By Suzanne LaKamp, OD, FAAO
April 18, 2018
In most practices, there are many patients who are at high risk for developing a sight-threatening condition. With the right patient education, technology, and care, you can turn this portion of your practice into a source of growth and profitability.
About 10 percent of the patients in my shared OD-MD practice, which specializes in refractive surgery, are high-risk, meaning at risk for losing sight from a disease, or at high-risk for a bad outcome from surgery. For a refractive surgery practice, in particular, many patients have high-refractive error, among other conditions. Patient eye findings, in addition to family history, contribute to a high-risk status.
In addition to refractive surgery, we work with patients, who have long-term medical eyecare conditions, and find that diagnosing those who are at high-risk of losing sight, and managing their care, engenders loyal patients, who refer others. It also allows us to better identify the best candidates for surgery.
High-risk patients require more visits to our practice, and an introduction to co-managing doctors, which keeps our exam chair full. As a mostly cash-pay practice, patients pay for comprehensive exams, refractive consults, dry-eye exams, or for office visits for acute conditions, such as a red eye, PVD and other medical conditions. The exam fees are all structured to be inclusive, so any imaging or testing in our office is covered, rather than billed as a separate fee. An exam can range anywhere from $100 to over $300 depending on exam type.
What Do I Say to a High-Risk Patient?
I have patient pre-testing, retinal imaging and anterior segment photos already loaded into the exam room computer by the time the patient enters the exam room. The imaging is helpful for discussions about glaucoma suspicion, or problems with the macula.
After a comprehensive eye examination, I then discuss all findings with the patient, present options if they are candidates for refractive surgery, and may get referrals to outside specialists if there is a high-risk condition identified needing additional evaluation.
For example, a patient who has had previous IOL surgery, and has visually significant posterior capsular haze formation, will need a YAG procedure to clear the opacity. If the patient has a significant epiretinal membrane, I might tell the patient: “Mr. Jones, you have some haze forming behind your lens, which is interfering with your vision. We can do a YAG procedure, which will clear this haze, but you have an epiretinal membrane, or extra tissue, in the back of the eye. The YAG can cause complications with the membrane and your vision, so we would like to refer you to a retina specialty practice to get prior clearance.”
For a patient with large C/D ratios, and a suspicious optic nerve appearance, I would tell the patient I recommend additional testing in office, or a referral to a glaucoma specialist for testing prior to any refractive surgery. These patients should be educated that glaucoma needs to be ruled out, and if diagnosed, controlled prior to any future eye surgery. Glaucoma may be a scary diagnosis, but if handled appropriately, patients can handle the news well, such as by emphasizing that it is rare for patients with glaucoma to lose total vision. If explained that it is typically slowly progressive, as with the primary open-angle types, the diagnosis is not as shocking to the patient.
Make It More Likely Patient Will Comply With Treatment Plan
A patient whose doctor spends time in the exam room educating the patient, and making the patient feel cared for, will help that patient understand and comply with recommendations. This includes further testing and follow-up visits. Welcoming patient questions also makes the patient feel more comfortable.
Patients appreciate and often expect discussion on any photographs or imaging of their eyes. For more detailed explanations of anatomy or disease course, Rendia animations are also available on the computers in all our exam rooms.
Patients with high myopia are educated that they are at higher risk than average for developing myopic degeneration, glaucoma and retinal detachments. We may even refer patients with severe myopia to a retinal specialist to get clearance prior to lens surgery, whether phakic IOL, refractive lens lens exchange or refractive cataract.
Manage Patient Anxiety
No one wants to hear bad news, especially about vision-threatening conditions. The style of delivery and tone of voice–patient and in a normal speaking tone– can have a big impact on how the patient receives any poor news. Patients also feel better when there is a plan presented on how to move forward. Educating the patient, and having a plan, empowers them in an otherwise stressful scenario.
For example, advancing keratoconus, a sight-threatening condition, can now be halted. In relaying the news of a worsening diagnosis, patients may be fearful of losing sight or needing a corneal transplant. After reviewing testing with the patient, I may include dialogue such as: “procedures like cross-linking have long-term historical success for advancing keratoconus, and can save your eyes from further change and worsening.”
Be Transparent About Out-of-Pocket Costs
Patients who require extra testing and visits to specialists may have higher out-of-pocket costs. It is important to communicate the reason for tests, and the importance to the patient’s eye health and vision. If a patient needs further testing, they will rarely decline as long as everything is well explained, with photos used to illustrate, if possible.
Invest in Needed Instrumentation
Practices that wish to manage high-risk patients should invest in the appropriate technology, depending on practice modality and patient population. Some of the more common instrumentation includes the following:
Fundus cameras are used to take photos of the posterior pole of the eyes, which help documentation and monitor disease progression. An Optos can be leased for around $2,300 a month.
OCT imaging can guide treatment for glaucoma or macular degeneration. The Optovue iScan can be purchased for $44,000. Costs to break even takes years in most practices.
Pentacams are valuable for imaging the anterior segment of the eye, and help with keratoconus diagnosis. Pentacams can cost $25,000-$50,000, and also can take years to break even.
Visual field testing such as Humphrey HFA II-I cost around $17,000. Break-even points on the visual field may take years, but yields invaluable information about a patient’s eyes.
Build Relationships with Specialists
As a predominantly refractive surgery practice, our goal is to ensure that a patient’s ocular health is stable, and OK to undergo surgery. For certain high-risk patients, this may include referrals to specialists for some, and clearance prior to surgery. We often work with a local retina specialist group, and also refer our patients who need treatment for various conditions. We do not treat retinal tears or other disorders, so it is important that we work with retinal specialists who provide this service.
Protect the Practice from Lawsuits
There are important measures a practice can implement to monitor all patients, especially high-risk cases that need to be followed closely. Scheduling the next appointment in-house, or with a referral center, helps to reduce no-shows, and reinforces to the patient that care has not ended. Scheduling systems can flag missed or cancelled appointments, and a practice can reach out to the patient to reschedule.