Starting your dry eye center of excellence

Proven demand + business know-how = practice success

Starting your dry eye center of excellence

Proven demand + business know-how = practice success

By John D. Sheppard, MD

The confluence of demography and opportunity has markedly enhanced patient and practitioner awareness of ocular surface disease (OSD) and its near constant companion, dry eye. To meet these burgeoning societal needs requires a focused, practice-wide approach in order to deliver advanced diagnostics and innovative therapeutics. But distractions from real medicine, both of a business and regulatory origin, tend to impede the practice from intelligently focusing on the issue.

Numerous names are used synonymously for this condition, including:

    • Dry eye disease (DED)

    • Dry eye syndrome (DES)

    • Sjögren’s syndrome (SS)

    • Ocular surface disease (OSD)

    • Keratoconjunctivitis sicca (KCS)

    • Meibomian gland disease (MGD)

    • Dysfunctional tear syndrome (DTS)

    • Ocular surface inflammatory disease (OSID)

OSD, DTS, DED and a host of other designations all describe a disturbance in the tear film leading to dry eye. “Dry eye” provides a universally recognized term, readily identifiable by sufferers as well as clinicians. Thus, the numerous other names used in medical literature as well as the lay press create confusion. As a result, we use the term “dry eye” for all clinical correspondences and advertising to provide consistency. OSD, better termed “dry eye” henceforth, is ubiquitous, affecting most glaucoma patients and cataract surgery candidates, as well as a significant number of corneal transplant, blepharoplasty and LASIK candidates.

Dry eye must be recognized and addressed to provide first-class care, so why not grow your business in the process? My practice has pulled off both objectives with our “Dry Eye Center of Excellence.” This concept produces dedication within the practice and better understanding of the importance of DED among patients. However, creating such a center requires diligent organization in the following aspects.

Virginia Eye Consultants’ Dry Eye Center of Excellence brings a welcome revenue stream to the practice.

Management perspective

A first-class practice must prioritize patient satisfaction. Essential to this end is the active engagement of dedicated employees. In addition, the procedures and products that bring the most value to patients must be selected, tested in clinical trials, analyzed and collectively tracked, weeding out the least productive while enhancing the most productive. With continuous overhead management and staff education, the model flourishes. Patients first, employees second, the practice wins.

In an era wherein 18% of this country’s gross national product is spent on health care and 12% or less is the norm in virtually every other industrialized economy, regular annual reimbursement cuts have become expected. As personnel, regulatory and supply costs inevitably rise each year, retail- and cash-based business assumes top priority consideration. Therefore, it is incumbent upon administrators, managers and physician-owners to embrace key unencumbered revenue streams including premium IOLs, refractive corneal surgery, refractive cataract surgery, cosmetic plastics and retail sales.

Skilled clinical acumen and continuing education

The dry eye space has grown at a remarkable pace, coupling improved diagnostics, many new directed therapeutics and increased awareness by ECPs, PCPs and patients. Thus, education promotes earlier diagnosis and targeted care for dry eye patients. ECPs and, even more importantly, their physician extenders, provide the bulk of this educational piece, keeping patients and their families on top of their game and deterring noncompliance. Physician extenders include physician assistants, nurse practitioners, scribes, technicians, counselors, telephone operators, triage nurses and checkout staff. A unified message and consistent protocols within a practice are central to instructional messaging.

Ophthalmologists can provide continuing education to network and in-practice optometrists, as well as PCPs, rheumatologists, obstetricians and endocrinologists who are likely to see dry eye patients in their practices. Finally, industry leaders including Allergan, Alcon, Bausch + Lomb and Shire provide key dry eye educational pieces through promotional and continuing medical education programs.

Staff education is critical to practice success, especially the dry eye center of excellence. Employee buy-in and engagement grow the dry eye practice far more rapidly than relying solely upon the ECP to drive education and sales. Regular educational programs from the ECP, the billing office, administration, as well as the vendors keep the staff motivated.

Diagnostic, therapeutic and staffing essentials

Practices proposing a dry eye center of excellence require a minimum sufficient proficiency in diagnostics, therapeutics and staffing. Logical practice organizational metrics depend upon the practice size, personnel skill sets, local climate, community health characteristics and socioeconomic factors. Although dry eye is universal, each practice will gradually become best suited to its specific needs.

Dry eye center profit potential

Amedical-legal, low-risk practice addition, a dry eye center of excellence can benefit patients and be a very profitable endeavor. Increasing your efforts with dry eye patients creates several potential revenue opportunities via initial diagnostic tests as well as implementation of treatment and follow-up.

Here are approximate revenue figures for a dry eye center. These figures are based on patients who present with initial complaints of blurry vision:1

New patient, comprehensive exam $149.66
1 month follow-up exam $73.40
3 month follow-up exam $73.40
12 month recall exam $73.40
Total annual revenue per patient $369.86
x 1,500 patients (assuming minimal marketing efforts)

Additional revenue from office visits based on percentages of how often dry eye patients experience other conditions (assuming half of the dry eye patients stay with the practice for treatment of those conditions):2

Dry eye patient with additional treatment Tests and treatment Rate per patient
Cataract patients from DE Bilateral cataract surgery, including surgery, exam, diagnostic testing $1624.59
X 105 patients
Glaucoma patients from DE With POAG, no systemic disease $500
x 23 patients
Punctal plug patients 2 plugs $223.95
x 150 patients
TOTAL VALUE - $770,464.45


1. McDonald M. Adding a Dry Eye Center of Excellence. ASCRS 2014. (2016 Medicare rates via Paul M. Larson, Corcoran Consulting Group. Original figures via Bruce Maller, BSM Consulting.)

2. 2005 Gallup Study of Dry Eye Sufferers.

At a minimum, diagnostics should include:

    • Fluorescein

    • Lissamine green

    • Rose Bengal strips

    • Schirmer’s tear strips

    • Osmolarity (TearLab)

    • InflammaDry (RPS)

    • Doctor’s Allergy Formula antigen skin testing

    • Oculus Keratograph or TearScience Dynamic Meibomian Imaging

    • Advanced topography, such as the Cassini, Marco OPD or Pentacam.

Also, a variety of manufacturers offer additional capabilities to measure tear meniscus height, tear film breakup time and blink rate. TearScience’s LipiView I imaging system quantifies the lipid tear layer thickness and blink rate, LipiView II images the meibomian gland anatomy and the LipiScan provides dynamic meibomian gland imaging.

Minimum therapeutic capabilities should include LipiFlow (TearScience) thermal pulsation or at least lower-cost devices such as the MiBoFlo (Mibo Medical) or BlephEx (Rysurg). LipiFlow should be treated exactly like premium IOLs, refractive corneal surgery or oculoplastics: A fully operational, informational, promotional and counseling apparatus must be in place to make this program successful. Furthermore, make available a full panoply of in-house retail dry eye products and ensure that the entire staff understands them. Nutritionals, artificial tears, masks, compresses and shields promote ocular health and drive patient loyalty. For online sales, consider, an effective overhead reduction apparatus that simultaneously drives sales.

Adoption within the practice environment

Quantify adoption success for every major procedure and revenue stream. This is especially true of dry eye diagnostics, procedures and sales. Tracking insurance plans, patient zip codes, counselor and technician recruitment success and, of course, ECP assigned numbers, allows practice administration to reward producers and better motivate laggards. Satellite offices often display remarkably different technology adoption characteristics, necessitating changes in marketing strategy or even the products offered for sale. Large multi-specialty groups can benefit from in-house education efforts to motivate PCPs to refer internally. Patients traveling long distances in rural practices should be rewarded with every effort to provide one-stop shopping and maximizing every visit.

Internal and external marketing

Internal, or “warm marketing,” is by far the most effective method to recruit and motivate patients. Brochures, pamphlets, posters, reception area TV advertorials, exam lane patient education materials, friends and family referral incentives and e-mail blasts are among the lowest cost, highest yield marketing strategies available. These numbers should be tracked to assay effectiveness.

External, or “cold marketing,” often just brands a practice, center or physician. Whether branding is truly necessary remains debatable. Even more so than internal marketing, cold marketing through radio, television, newspaper, flyers, posters or billboards must be tracked to ensure that considerable sums of money are not repeatedly wasted.

Big picture

Insurance reimbursements are declining. Unfunded regulatory burdens are burgeoning. EMRs create massive overhead increases. Supply costs are growing faster than CPI. Staff salaries and benefits continue to grow even as more employees are needed for compliance and automation. Thus, cash-based businesses provide insurance against income contraction and ensure the survival of our profession. The dry eye center of excellence, when well managed and monitored, can create a significant improvement in every practice’s bottom line while improving patient care:

    • Patients win. Correct diagnosis made the first time

    • Payers win. Unnecessary empirical therapy is avoided

    • Providers win. Expanded therapeutics and diagnostics create better results

    • Practices win. New income streams aid the bottom line.

Every practice should consider creating a dry eye center of excellence. OM

About the Author

John D. Sheppard, MD, is president of Virginia Eye Consultants, and professor of ophthalmology, microbiology and molecular biology, Eastern Virginia Medical School, Norfolk, Va.