By Steven Faith, OD
Feb. 24, 2016
Our aging population is bringing with it an increase in conditions like macular degeneration, glaucoma and diabetic retinopathy, all frequently leading to low vision (LV). This condition, which can impair a patient’s ability to live their life, is something optometrists are well suited to help with. Our practice has made low vision care one of our key professional services. It has become one of the ways our practice is growing.
LV patient-generated income still accounts for less than 5 percent of our total gross revenue. But it’s net income generation is on the upswing, with 3-4 patients per week. We are no longer the “Oh my gosh, another 20/100 AMD patient in my chair” office. We are now the “Another 20/100 AMD patient in my chair, let me tell you what we can do for you” office.
We are very comfortable sending our more challenging patients to the LV specialty clinics we have in Northern California for consults. But we have found it not as necessary as we did 10 to 15 years ago, due to the greater LV expertise and capability we have acquired.
The page on Dr. Faith’s practice web site devoted to low vision services. Dr. Faith recommends concentrating on low vision therapy, as the aging population makes these services a source of practice growth.
Market Low Vision Care
We are still in our infancy in promoting our LV services externally. Until this year it has generally been via internal marketing channels: online e-mail newsletters, family and patient referrals, web site traffic, and direct consults from MDs, both in the ophthalmic and general practice arenas.
Gauge ROI of Seeing LV Patients
Here are the practical factors and economics of LV patients in our office. Let’s take the new LV patient with AMD, who was sent to us by a retinal specialist. We have LV coordinators who review the consult information from the retinal specialist with the doctor in our office to discuss an appropriate appointment schedule, and whether we can even see the patient.
Before seeing the patient we might need to coordinate the consultation through their PCP for in-network or out-of-network HMO coverage. If they do not get approval, we let the patient know of the out-of-pocket costs for the evaluation. The initial evaluation is $250.
We generally receive a 99204 reimbursement from the insurer for the initial evaluation, and usually two 99213 follow-up visits for subsequent care. The insurer generally does not pay for LV devices or aids.
We schedule LV evaluations on a Tuesday or Thursday afternoon on the LV coordinator’s schedule and parallel on the doctor’s schedule. Our EHR LV schedule looks very similar to the schedule for a return visual fields or OCT with a clinical technician performing the test.
There is a parallel follow-up on the doctor’s schedule after the testing is complete. By the time the patient is seen in our office, the LV Coordinator has talked with the patient, or family, or both, and discussed the case with the doctor and the technicians in our office who conduct testing.
The average time that the patient is in the office for the first LV evaluation is roughly an hour. While the LV coordinator is working with the patient, the doctor is seeing other patients on their regular clinic schedule. The doctor will spend 20-30 minutes with the patient after the coordinator completes their time with the patient.
If vision aids are prescribed, the LV coordinator will order the aids and follow through to delivery like they would for any other product sold in our office. The dispensing will again be on the LV Coordinator’s schedule with a parallel appointment on the doctor’s schedule and the doctor having the final discussion. Most of the magnifiers we prescribe have a patient cost between $50 to $200 per device.
The typical revenue for the average initial evaluation and typical devices we prescribe is roughly $600 with a COGs and overhead cost of approximately $250 for a net income of $350. In California, where we have more insurance coverage types than protected animal species, insurance coverage always seems to cloud the net income waters. Fortunately, we treat most of our LV patients privately.
If they insist on using whatever insurance or supplemental coverage they have, we utilize Compliance Specialists, Inc, (CSEye) to work out the coverage and billing issues for us. We also use CSEye for all third-party insurance billings not related to the patient’s LV evaluation.
For those LV patients younger than Medicare age, many of our patients in California have vision plans that have a LV supplemental coverage with prior authorization. VSP Signature plans are the most common for us in California with a fair coverage for the patient and nice reimbursement for the doctor. Most Signature plans we see in California have a LV supplemental coverage reimbursement of $250 for initial and subsequent visits. The patient is then allowed up to $1,000 of coverage for LV devices for a two-year period with the patient required to pay a 20 percent co-pay of the device costs.
Develop a Reputation as LV Specialty Office
The LV patient has become an integral and increasing portion of our practice, from both a clinical and economic perspective. None of our doctors are LV residency trained, none of us dedicate 100 percent of our practice to seeing LV patients, nor do we have anymore LV knowledge than any of our optometric colleagues. We have simply developed a reputation as being the LV specialty office in our area by both patients and other professionals.
Prepare Support Staff for LV Patients
Think of your staff being you in optometry school and you are the attending LV specialist doctor coordinating what you did as an intern with the patient.
The training of the staff is easier than you think. We have found that LV visual aid vendors, such as Eschenbach and Optelec, will train your staff and help guide you in the proper tools and techniques you will employ. We have also done many in-house training sessions led by the doctors in our office, so we could provide staff with more specific information about what our office expects and needs in an LV evaluation.
Recognize Most Common LV Patient Profiles
As in most of your practices, a majority of our LV patients have macular degeneration as their primary etiology. Diabetic patients are next in frequency with the bulk of the remainder having everything from congenital retinal disease to co-morbidities of other systemic conditions (stroke, brain surgery, TBI, etc.). The predominance of our LV patients have 20/60 to 20/100 BCVA. Less common are the 20/200 to 20/400 patient.
Optelec magnifiers and a TV telescope that Dr. Faith sells in his practice to aid low vision patients. Offering these products right in the office provides a one-stop-shopping experience for patients.
Sell LV Aids In Office
In the last few years, we have added a comprehensive LV trial kit to our clinic inventory, which has made a big difference in the care we offer LV patients. We have a blend of Eschenbach and Optelec professional trial kits we have added. A simple, yet effective, trial LV kit is easily available and quite affordable to the average primary care optometric office. You can get a nice trial kit from $400 up to $1,000 depending on your needs and patient base.
Most of the LV patients we see opt to purchase an illuminated stand magnifier, illuminated hand magnifier, along with a combination of non-illuminated magnifiers for specific near purposes.
Since a majority of our patients end up with some form of magnifier, we have even put a catalog of the most common Optelec devices and aids we prescribe in our online store on our web site. If the patient, or family, needs an extra device, or replacement aid, they can just order it online through us.
Consider Offering Bioptic Eyewear
Both Eschenbach and Optelec have nice generic standard design telescopes that work well for most tasks our patients require for distance viewing. Don’t worry about virtual or real images. Although entrance and exit pupils have relevance in many telescope aids we prescribe, none of our doctors are too concerned about these characteristic variables on a daily basis.
For those patients who require it, and since we have a complete edging and finishing lab in our office, we have the ability to make spectacle mounted bioptics with our Santinelli edger through the use of a specially designed Eschenbach system. Whenever we choose, we now have complete in-house control over the order and manufacture of bioptic spectacles.
However, we rarely use such a convenience, so this is not something the average office needs to pursue. Even though we have more control over the process, the typical spectacle mounted bioptic telescope system can be expensive and cost prohibitive for many patients ($600 – $1,500). Totally unnecessary for the average optometric office. But it is there if you want it, and if you have a skilled optician on staff.
Sell LV Sporting Goods
To help with the cost of many LV designed telescopic systems, we have a selection of standard small-size Bushnell binoculars in office to provide a less costly method of helping the distance viewing tasks of many patients. These have been useful in helping grandma have something in her purse to use at the soccer game, or to see the channel number on cable box.
And at a low-end price point of $50 and up, if the task warrants its use, it is a nice affordable option with many of our patients. A side benefit for us has been that our “normal sighted” patients have even purchased their own binoculars through us rather than their favorite sporting goods retailer.
Offer the LV “Click-Kit”
An easy addition to any optometric office for many low to moderate LV patients (20/60 to 20/100) is what we call the Low Vision Click Kit. Many years ago we started working with a company called Eyenavision that produces Chemistrie lenses. The original design was for magnetic-mounted sunglasses over a clear prescription Rx.
If the situation is correct for it, and the patient’s Rx needs satisfy it, we can develop a magnetic lens clip that “clicks” over the front of the LV patient’s Rx lens. We can use SVL with powers up to +3.50. We can even use a FT bifocal design if the situation calls for it.
The nice thing about this system is you can develop a standard general purpose prescription, like we do with every patient, and then add a reading prescription with a low-to-moderate add that they simply “click” onto their regular glasses. At a cost of $150, this is a reasonable value option for many patients. And it is simple to have multiple clips in multiple locations if needed. And we can incorporate absorptive lenses, too.
Offer Absorptive Lens Filters
By far the easiest addition to our office was the addition of an Absorptive Lens Filter trial set. We have not found a single LV patient who has not benefited from the proper lens filter system to use in various lighting environments.
With the proper presentation and discussion, most patients can see a real benefit to these simple devices. In our office we utilize the Cocoon family of products with the “Side Kick” being the most widely accepted for comfort and cost ($30-$40).
Take Sale of LV Products to Next Level with Electronic LV Devices
We have found a local Verizon Wireless retailer that has taken an interest in helping some of our LV patients with the use of smartphone technology as a portable electronic magnification device. An entry-level large-size smartphone (Samsung or HTC devices have worked well) with all the unessential apps removed and the phone pad and camera as the only desktop icons has helped many of our LV patients as a relatively low cost electronic magnification device.
Although not a traditional LV device, we have found that it really helps to incorporate the family into the care and treatment of the aging LV patient. The grandson can help grandpa with his new electronic magnifier he uses at the store or to read his letters or cards in the mail. Yes, LV patients still get traditional mail.
Address Patients’ Emotional Needs & Expectations
A challenging, and sometimes time consuming, aspect of working with LV patients is the psychological counseling that accompanies these patients. They are either not sure of their diagnosis, realize or don’t realize they can’t drive anymore, fear they will go blind, afraid that they will not be able to read their Bible or newspaper, or worse, become a burden to their families and be isolated due to their visual impairment. They “know” that if they just had stronger glasses they would be OK.
As we tell all of our LV patients: “We can help you see anything you need to see; we just won’t be able to make you see everything you want to see.” And depending on the personality of the patient, and dynamics of the family, the discussion typically goes from there.
We have a few occupational therapists in our area who can assist the LV patient with their home life, but sometimes there are insurance restrictions on who and how they can see patients. And it is difficult to find occupational therapists who can do it privately. Most in our area are under contract with regional groups or networks. We are considering training our LV coordinators to assist our patients in their home environment, but haven’t gotten that far in their training–yet.