Starting A Practice With An Interventional Glaucoma Mindset
Rachel Simpson, MD:
Hello, welcome to Ophthalmology 360 podcast, where today we are so excited to be focusing specifically on starting a practice with interventional glaucoma as the centerpiece of that practice. I’m Rachel Simpson. I am a glaucoma specialist at Moran Eye Center, and I’m so lucky to be joined today in this conversation by Brian Schafer. Brian, why don’t you tell us about yourself?
Brian Shafer, MD:
Thanks, Rachel. I’m really excited to be talking to you about this too. My name is Brian Schafer. I’m a Cataract, Refractive, Cornea and Glaucoma Surgeon out of the Philadelphia area. I did my residency in the Philly area and then left for a year for Fellowship to Sioux Falls, South Dakota, where I was at Vance Thompson Vision. And the fellowship there is quite unique because it involves… It’s technically a cornea fellowship actually, but during the year, you perform thousands of surgeries, both cornea, cataract, refractive, and importantly, a lot of glaucoma. And it’s mostly minimally invasive glaucoma surgery as well as the mixture of subconjunctival surgery. But a lot of what took place there was the beginnings of interventional glaucoma because that practice in and of itself has a robust system in place for clinical trials. So a lot of the new and novel devices get trialed there, and as a Fellow, you have the opportunity to take part in these trials and utilize new technology.
So once I finished my fellowship, I came back to the Philadelphia area and I joined a practice that wasn’t really a great core fit for me in that I came from Fellowship where the answer is always yes, and there’s something new, “Let’s try something new. Let’s do what’s best for our patients,” because what’s new is sometimes what’s best, not always, but sometimes is what’s best. So I realized it wasn’t a really good foundational fit for me, and I decided over this past summer, really April of this past year, that I was going to go off and go solo. So April 1st was the last day I had a job at a normal practice, and from April until August 1st, I worked really hard to build out the operations of what is now the Schafer Vision Institute. And I opened the doors for my first patients on August 1st.
And so we’re now about three and a half, almost four months into the journey. And it’s been a really fun time setting up this brand new practice, wearing all of the hats of this practice, everything from HR to operations to billing, everything to it and learning so much about what goes into setting up a practice with this interventional glaucoma mindset.
Rachel Simpson, MD:
Well, let’s talk about that. Obviously interventional glaucoma is the buzzword of the year really. It’s been the topic of so many conversations. I think a lot of us, especially those of us who are in glaucoma, have a good idea of what it is where really, the previous paradigm that we’re all familiar with is these patients where you just sit there and you watch them progress and you add a drop and you add a second drop and you add a combo drop and you add a fourth drop, and by the end they’re on five drops a day and their conjunctiva is dry as the Sahara Desert. And now we are getting into this.
This is clearly one, not the best way to treat glaucoma, and two, this is clearly not a benign way of treating glaucoma, and so interventional glaucoma really turns that paradigm on its head. But in order to do that in a really successful way, interventional glaucoma has to be really at the cornerstone of every part of your practice. So let’s start practice planning from the ground up. What were those cornerstone pieces of your practice that you knew you needed to establish to make interventional glaucoma a big part of it?
Brian Shafer, MD:
One thing that is important in interventional glaucoma is the ability to easily perform the interventions because as you mentioned, the whole shtick with interventional glaucoma is our ability to intervene upon a patient’s intraocular pressure without relying on their compliance and their inability to do things themselves. So really, the three main components of interventional glaucoma right now are drug delivery, laser trabeculoplasty and minimally invasive glaucoma surgery. So had to figure out those three pieces.
The surgery, that’s the easy piece. You find an ASC that knows how to do MIGs and has a good system in place that can make sure that they get paid for their MIGs and do all of that. So that piece was not the trickiest because I can just step into a place. I don’t actually have to establish anything.
So once the MIGs piece was aside, then it came down to Durysta and SLT. Well, to buy a laser for SLT, you can get one on the open market used for a couple of thousand, maybe $8,000 or so. But if you’re going to do lasers, you’re going to want to be able to do LPIs as well, and you’re going to want to be able to do YAG caps of course. So to get a combo YAG SLT laser, all of a sudden, the price drives up a lot. And if you’re starting a practice new and you’re trying to maintain a low overhead, it’s not exactly the most tenable to say, “Okay, I’m just going to get this $50,000 piece of equipment.” That of course does reimburse 250 bucks each time you use it, but that’s a lot of patience you don’t have yet because it’s a new practice, there’s no patience. So the laser portion was my first challenge, and what I found is that in the Philadelphia area, there’s this guy named Jeff and Jeff has a laser and Jeff-
Rachel Simpson, MD:
Jeff has a laser.
Brian Shafer, MD:
Jeff has a laser.
Rachel Simpson, MD:
Jeff has a laser.
Brian Shafer, MD:
And Jeff takes that laser wherever that laser needs to be brought to.
Rachel Simpson, MD:
Jeff is a handy guy to have around.
Brian Shafer, MD:
He’s super handy, and he actually has two lasers. One of them is just a YAG and one of them is a combo YAG SLT. And what I worked out with Jeff is that for each patient that I do a laser on, whether that’s a YAG cap, a YAG PI or an SLT, I paid him X amount, until I got busy enough that I could cluster all of my laser patients into one day and then he would charge me his half-day rate. And so that was how I set out to do my lasers, and I’ve now had three or four laser days, and I basically just stack them all together, which I didn’t do in my last practice, but I did in residency, and it’s working out beautifully. I actually had a laser day yesterday. We did 10 lasers, mixture of YAG caps, PIs and SLTs. I paid Jeff for an afternoon and we both went on our merry way. He set up the laser and he took the laser away.
So with the exception of the rare angle closure patient that needs an emergent LPI, I’ve got my laser situation figured out. Then there was the drug delivery side of things. Durysta has a set price. That’s just what the price is, period. Whether you get it through Allergan or whether you get it through one of the other sources that you can get drug through. That’s a lot of money to shell out to put it on your shelf. And then once you administer it and you go through all of the billing process, you hope that you get fully reimbursed for that J-code plus 6% over the whack, but the upfront cost is a lot.
Rachel Simpson, MD:
And there’s a certain amount of risk with that too. You may not get reimbursed.
Brian Shafer, MD:
You may not get reimbursed, you really may not. And fortunately, Avvy has a nice system in place. They’re totally kind about it, and they will help you if that happens. The other thing that I was able to negotiate with them, so what I did is I got two Durysta, but what I was able to negotiate with them was the terms of the payment and instead of… So the term net, whatever, just means how quickly you have to pay something back. So if it’s a net 15, you pay it in 15 days, whatever. I was able to negotiate a net 90-day payment for it.
So I was able to hold it, hold the payment for 90 days and just hope that in those first 90 days I was able to find that perfect unicorn patient and I was able to do that. Fortunately, it did work out in that regard, but that’s a challenge because you don’t have a lot of working capital upfront and the working capital you do is so precious that you don’t want to spend all of it right upfront to just put something on your shelf. So thinking about the drug delivery side there was actually a little bit more of a financial burden, but has worked out now that things are flowing a little better.
Rachel Simpson, MD:
I love that. This is the real nitty-gritty where the rubber hits the road details that people who are wanting to set up these kinds of practices really need to know. And so thank you for sharing that hard won wisdom. So now you’ve got your practice, you’ve got your laser, you’ve got your drug delivery. Now you need patients to treat. And I’m curious, when you set up your practice, what kind of marketing scheme did you employ? How prevalent is interventional glaucoma in how you’re marketing yourself to your patients?
Brian Shafer, MD:
Yeah, so that is probably the most important part of the whole thing, is figuring out how to get patients on board with this mentality right away and not just get patients on board with it, but also get the referring providers on board with it so that they know that that’s what to expect when they send a patient to you. And John Berdahl always has the best quotes, and one of them that he always says to me is, “You become what you say you are.” So when I established SVI, I established it as a specialty surgical practice with a mission statement of providing university caliber care in an intimate private practice setting.
In other words, for the things that you normally would have to go to a university and go see someone like you for, you can come to this nice build out private practice, get to know me, and this is where the marketing piece comes in. Get to know everything that I and my family stands for. So in those four months from April 1st until August 1st when I was waiting for the doors to open and building everything out, there was a lot of lag time. There were a lot of things where I was just waiting. I was waiting for credentialing. I was waiting for my lease to go through. I was waiting for an asset purchase agreement to go through. And during that time, there was literally nothing I could do to move those things along.
So instead, I shifted my focus towards my marketing. So again, because budget was really tight at the beginning, I went to the bank and got a loan by the way, that’s how I funded the practice. I did it all on debt from the bank, which was nice because it means I retain 100% of the equity for right now. So I’m not really answering to anybody but myself, which also means that if it doesn’t work out, it’s on me. But that’s better in my mind than having to defer to somebody else.
But anyhoo, so when I had that time, I didn’t have the financial resources to hire a full-time marketer or a full-time videographer or a full-time website developer. And I spent that time actually figuring out a lot of that stuff on my own. And so I made my website and because I made the website, and all of the sites that you use to make a website are so easy now, it’s like drag and drop, it’s square space. You literally just drag and drop, put pictures of yourself or whatever.
Rachel Simpson, MD:
It makes us all look like brilliant web designers.
Brian Shafer, MD:
100%,
Rachel Simpson, MD:
Yet we’re clearly not.
Brian Shafer, MD:
I get compliments on my website all the time, and it is a potato compared to a professional web designer. But the difference is that it’s obvious that I made it, which patients actually like. They can feel that personalized touch.
Rachel Simpson, MD:
I’ve been to it and I feel like I know who… You see your family there. You really see not only what your practice is about, but the highlights of your training, the impact of John Berdahl’s mentorship on you, the legacy of Vance Thompson. It’s all apparent in every part of that. And also who you are as a person, who your family is, what they’re getting in this practice. I thought it was really lovely.
Brian Shafer, MD:
I think that it turned out pretty good actually. And I ultimately, in addition to building out that website to explain who I am, the other piece, and I think that this is so critical and we’re all starting to realize it, is that words matter. And when we’re communicating with our patients, the words we use have a direct impact as to whether they’re going to comply with our requests or not. So for example, with Durysta, we all had to learn how to talk about putting this medicine in the eye.
Rachel Simpson, MD:
Absolutely.
Brian Shafer, MD:
A lot of us started by saying, “We’re going to stick a needle in your eye and put the medicine in.” [inaudible 00:13:54]
Rachel Simpson, MD:
Not received so well, not known.
Brian Shafer, MD:
It’s really not. Instead, we’ve learned to say things differently like, “We’re going to put the medicine right where it’s needed, right at the target tissues,” and that is all the patient education piece that helps our patients feel more comfortable about the journey they’re about to be set out on. And another quote that John Berdahl always talked about all the time, and he quoted his grandma saying it, but it turns out it was actually Teddy Roosevelt. I love that fact about him. He always attributes everything that he can’t remember who said it to his grandma, when in reality they’re just in the mainstream media.
But anyway, that’s this one is that, “People don’t care until they know that you care. Once they know that you care, they’re yours and they will listen to what it is that you suggest to them.” And that’s very poignant in interventional glaucoma because these are patients who otherwise were like, “Why wouldn’t I just use a drop?” Well-
Rachel Simpson, MD:
Absolutely.
Brian Shafer, MD:
I care about-
Rachel Simpson, MD:
They’re putting their eye in our hand, they’re putting their vision in our hand, and we are asking them to trust us, sometime on almost no interaction, very, very minimal interaction. And so the fact that they can sense that you genuinely have their best interests at heart, and also that you genuinely believe this is the right intervention for their eye, those two things I think in tandem are so powerful.
Brian Shafer, MD:
I think you’re so right. Patients totally can recognize if we believe in what we’re saying and as soon as we start to falter, it goes away. And I see the same thing on the premium IOL side of things, which is the other leg of my practice. That’s kind of the financial leg of my practice. I tell my employees all the time that we take care of two types of patients, those who want our help and those who need our help.
Rachel Simpson, MD:
People are always like, “How do you educate your patients? How do you get them on board?” One, you’re setting the tone for their appointment before they even arrive. And two, the other question people often ask is, “How do you get your staff on board? How do you train your staff to talk about interventional glaucoma or some of these procedures in a way that makes them not sound scary?” And you are essentially… Not to minimize the importance of your staff and having your staff on board, but you’re almost taking that out of their hands. You’re giving you direct to the patient in a conversational way that you wouldn’t have time to have in an actual clinic setting.
Brian Shafer, MD:
It’s totally true.
Rachel Simpson, MD:
They’re coming into you and they feel like, “Hey, I’ve already talked to this guy about what we might do today.” So [inaudible 00:16:40].
Brian Shafer, MD:
It also gives the staff the actual script because I force all of them to watch it too.
Rachel Simpson, MD:
I love that. I want to shift gears just really quickly because your experience, I think is so poignant because it is so disparate as well. Your first practice really is it seems like in every way a contrast to the practice that you have managed to set up for yourself. And I’m curious for those of us out there practicing like me, where I stepped into a very traditional established glaucoma practice where I took over for someone who’d been practicing for 30 years, what the barriers were at your first practice? Were they institutional? Were they patient? Were they support staff? And then how you turned those on your head to create your own practice?
Brian Shafer, MD:
Okay, this is really important, and I didn’t fully grasp this until I went and opened up my own practice, but what you stepped into is one of the hardest things to shift into interventional glaucoma because you have a book of established patients who are rock solid, stable on the medications they’ve been on for years, and now you want to do something to them. It’s a hard conversation.
In my current practice, because it’s all brand new, the first time I’m seeing a patient, we can begin the conversation and we’ve never not had that conversation. And it’s a lot of first time diagnosed as glaucoma patients, and that is an absolute gift that I was given.
Rachel Simpson, MD:
You’ve got a blank slate.
Brian Shafer, MD:
It’s a blank slate. It’s so much easier. Now, in my last practice, I will give a lot of credit that they were willing to bring on Durysta for me, and I had the ability to do SLT. Some of the other stuff was a little bit trickier, and I know that when newer technologies do come out and become available, that would’ve been a bigger barrier. But the biggest barrier is what I just mentioned, where it’s when you have an established patient book and you’re seeing an established glaucoma patient who’s been followed by a glaucoma specialist, and now you as a glaucoma specialist are recommending something different than their trusted doctor they’ve had for all these years. That is really, really hard and not something that I have the wisdom or experience to speak on. I’m curious, how do you navigate that?
Rachel Simpson, MD:
So it’s been an evolution certainly for me, and what I’ve realized is for those patients where I’m taking over, you’re exactly right, the person I took over for was beloved and followed these people through tumultuous events in their lives, was married, act as the master of ceremonies for their wedding in some of these patients, and then they’re coming to me and I’m saying, “Hey, I see you’re on four drops and also your dry eye is terrible. Maybe there’s something we can do about that.”
What I realized is I’m not going to win anybody over on the first try. And it’s exactly what you were touching on with your videos is I have to establish that trusting relationship before they’re going to believe anything that I say. Otherwise, I’m just the young kid who doesn’t know what I’m talking about, trying to ruin all the good work that their last doctor did, saving their vision, and then I’m going to come in and try and ruin that.
So it’s been a very intentional, slow, steady process for those people, where I’ll casually just say, “I notice you’re taking a lot of drops. Do you have any interest in reducing the number of medications that you’re on? Or how are your eyes feeling? Do you notice they’re really red in the mornings? Or how are they reacting after we put the drops in? Oh, they’re burning, okay. Oh, they’re tearing throughout the day. Some of that might be my fault. You’re on so many medications, there might be something we can do about that. We can talk about that at your next appointment.”
And then I’ll leave a little note for myself. “Disgust, drop burden, we’ll discuss SLT next visit,” and they say, “Okay, there’s this procedure we do in clinic and 90% of ophthalmologists who need glaucoma medication would actually choose this over any type of eye medication. It’s what I would do if I were diagnosed with glaucoma. No question. Hands down, it’s really great. We might be able to get you off one or two of your medications. Is it something you’re interested in? We can talk about it again at your next visit. Here’s some information.” And then I don’t try and… They’re always like, “Is she going to try and make money off this? What’s the catch here?”
So you really have to be like, “I don’t have anything to gain from this. I really am just about treating you in a way that I believe.” And you usually by the third visit, they’re like, “Talk to me more about this.” And so over the course of the last three or four years, I’ve been able to, I’d say, convert maybe 50% of my patients who were on one or more medications and had never had SLT, to SLT only or SLT in one medication. So we’ve been able to pretty dramatically decrease the drop burden for the patients.
And one thing I have the advantage of is residents who I get to talk to them about what interventional glaucoma is, and that SLT is first line, and this is how we talk to patients. And so they get to spend a ton of time talking to patients as well. And so they know now when they’re in my clinic, SLT, SLT, SLT, they’re talking SLT all the time. Then I come in and I’m reinforcing SLT. And it’s the same thing that you get with your staff.
Brian Shafer, MD:
Yeah, that’s important. There’s nothing that a patient hates more than two completely different opinions within 10 minutes.
Rachel Simpson, MD:
Yeah, exactly. So we are very coordinated in our world as well. And luckily I’m at Moran, which is a very progressive glaucoma department, and we’ve got Ike here from time to time leading the charge in interventional glaucoma. And all of my colleagues are all very, very interventionally minded. We’ve tried to adopt within our own practice a much more progressive approach to glaucoma as well. It’s a little bit slower in the academic world for all the reasons that you just mentioned where we don’t have as much control, but there’s definitely an effort. And I think there’s been some talk in glaucoma community about, “Is there a slow adoption of interventional glaucoma or how can we speed up that adoption?” And I don’t know that we necessarily need to speed it up. I think we just need to talk about exactly what we’re talking about right now. What do you think?
Brian Shafer, MD:
Yeah, I think that that makes a lot of sense. I think that way about new products in general, especially when a company drops a new product, the overall way to recoup your R&D costs and drive revenue is in sales and utilization. But in reality, I think that sometimes the slow burn approach is actually better because then you don’t have this flash in the pan phenomenon where all of a sudden, you’ve got this fancy new thing, you use it a couple of times and you have one bad outcome, and you get burned and you stop using it. I think that that slow smoldering approach within academia as well makes a lot of sense.
Rachel Simpson, MD:
So I know we’re probably going over on time, but this conversation has just been so great. I think just to summarize some of the themes that we touched on today, I think number one that you hit on so beautifully is that that relationship with your patients, that trusting relationship with your patients is really at the core of any type of interventional glaucoma practice. And how you foster that and develop that might look different from practitioner to practitioner. But you were so brilliant in the way that you established everything with that being at the heart of it.
And then I think number two, it’s the nuts and bolts, nitty-gritty, setting up a practice with intervention at its core and how you finance that. And I think some of your tips are going to be really valuable to the people out there listening. And then lastly, you have to believe in interventional glaucoma because patients know, they can tell.
Brian Shafer, MD:
Yeah. And patients don’t care what you know until they know that you care.
Rachel Simpson, MD:
Oh, I love it. Leaving it on the brilliant words of John Berdahl’s grandmother.
Brian Shafer, MD:
Correct. Otherwise known as Teddy Roosevelt.
Rachel Simpson, MD:
Well, Brian, it’s been such a pleasure talking to you today. I’m so glad you were able to join us. Thank you so much.
Brian Shafer, MD:
Thank you for having me.
