Article

THE 1-2-3S OF BUILDING A DRY EYE CENTER OF EXCELLENCE

Once you are sure that you want to create a specialized dry eye center, these tips will get you on your way.

It’s 2018. Nearly everyone is posting, tweeting, and pinning. Large numbers of consumers have abandoned brick-and-mortar shopping establishments in favor of online marketplaces. Many have opted for the convenience of delivered groceries and meal kits and turned the local grocery store into a ghost town. And, it seems that everyone, including your next-door neighbor, is opening a specialty dry eye clinic. If you are like me, you may have wondered what the impetus behind this transition is and whether there is still time—and opportunity—for you to follow suit.

AN EVOLVING DRY EYE LANDSCAPE

Beginning in the mid 1980s, dry eye research became more prevalent. By the early 2000s, there was a clear exponential increase in the number of dry eye-related research articles published each year, reaching 662 peer-reviewed articles in 2017 (Figure 1). From this upsurge in research findings, new diagnostic devices and new therapeutics have stormed the market. Industry is more vested now than ever in dry eye disease, but from industry’s perspective, there is a critical middleperson that mediates the use of these newly developed products. That middleperson? Each of us. As eyecare providers, we hold great power in our opinions, clinical protocols, and prescribing patterns. Although the concept of a Dry Eye Center of Excellence may have spawned from industry, the immense success of the early adopters has resulted in a physician-led propagation of this trend.

Figure 1. The number of peer-reviewed dry eye publications has exponentially increased since 1980, a trend that has given rise to the flood of new diagnostic and therapeutic devices for the assessment and management of dry eye in recent years.

With the uptick in new dry eye clinics, you may be curious as to whether there is still a demand for more specialized dry eye care where you live. Based on odds alone, you already have a self-sustaining dry eye population in your practice. You just need to tap this existing resource. More importantly, dry eye patients talk. I sometimes wonder whether there are underground dry eye clubs. Nearly all dry eye patients, at some point in their examinations, will refer to one, if not two or three, friends who have dry eye and swear by treatment X. I almost never hear this from my glaucoma patients. The good news? Happy dry eye patients become your best referral source. In my experience, competition among dry eye clinics is nearly non-existent; there are too many dry eye patients and too few specialty practices.

A better determinant of whether you should develop a dry eye clinic resides within yourself. Do you like dry eye? Does the disease interest you? Do you enjoy managing it? If your answer to any of these questions is anything other than an immediate yes, then you may want to reconsider before investing your time, effort, and resources into developing the clinic.

In late 2014 to early 2015, we at the University of Alabama at Birmingham (UAB) decided that we wanted to join the ranks of other academic centers featuring a specialty dry eye clinic. We spent much of the first year planning, developing protocols, consulting with other practices that shared our organizational structure (mostly optometry schools), and meeting with business advisors. In early 2016, we opened the Dry Eye Relief Clinic of UAB Eye Care with a “soft launch,” meaning that we began accepting patients through internal referrals only without doing any marketing. This strategy allowed us to refine our protocols and optimize our efficiency prior to opening our clinic to the dry eye public. Now, in 2018, we have a fully operational dry eye specialty clinic with dedicated staff members and regular referral sources. Developed from these experiences, I share with you the following six tips for opening your own dry eye specialty clinic.

TIP #1: CRUNCH THE NUMBERS

You business-savvy practitioners are likely already doing this. The rest of you not-so-business-minded folks (like myself) will have to fight your way through. Let’s walk through this together.

Assessment First, let’s make some assumptions. Because you will be recruiting, at least initially, from your existing patient population, let’s assume that each patient is established and already seeing you for their comprehensive examinations. Our calculations below will then indicate how much more per year you could be making on each established patient who has dry eye disease.

For moderate-to-severe patients who respond well to your treatment regimen, you can expect to see them for baseline dry eye workups and for follow-up visits to occur at one month, four months, and 10 to 12 months. These examinations are likely to fall within the range of Current Procedural Terminology (CPT) 99213. Let’s also assume that you perform osmolarity testing (CPT 83861, both eyes), matrix metallo­proteinase-9 (MMP-9) tear testing (CPT 83516, both eyes), and meibography imaging (CPT 92285) at your baseline evaluation, at minimum. Use your own practice’s values in Table 1 to determine the additional gross income that you could be making annually on each dry eye patient. You should land somewhere in the range of $450. After deducting the cost of your supplies, the net value per year would be approximately $405 per patient. This is a modest estimate. New patients, more severe patients, or those who respond poorly to your treatment regimen may require more frequent follow-up visits and/or more frequent specialty testing.

Table 1. Insert your unit amounts for each CPT code in the table and perform the calculations to determine your annual gross income per dry eye patient. Note that the CPT 92285 may not be reimbursable by insurance providers for this indication and may be an out-of-pocket expense for your patients.

Let’s take this a step farther. Let’s assume that you see approximately 4,000 patients per year, and you identify 5% of them as dry eye patients—another very modest estimate. From these 200 patients that you already have in your practice, you can now net about an additional $81,000 per year. Say that you identify 15% as dry eye patients; that value changes to $243,000. And, if you have two partners who do the same thing, you are now looking at up to $729,000 more per year. Interested yet?

Treatment The assessment of dry eye, though, is only part of the income source. Many dry eye treatments are performed in-office. Punctal plugs, lid margin debridement, manual gland expression, automated gland expression by thermal pulsation, amniotic membrane placement, and others are all additional sources of income that can vary widely among practitioners but contribute greatly to the financial success of your dry eye specialty clinic. You may also choose to sell products, such as microwaveable masks or eyelid cleansers, that can further boost your earnings.

In summary, there is a clear financial incentive to start your own specialty dry eye clinic, and the best part is that you can do so without much overhead.

TIP #2: UPGRADE YOUR TECHNOLOGY

What was that about overhead? In an ideal world, you could start the clinic with low risk and high gain. In a more realistic world, high gain typically follows a sizeable investment. I will spare you another lesson in arithmetic, but there are a few important lessons worth sharing.

First, you get to choose your investments. Determine what tests are most meaningful to you and your practice. MMP-9 testing is an easy addition because there is no capital expense, only the cost of the single-use tests themselves. Osmolarity testing also deserves some serious consideration. Personally, I would not want to diagnose and manage dry eye and meibomian gland dysfunction (MGD) without meibography (Figure 2). Understanding the structure of the glands guides my patient education, informs my treatment plan, and allows me to set reasonable expectations for my patients. Several well-known meibographers are available, each with its own array of additional functions, and several new ones are available including one that can be attached to many mainstream slit lamp models. At a minimum, take a look at what these devices can add to your ocular surface evaluations.

Figure 2. These are example meibography images, each taken with a different commercially available meibographer. The top and middle images show severe meibomian gland atrophy of both eyelids. The bottom image, taken with a newer meibographer, shows normal meibomian gland morphology of the upper eyelid.
Bottom image courtesy of Box Medical Solutions

The second lesson is to understand the value that these specialty diagnostic devices can add to your practice. You may be tempted to lean heavily toward reducing your expenses in the early stages of clinic development and forego any big-ticket purchases. You may also be tempted to lean heavily toward the financial calculations covered in Tip #1 and focus only on what devices are likely to yield a monetary advantage. However, there is an additional, non-quantifiable value that these devices provide: they have a huge impact on patient perception and patient experience. These two factors drive patients’ decisions to return and drive their word-of-mouth referrals. Remember that underground dry eye club that I mentioned earlier? Technology, when used correctly and prudently, brings patients to your practice.

TIP #3: TRAIN YOUR STAFF

This new technology will definitely generate the need for more skills-based training for your staff. Don’t stop there, though. Make sure that your technicians are fully fluent in the language of dry eye. Throughout the examination, your technicians should be priming your patients for the education that you will ultimately provide at the end of the exam. They provide the foundation on general dry eye disease. You provide the specific interpretation of all testing and recommend a treatment plan. This model serves to engage patients throughout the entire examination, helping to develop a positive patient experience.

To accomplish this, consider holding weekly educational seminars for your staff for three to four consecutive weeks. Your staff will also likely appreciate your efforts to further develop their skills and knowledge. Many staff members feel honored to play a personal role in providing meaningful care to patients (Figure 3).

Figure 3. Highly trained technicians are a critical component of a specialty dry eye clinic. Technicians should be able to perform all diagnostic testing and describe how the tests relate to dry eye disease.
Courtesy of the University of Alabama at Birmingham.

All staff, including receptionists, technicians, and opticians, should be trained on how to deliver a few dry eye catch phrases to promote the clinic. Sometimes patients are more forthcoming to staff members, so engage your staff in several role-play scenarios to ensure that they know how to communicate about dry eye and how to generate excitement about the specialty care that you can provide. You shouldn’t be the only one with an elevator pitch—your staff should know it and be able to deliver it flawlessly as well.

TOPICAL AREAS FOR STAFF TRAINING:

→ Skills-based training

→ Educational training

→ Promotional training

→ Administrative training

Caution: downer alert. As exciting as a specialty dry eye clinic can be, you should be prepared for this realistic and frustrating component: the medical management of dry eye creates a ton of administrative work to seek prior authorizations (PA), to file appeals for declined medications, and to request tier exceptions, when applicable. As you increase the amount of specialty dry eye care that you provide, you will likely start prescribing more dry eye medications. Your staff will bear the resulting administrative burden.

There are a few tips to improve efficiency, however. First, train your staff to use an electronic service to transmit PAs. One example is covermymeds.com, but you should research similar services that cover the major third-party payers and pharmacies in your area. Secondly, write a template for your staff members to use for each PA. A commentary is typically requested to explain the medical justification for the drug to be used. Providing your staff with a template so that all they have to do is insert patient names and relevant health information that can be extracted from the medical record will save time and increase your chances of receiving an approval.

TIP #4: INCREASE YOUR VISIBILITY

There are a number of simple internal and external marketing strategies that you can employ to make sure patients know about your expertise. While you don’t necessarily have to contract with a marketing agency, you should consider at least a few of the options below to make yourself more visible.

  • Chatter among your staff can prompt patients’ interest in dry eye. As mentioned previously, train your staff to know when and how to effectively discuss your specialty dry eye clinic with prospective patients.
  • Post signs throughout the practice. Patients notice the information that you place on the walls, in the waiting area, and in the optical. Consider strategically placing some informational signs that introduce your specialty services and some non-branded, general dry eye posters or flyers.
  • Invest time into creating educational pamphlets. One of the best ways to extend the education that you provide in the exam lane is to provide high-quality educational material to be read at home. There are plenty of brochures that can be purchased, but patients will really value the literature that you create. Consider enlisting some help in graphic design to ensure that the final product is not only clinically accurate but also visually pleasing.
  • Advertise on social media. Not only does this medium give you access to a substantial population of local patients, you can also choose your age groups, geographic location, and more.
  • Create a website. You likely already have a website for your practice, but consider taking it a step farther. Develop a dedicated portion of your webpage to your specialty dry eye clinic. Include informational content on dry eye, and include a link to request an appointment. Importantly, make sure that it has a friendly URL to make it easier for prospective patients to remember it and for search engines to locate it.
  • Educate local healthcare providers. One of the richest sources of referrals, other than through word-of-mouth, is through local rheumatologists and dermatologists. Many of them regularly, but often unsuccessfully, treat dry eye. Offer to give a one-hour lecture on autoimmune dry eye disease or ocular rosacea. If you position yourself as a resource for consultation, they will likely respond by referring their patients. Plus, there are so many opportunities for a symbiotic relationship with other healthcare providers that this collaboration could represent a strong win-win for all parties.
  • Educate local patient groups. Local support groups, especially for autoimmune diseases, often hold meetings or events to help inform the members on a variety of topics. Offering to lecture to these populations could be a great step toward increasing your visibility among prospective patients.

TIP #5: STAY CURRENT IN THE EVER-CHANGING FIELD OF DRY EYE

As someone who practically lives in the dry eye field, I still find this challenging. Recall the previous statistic—662 peer-reviewed articles were published last year alone. It’s impossible to keep up with everything. Journal articles, trade journals, electronic newsletters, networking with new and old colleagues, and attending continuing education lectures are all great resources to keep you current. Consider taking a half day per month, at minimum, for self-study to explore these resources, specifically as they relate to dry eye disease.

TIP #6: REAP THE REWARD

Last, but certainly not least, is to make sure that you enjoy the fruits of your labor. To me, there is a strong financial incentive to open a specialty dry eye service, but it’s just that—an incentive. The real motivation is helping those who need it. These patients are often miserable and have jumped among providers, often to no avail. Be the practitioner who listens. Be the one who tries something different. Be the practitioner who finally brings relief. CLS