By Jake Letourneau, OD
Nov. 27, 2019
As members of an ever-changing national healthcare community, optometrists are acutely aware of the need to look for new revenue streams. But which investments will pay off in a your individual practice? Most options can’t be applied universally since your unique setup, size, staff, demographics and clinical strengths weigh heavily on your decisions. Nonetheless, there are a few sound basics that every practitioner should consider.
Hop on the Sure Thing
In most primary care optometric settings, I am convinced that AMD is a great opportunity for growth. Clinical AMD is more prevalent than glaucoma and diabetic retinopathy combined—and by the year 2050, it is estimated to double.1, 2 With this in mind, take a look at your medical records. Do you have twice as many AMD patients? If not, do yourself and your patients a favor and take a closer look.
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You can be a great diagnostician, but making sense of small drusen is no easy task. A study published in JAMA Ophthalmology showed that both optometrists and ophthalmologists miss AMD about 25 percent of the time —even when doctors are aware that their findings will be double-checked by trained graders.3
Evaluate the Potential
Two amazing things will happen when you start uncovering AMD earlier. First, your patients will fare far better because they won’t be part of the unfortunate 78 percent of patients who are first diagnosed with AMD after having already suffered irreversible vision loss in one eye. 4,5
Second, you’ll be adding more medical services, which is sure to boost your bottom line since the demand for medical eyecare services is growing at a pace nearly three times the growth of comprehensive eye exams.6
More than 70 percent of the average optometrist’s income still comes from goods and services related to glasses and contact lenses, but when you look at the top 5 percent of optometrists, they receive at least 50 percent of their income from medical services.8 What is the medical versus goods and services breakdown in your practice? If it’s not where you want it to be, AMD is a great way to help build it.
Acquire the Right Tools
Adding medical services can sound daunting and time consuming, but it doesn’t have to be. On the contrary, with the right tools, it can simplify your routine while enabling you to provide better care. In AMD, dark adaptation testing with the AdaptDx can make all the difference. Impaired dark adaptation is a biomarker—not a risk factor—for AMD and it can be performed by a technician in just a few minutes.
Dark adaptation measures a patient’s Rod Intercept (RI) time. RI is the number of minutes it takes for the eye to adapt from bright light to darkness at a standard threshold stimulus level. The test delivers a simple output that requires no interpretation, providing clinicians a clear and objective measurement of retinal function, with 90 percent sensitivity and specificity.9
An RI time less than 6.5 minutes indicates normal dark adaptation consistent with healthy photoreceptor function. An RI time greater than 6.5 minutes indicates impaired dark adaptation, most often due to AMD in patients over age 50, unless there is a pre-existing hereditary retinal degeneration or significant vitamin A deficiency, which is rare in the United States.
Whenever you invest in new technology or aspire to build a specialty, it’s important to have a plan to optimize success. This will be different in every practice, but I’ve found that there are a few tips that would apply in most settings. First, figure out how you’re going to make sure that you utilize new equipment so that it’s a worthy investment. When we installed the AdaptDx in our practice, we decided that, initially, we would identify patients through our EHR. For any patient in the system who had AMD or drusen, we added 10 minutes to their next exam slot to test for impaired dark adaptation.
In addition to this customized strategy that we incorporated when we first rolled out the technology, most AdaptDx users routinely test all patients who report issues seeing or driving at night. Since night vision difficulty is the first symptom of AMD, all patients who have issues seeing or driving at night should be tested for dark adaptation impairment. Acquired night blindness (ICD-10 H53.62) is a billable reason for performing a dark adaptation test (CPT 92284). Simply add the following question to your intake form: “Have you experienced problems seeing or driving at night?”
Patients over 50 who are at high risk of developing AMD should also be tested on an annual basis, even if they do not experience night vision problems. Risk factors include age, family history, smoking, obesity and overall cardiovascular health (heart disease, high blood pressure or high cholesterol).
Finally, patients with diagnosed AMD should take the AdaptDx Extended Test every six months or more to monitor disease progression. There are several ICD-10 codes that can be used for an extended dark adaptation test.
Develop a Plan
Whether you aspire to grow into a large full-service AMD Center of Excellence or simply commit to saving sight in your existing patient base, I have found that it’s helpful to designate a point person for AMD services and check in with them regularly to discuss challenges and opportunities. Your AMD service director can help ensure that protocols are being followed and patients are receiving the best possible care. For example, the AMD coordinator will keep tabs on whether patients are completing risk profile questionnaires and whether they are being followed up with dark adaptation testing.
In our practice, we try to perform dark adaptation testing the same day as the comprehensive exam when the questionnaire or patient profile dictates the need. However, in many instances, we prefer to bring the patient back for a specialized visit. The important thing is that you make sure that the test is performed. If you encounter any staff resistance, consider innovative ways to turn the added work into a positive.
For example, in our practice, our staff felt they were already stretched too thin and couldn’t find time to perform added tests. So we assured them that if they hit a certain number of tests per month, we would hire an additional staff member to perform the majority of testing. Enthusiasm for AdaptDx quickly spiked and they hit the number in no time.
Begin to Build
Once you start detecting AMD sooner and managing it proactively, several new revenue streams present themselves, the most important of which is increased examination frequency. Certainly, patients who have documented AMD should not wait a full year for their next exam. Furthermore, these same patients will need additional billable tests including OCT and extended dark adaptation.
UV protection is also important for patients who have AMD, as are nutritional supplements. Whether you dispense these in your practice or provide a written recommendation to the patient, you are improving their chance of a healthy future while strengthening your own.
1. Kempen JH, O’Colmain BJ, Leske MC, Haffner SM, Klein R, Moss SE, Taylor HR, Hamman RF; Eye Diseases Prevalence Research Group. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol. 2004 Apr;122(4):552-63. PubMed PMID: 15078674.
3. Neely DC, Bray KJ, Huisingh CE, Clark ME, McGwin G, Owsley C. Prevalence of undiagnosed age-related macular degeneration in primary eye care. JAMA Ophthalmol. 2017;135(6):570-5.
4. Olsen TW, Feng X, Kasper TJ, Rath PP, Steuer ER. Fluorescein angiographic lesion type frequency in neovascular Age-Related macular degeneration. Ophthalmology. 2004;111(2):250-255. doi:10.1016/j.ophtha.2003.05.030.
5. Cervantes-Castañeda RA, Banin E, Hemo I, Shpigel M, Averbukh E, Chowers I. Lack of benefit of early awareness to age-related macular degeneration. Eye. 2007;22(6):777-781. doi:10.1038/sj.eye.6702691.
6. Jobson Optical Group. Defining the Future of Optometry. Presented at the American Optometric Association Optometry’s Meeting, June 23, 2018.
7. AOA Excel and Jobson Medical Information. The State of the Optometric Profession. 2013.
8. Management & Business Academy. Key Metrics: Assessing Optometric Practice Performance. 2015 Edition.
9. Jackson GR, Scott IU, Kim IK, et al. Diagnostic sensitivity and specificity of dark adaptometry for detection of age-related macular degeneration. Investigative Ophthalmology & Visual Science. 2014;55(3):1427-31.