of equipment as they’ve implemented it. Having pharmaceutical or medical equipment vendors provide in-clinic training focused on the practice’s processes was extremely valuable. Many vendors also offer online, self-paced courses.

STEP 6:  Conduct a financial review.

You can appoint the same person who handles finances for enhanced cataract surgeries and refractive procedures. As a provider, it is important to remove yourself from the financial discussion.

Dr. Shah’s six-step chart (with some additions from Patti Barkey and Laura Periman, MD)
Six Steps Dry Eye Clinic North Georgia Eye

    1. Identify a need

    • Analyze current dry eye management

    • Identify the gaps

    • Up to 75% of our patients have dry eye symptoms

    2. Appoint point person

    • Ophthalmologist, optometrist (maybe dedicated counselor)

    • Ophthalmologist (cornea trained)

    3. Create a patient base

    • Internal

    • External

    • Internal patient base

    4. Decide what diagnostic tests and treatments to offer

INVESTMENT

    • SPEED, TearLab, InflammaDry, LipiView, LipiFlow, BlephEx, PROKERA, dry eye products

    (Patti Barkey adds: for diagnostic, B + L ocular allergy diagnostic system and TearScience’s Korb MGE)

Low:
SPEED questionnaire
Medium:
InflammaDry TearLab PROKERA LipiView
High:
LipiFlow BlephEx

    5. Create a team; educate and train

    • Point person

    • Technician(s)

    • Dry eye counselor

    • Financial counselor

    • Front desk

    • Office manager

    • Eye care provider, technician, scheduler, financial counselor

    • Utilized vendor resources and other established practices as a model.

    6. Review and refine

    • Benchmarks; financial performance review

    • Inventory systems; as practice grows, add staff, clinic needs

Also, Patti Barkey notes that many dry eye procedures and products are out-of-pocket expenses. These procedures are relatively new and usually don’t have CPT codes that adequately describe the procedure. At times, you can have a CPT but not an assigned RVU value. Develop a fee schedule that includes dry eye procedures, diagnostics and products.

Develop the fee schedule based on cost of goods, cost of technology acquisition and cost of overhead. Be consistent with the fee schedule and follow your standards. Research your local carrier utilization policies.

If staff members follow the standard of care, order procedures based on diagnostics and review the financial portions with patients, then these will lead to captured procedures.

In addition, Zachary Smith notes that, with the release of LipiView II, it is easier to build value with patients because staff can produce high-quality images of patients’ meibomian glands almost instantaneously. As they review these images, the clear differences between the ideal and their own anatomy often compel them to seek treatment without much more discussion.

Evolve and refine

Having a growth mentality requires:

    • Considering and adding new technologies, when applicable.

    • Reviewing needs of patients. Are you meeting patients’ needs, and are they satisfied? How is the patient experience?

    • Reviewing goals and metrics with point person. Are there adequate supplies and inventory? How is the center’s financial growth?

    • Reviewing patient base. Optimize in-house capture, reach out to referring clinics, consider modest rewards for patient referrals.

    • Reviewing the team: Should you hire, redistribute tasks? Don’t forget about continuing education for treating OSD. OM

About the Authors

Patti Barkey, COE, is chief executive officer for Bowden Eye & Associates, Bowden Eye Services Management Organization and Eye Surgery Center of North Florida.

Sheetal Shah, MD completed a Cornea, External Disease and Refractive Surgery Fellowship at New York Presbyterian Hospital - Weill Cornell Medical College in New York, N.Y. She evaluates patients for dry eye syndrome, offering novel therapies.
Disclosure: Dr. Shah is a consultant and speaker for TearScience.

Zachary Smith is the chief operating officer at Evergreen Eye Center in Federal Way, Wash. He is also a Medical Service Corps officer in the U.S. Navy Reserve.