By Suzanne LaKamp, OD, FAAO
April 12, 2017
Dry eye is more prevalent with our aging population and ever-heavier use of digital devices. A year ago, my shared OD-MD practice launched a dry eye center, our Advanced Tear Analysis (ATA) Clinic. Creating a dry eye specialty, with a set office protocol, allows us to more easily diagnose and treat this condition.
A year later, our ATA clinic is on target to become profitable in the next quarter. We currently see about five patients per week in the ATA clinic, up from about three patients per week a year ago.
With more experience, after a year, at managing different presentations of dry eye, the demographic in our dry eye clinic has broadened. While dry eye typically worsens with age, younger patients are not immune. In years past, I would treat dryness more aggressively in only my older patients, thinking they suffered more. However, that is not, and should not, be the case. Patients across the country start to experience dry eye at younger ages than previous generations. It is likely that an increasing number of younger patients will seek dry eye services. Our clinic is getting better at treating these younger patients, and we continue to see a growing number of them in the ATA clinic.
Create a Dry Eye Specialty Center
We created the ATA Clinic to better serve our patients who struggle with dry eye. The ATA examination was created for patients who do not improve with first-line treatments, such as with artificial tears alone.
The testing for the ATA clinic requires more chair time than the annual eye examination can provide. We perform extra imaging and testing at these ATA visits. More chair time also allows for in-depth patient education and customized treatment plans.
How Much Chair Time & How Much in Revenues?
The ATA examinations are scheduled on two half-days a week. We typically allow for 45 minutes. Follow-up appointments, which are much shorter, can be scheduled at anytime. We schedule about 4-5 full ATA exams a week. The LipiFlow treatments are scheduled during the 45-minute slots. One ATA exam with LipiFlow treatment can bring in more than $1,000.
The first visit to the dry eye clinic takes at least 45 minutes. This visit includes pre-testing, imaging, refraction, the SPEED questionnaire and examination by the OD. All of the doctors in the practice manage dry eye patients, but the current model has the ODs manage the more refractory cases of dry eye. The MD will write a prescription for Restasis refills, for instance, if the patient is stable. If the patient has worsening symptoms, or signs of dryness, the MD will refer the patient back to the OD. More significant dry eye requires more chair time, which is better suited for OD appointment slots.
Add Needed Instrumentation
Last year we added the LipiView II and LipiFlow to our practice. We use LipiView on all of our patients. There is no additional charge for this service, since we built it into our fee for the examination.
The combined price is typically around $60,000 for LipiView/LipiFlow. When we first started the dry eye clinic, our monthly goal was two LipiFlow treatments a month to break even according to how we budgeted for the month. We now aim to perform at least that many each week. There are also service agreement fees, which can run about $3,000, and then the activators are an additional price for an average of $175 a pair (bilateral treatment). Performing even a few treatments a week can make your investment in the LipiView/Lipiflow systems profitable.
The LipiFlow treatments are scheduled during the 45-minute slots. One ATA exam with LipiFlow treatment can bring in more than $1,000. We have thousands of patients, and less than 1 percent have had LipiFlow treatment. There is great opportunity to perform more LipiFlow treatment within our current patient base, and we are working to increase this. Patients who return for annual eye health examinations are now being referred back to the dry eye clinic for LipiFlow treatments if they are candidates.
The practice technicians perform LipiView imaging. The ODs perform LipiFlow treatments. After installing the LipiView and LipiFlow instrumentation, TearScience provides the hands-on training.
Educate Patient about Benefits & Cost
LipiView bilateral treatments in the Kansas City area, where my practice is based, currently range from $950-$1,800, and our fees fall within that range. After LipiView is recommended by the doctor during patient education, cost is then discussed with a scribe or technician. While the majority of our revenue consists of refractive surgery, it is still important to make the dry eye center profitable. Our goal with the implementation of LipiView was to enhance patient education during the eye examination. With LipiFlow, we wanted to take even better care of our patients who suffer from meibomian gland dysfunction. We could charge more than our current prices, since our competition are as much as 50 percent higher. However, we decided to keep our prices in a range that was accessible for most patients, and increase the volume of treatments.
In discussing pricing of the LipiFlow treatment, I discuss the health benefits first. I also explain that the technology itself is expensive, and not currently covered by insurance. I also inform the patient that the activators are single-use, which while more costly, are safer for the patient. There is research to show benefit from treatment to last a year, but some patients may have benefit for slightly longer. More advanced cases of meibomian glass dysfunction may require treatment more frequently, such as every six months.
We do not currently offer financing for LipiFlow treatments. Fortunately, we do not get much push-back on cost. For other practices, offering CareCredit is an easy way to make the treatment more affordable for patients.
Track Growth of Specialized Dry Eye Care
Our doctors now refer even more people to the dry eye clinic than they did six months ago. Patients who get their annual eye health examination, and continue to have difficulty with dry eye, are prime referrals to the ATA clinic. We also see more patients in the dry eye clinic pre-surgery. It is important to improve any ocular surface disease prior to refractive surgery. More people are getting the specialized care that they need, especially since we are more proactive about treatment.
Make Needed Improvements & Additions to Dry Eye Center
The most important adjustment to the dry eye clinic over the last year has been the division of testing over multiple appointments. All of the imaging, questionnaires and testing takes a lot of time, and patients were spending too long in the office. Forty-five minute appointments turned into an hour, or longer. While doctors want every single test and result available to them, it often comes at the expense of patient time. Patients are better served when the testing is streamlined. For instance, I do not feel the need to get a Schirmer’s at all patient visits. I will use a Schirmer’s test only if I feel it will yield valuable information about the particular patient. It is not something to be repeated often.
I have written for lab orders and scripts to have patients get plasma tears, or autologous serum made, which is a more advanced treatment than we previously offered. There are also times when I work with a local pharmacy to get custom compounded Cyclosporine eye drops. While not yet available, I look forward to experience with the Allergan intranasal tear neurostimulator for dry eye. The multi-dose Restasis will also be a improvement for patients who do not like the hassle of vials.