If you have been an ophthalmologist for at least 10 years, your perception of dry eye treatment has likely evolved in tandem with the clinical research concerning this chronic, progressive disease.
Included in this evolution is knowledge that you must optimize the ocular surface before cataract surgery by treating every cataract patient with dry eye who walks through your door. New diagnostics and therapy options have improved our treatment efforts, preoperative biometry and postoperative outcomes for a disease that compromises the quality of life for so many.
Providing the best care for our patients, via the best treatments, is always our North Star. But good business reasons exist to treat this disease.
For one, treatment brings considerable profits and “halo effect” referrals. Two, there is virtually no medicolegal exposure to treating dry eye. And, dry eye patients often have comorbidities that require treatment. These patients will remember your practice when they or family members requires elective procedures.
In this article, I discuss, in dollars and cents, those revenues earned from routine dry eye visits and testing and breakdown dry eye tests and treatment technologies based on manufacturer-provided pro formas.
YOU’VE ALREADY GOT THEM
Your existing ophthalmic patients likely have dry eye disease, and that includes the surgical patients. In a 2005 Gallup poll of dry eye patients,1 14% had cataracts, 4% had macular degeneration and 3% had glaucoma. Some 17% of patients said they had failing eyesight, and 48% had myopia. If you treat ocular allergies, you see dry eye — 60% of dry eye patients have this problem.
Insurers offer a set of reimbursement codes specifically for DED.
ICD-10 codes include:
- Dry Eye Disease with Hyperosmolarity (H16.221 – H18.833)
- Dry Eye Symptoms with Normal Osmolarity or Undiagnosed Dry Eye with Symptoms (H53.141 – H53.8).
The 2017 Medicare allowable is $22.66 per eye ($45.32 per patient), with no deductible or patient copayment. The manufacturer of the tear osmolarity test card charges a $10 fee per eye, and the test requires a CLIA waiver. About the only reimbursable treatment for DED is punctal plugs (CPT code 68761).These codes allow us to bill for dry eye services performed for existing patients, as well as patients whose primary complaint is blurry vision or red eyes.
First, I want to thanks Bruce Maller, widely considered to be the foremost ophthalmic business consultant, and his team at BSM Consulting for their assistance in putting together this conservative financial model (See Figure 1, page 30).
We begin with a comprehensive exam (CPT code 92004, $150) and three follow-up exams in the first year (CPT code 99213, $74 x 3). I perform tear osmolarity testing at all four visits. Reimbursement comes to about $22.66 per eye, less the $10.00 cost of a test card (card prices are negotiated and therefore variable), for net revenue of $25.32 for bilateral testing, or a total of $101.28 per year for four visits. The visits and tests bring the total annual revenue per patient to $473.28. Nearly all dry eye patients also have at least one punctal plug in each eye, which comes to $224 for two plugs (CPT code 68761: first eye $149, second eye $75).
Let’s extrapolate those numbers for all of your dry-eye patients based on rates for Medicare Part B patients (which may be slightly less than Medicare). I want to approach this very conservatively, so imagine you have a low-volume practice, are not very good at convincing patients with dry eye symptoms to pay for out-of-pocket procedures, so your conversion rate is remarkably low. Also, in this example, your marketing effort is minimal: a link on your website, a photocopied announcement mailed along with your invoices, technicians wearing “Ask me about dry eye” buttons and a poster in your exam lane.
Despite these limitations, in one year, your two- or three-doctor practice could easily capture 1,500 new dry eye patients, generating $709,920 in dry eye visits and testing. If only one in 10 of those patients gets two punctal plugs (most of my patients get four), add $33,600. Now think of those numbers from the Gallup study. About 14% of those patients have cataract and 3% have glaucoma. You diagnose these problems during the examination. Even if you only capture half of those patients for cataract and glaucoma treatment, you can add $177,975 and $12,190, respectively.
The total revenue for these 1,500 patients is $933,685 (See Figure 2). And the dry eye portion of that figure only includes reimbursement of routine care, including tear osmolarity tests and a few plugs. Most dry eye treatments are paid out of pocket.
My tried and true tests and treatments
TearLab Osmolarity Test (TearLab): I tell patients that tear osmolarity testing measures the “saltiness” of their tears, as dry eye patients have salty tears. I recommend this testing first because it has an 87% predictive value for dry eye disease, whether the dry eye is evaporative or aqueous deficient.2 This is a far higher predictive value than any of the other traditional dry eye tests (Schirmer’s, etc.). I consider the test essential at every visit for every dry eye patient. And, it is reimbursable.
Oculus Keratograph 5M (Oculus), with its Placido disc corneal topographer, is a keratometer and multipurpose dry eye diagnostic unit. You can get detailed information on the tear film in several ways: meibography, automated tear film breakup time, redness scale, tear film lipid layer thickness, tear film viscosity measurement and tear meniscus height.
InflammaDry (Quidel) tests for the inflammatory marker MMP-9. All dry eye types have an inflammatory component, but this test helps physicians make treatment decisions. For instance, if the tear osmolarity is normal but the MMP-9 test is positive, the patient is likely dry eye-free but has another diagnosis that is causing the inflammation, such as allergic conjunctivitis.
LipiScan and LipiView (Johnson & Johnson Vision) provide high-definition meibography (both) and ocular surface interferometry (LipiView). Physicians can charge a $20 fee for LipiScan on the return dry eye exam if the patient receives treatment with LipiFlow (below) and bundle payment for additional scans with advanced level III evaluations. Currently, we perform LipiScan at no charge, as we await an official code for it; some practices code it as an external photo. We find the LipiScan is well worth it because of its motivational power: Patients will often opt to have an out-of-pocket treatment such as BlephEx or LipiFlow once they see their scans.
LipiFlow (Johnson & Johnson Vision) is a thermal pulsation treatment for meibomian gland dysfunction (MGD). If you see 100 patients per week and 50 have and about one in four of those, or about 13, have a LipiFlow treatment, each of the 13 could have three level-III follow-up exams (CPT code 99213, $75). In one month, the total for the exams and LipiScan is $980. Typical net profit is $640 for a bilateral LipiFlow procedure, or $8,320 for those 13 patients.
Prokera Slim (BioTissue) is an amniotic membrane corneal bandage used to treat inflammation and repair the corneal surface. Prokera reimbursement (available for severe dry eye only) is $1,453 (CPT code 65778). Let’s say you see 800 patients per month; one-third (about 266) have dry eye. About 5% to 15% of those whose disease will be severe enough to be Prokera Slim candidates, will use the 5%, or 13 patients per month figure. In my practice, the average cost is $729, for a profit of $724 per eye or $1,448 bilaterally. Prokera Slim is almost always inserted one eye at a time, as it somewhat blurs vision, and five days apart. If we multiply 13 patients per month by 12 months at $1,448 of revenue each, the total annual revenue from Prokera is $225,888.
BlephEx (Rysurg) removes scurf and debris from all four lids by means of a high-speed (2,500 rpm) rotating sponge soaked in professional eyelid cleanser. Patients have this blepharitis treatment an average of three times per year. In most practices, the net revenue is $170 per treatment.
eyeXpress (Holbar Medical) is a heated eye hydration system that softens the meibum for a more stable tear film. This therapy requires patients to have four treatments scheduled every 3 to 4 weeks. Charges for the initial four-treatment sessions range from $450 to $750, and follow-up treatments scheduled every 1 to 3 months are $25 to $75. Disposable sleeves for the system’s goggles cost $10 to $25. If, you charge $600 for four treatments (subtracting the cost of the four, $15 sleeves [$60]), you have a net profit of $540.
Swabstix and Oust Demodex Swabstix (OcuSoft) are sponges soaked in medical-grade cleansing solution that remove debris, scurf and Demodex from the eyelids and surrounding area. Swabstix enhances outcomes when used before a LipiFlow procedure but as a billable procedure, (usually $15 per treatment gross). Swabstix is billed by itself.
Medical-grade omega-3 supplements are re-esterified oils that support a healthy tear film. Several brands are available. If 15% of the 1,500 new dry eye patients (225 patients) buy these supplements at $100 per patient, the total revenue is $22,500.
You don’t need to use every test nor offer every treatment. While the total revenue for dry eye treatments is significant ($518,638, see Figure 3) a dry-eye clinic is profitable on a smaller scale as well. For practical, operational tips, visit a practice that is 50 to 75 miles away from you to observe its dry eye center without being a threat in that marketplace. Start with exams and a foundational test: tear osmolarity testing. Use punctal plugs because they work and are reimbursed. Add tests when you want more information. Research to find the treatments you think will be most effective for your patient population. This is a low-risk undertaking with great potential, so get started!
TESTS AND TREATMENTS
The range of point-of-care tests and treatments for dry eye disease has grown in recent years. Choose the options that work best for you clinically; perhaps the details about costs and revenues will aid in those decisions. OM
- Multi-Sponsor Surveys, Inc. The 2005 Gallup Study of Dry Eye Sufferers: Summary Volume. Princeton, NJ: 2005;1-160.
- Jacobi C, Jacobi A, Kruse FE, Cursiefen C. Tear film osmolarity measurements in dry eye disease using electrical impedance technology. Cornea. 2011;30:1289-1292.