By Daniel Epshtein, OD FAAO
Sept. 19, 2018
Diabetes is a significant health-care challenge. According to the Centers for Disease Control, 30.4 million Americans have diabetes, and one-in-four of them don’t know they have it. What is your practice doing to serve these people? Not only is taking care of these patients by addressing their diabetes the right thing to do; it’s a great practice-builder.
In my New York City-based private practice, about 20 percent of my patients are diabetic, and this number has been steadily growing. This number seems to be growing more rapidly in the past few years, likely due in part to stricter adherence to HEDIS measures by PCPs, increased patient knowledge on the need for diabetic eyecare and increased diabetes prevalence rates.
Get Equipped to Serve Diabetic Patients
The essential instrumentation to providing basic eyecare to diabetic patients is a slit lamp and indirect ophthalmoscope. A comprehensive exam with dilated fundus examination will reveal the presence of diabetic retinopathy, at which point a referral can be made if further treatment is necessary or if the clinical findings are equivocal. But to provide truly high-quality care, retain patients and create an additional revenue source, equipment such as fundus photography and an OCT is essential. These diagnostic instruments can elevate the care you provide and ensure that you practice at the highest level of optometry.
I get a fundus photo and macular OCT on all patients with diabetic retinopathy. Though this goes beyond the care of preferred practice guidelines, I like to have a baseline fundus photo and macular OCT to compare to any subsequent changes. I like to get an OCT on these patients because sometimes you can pick up small pockets of macular edema that are not appreciated with funduscopy. I will often monitor asymptomatic patients with mild non-foveal macular edema and good visual acuity because I know the retinal specialist is unlikely to offer treatment. I stress adherence to medications and strict control of blood pressure and blood glucose to the patient, and follow-up within 6-10 weeks.
Patients with a significant increase in macular edema, poorer glucose control, or vision reduction, then will be co-managed with a retinal specialist to consider treatment. Because I always include a review of images with patients during the exam, my diabetic patients have started treating fundus photos and OCT images the same way that my glaucoma patients treat IOP; it’s usually one of the first things they ask about when I enter the room.
The cost of a fundus photos and OCT ranges from $25,000 to $75,000 and $40,000 to $60,000, respectively. Combination photo and OCT models are often cheaper than the combined cost of each unit individually and help save on space. Based on Medicare national averages, fundus photography reimburses $58 and OCT reimburses $38. The cost of these diagnostic instruments may seem staggering, but these devices allow one to practice medical optometry.
The medical model of optometry can be a separate source of income for refractive-only practices and a very professionally fulfilling part of one’s career. These devices can also be used for other purposes such as glaucoma care, monitoring of choroidal nevi, central serous chorioretinopathy and chorioretinal scars. These other uses for the instrument, and the potential new patients that come with it, must be considered when calculating return on investment.
There are many ways to acquire these instruments including outright purchase, financing and leasing. Because I practice a significant amount of medical optometry, it made more sense for my office to buy the machines outright. Depending on your practice, the other options might seem more favorable.
My support staff had to add two steps to their work flow to ensure that we properly take care of diabetic patients. The first was requesting the patient’s PCP address, phone number and fax number for all diabetic patients, and the second was to ask a short diabetic history: how long have you been diabetic, are you type 1 or type 2 diabetic, what was your last blood glucose reading and last hemoglobin A1C? It takes an extra minute to complete all this once technicians become familiar with the questions.
Generate Referrals: Make the Call
I currently practice at a large hospital and at a private practice in New York City. I previously worked at a high-volume, multi-specialty practice where I provided refractive, medical and perioperative care.
My current practice is well-established, meaning decades-old, and many of my diabetic patients come with a generic note from their PCP for a diabetic exam from an eye doctor of their choosing. Due in part to my office’s promptness in scheduling an appointment and sending reports to the PCP, several primary medical doctors have begun sending me patients for diabetic exams. Many of my diabetic patients have referred their friends with diabetes for exams as well. With these word-of-mouth referrals, I also tend to get other family members who come in for refractive needs or wellness exams.
About a year ago, I called several PCPs in the area, and asked to make appointments to discuss the services I provide and the possibility of establishing a referring relationship. A few times the PCP would give me a few minutes of their time, but more often I spoke to the office manager. I explained that I provide full-scope primary eyecare and that I can treat and manage most diseases that do not require surgical care.
I made sure to mention that I have many patients who have not had a medical exam in a year, and that I need a doctor to refer them to. I also asked if they would be willing to complete uveitis/inflammatory blood work evaluations on the patients I refer. I also let them know that I am available for phone consultation or to see an emergency patient when I am in the office.
The PCPs seemed to appreciate that I would fit in their patients in a timely manner, especially for emergencies, and admitted that some of their patients complain about long wait times for the next available eye appointment. Not all of these meetings went great. I sometimes felt like a salesman peddling my services, but I always tried to present myself as a doctor offering medical eyecare and that I just wanted them to be aware that I am in the area.
Always Report Back to PCP
It is important to always send a report back to the PCP with pertinent information. For diabetic ocular wellness exams, I also make sure to include vision, anterior segment findings, posterior segment findings (most importantly the presence and grade of diabetic retinopathy), any secondary findings and my management plan.
My EHR generates a report using my slit lamp findings, fundus findings and my impression and plan, so this part is easy for me. The report is then faxed directly to the PCP. The whole process takes me maybe 30 seconds. For patients referred for specific acute issues such as eye pain, eye redness, or vision loss, I make sure to be a little more detailed in my impression and plan so that the PCP understands my findings and treatment plan. I make sure not to use any abbreviations and to send an update to the PCP at each follow-up visit.
Market Your Services
Quarterly we post a reminder on our practice Facebook page: “Don’t forget to get your yearly diabetic eye exam.” We also have a TV in our waiting room that plays informational segments, one of which is about the importance of diabetic eyecare.
Diabetes is affecting an overwhelming amount of people in the U.S., many of whom are already your patients. With a few tweaks to your office, you can seamlessly provide the proper care to these patients while building your practice and increasing revenue.
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Daniel Epshtein, OD FAAO, currently practices at Mount Sinai St. Luke’s and a private practice in NY. Previously he worked at a high volume multi-specialty practice where he provided refractive,medical, and perioperative care. He combines his research experience with the latest clinical practices to detect sight threatening disorders early and provide the best treatment options available for his patients. To contact him: firstname.lastname@example.org