Dry Eye

The Business of Dry Eye: 4 Steps to Boosting Practice Profitability with In-Office Treatments

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By Michael A. Farbowitz, MD

When I started practicing more than 20 years ago, we were all clamoring to do more laser vision correction (LVC) or premium IOLs to increase our practices’ profitability. Today, we’ve found that adding in-office procedures for dry eye disease (DED) not only provides practice-differentiating services that patients are actively seeking but also enhances the bottom line in relatively little time compared to surgery.

Consider the profit margins for traditional surgeries: For each LVC patient, I do a free consultation, a free preoperative appointment, a procedure at the surgery center, postoperative visits at 1 day, 1 week, and 1 month, and enhancements as needed (each with surgery and pre-and postoperative appointments). The profit after the facility fee is a few thousand dollars. Cataract procedures follow a similar pattern, with declining reimbursements for the preoperative visits and surgery itself being reimbursed between $500-$600. Even when patients elect to pay out of pocket for premium services, such as multifocal/toric IOLs or femtosecond laser, there is a time cost associated with the surgery itself, as well as increased chair time in counseling the patient in IOL choice or dealing with a patient who is dissatisfied with the result.

Now look at in-office DED procedures: After an annual exam or a reimbursed medical visit for ocular surface disease, we counsel patients and present appropriate treatment options. Our foundational treatment is OptiLight (Lumenis), a root-cause therapy that improves DED by addressing inflammation. With OptiLight, patients undergo four 10 to 15-minute, in-office treatments spaced 2-4 weeks apart. The total cost to the patient is more than $1,000. If patients have a significant number of stubbornly blocked glands, we recommend the addition of LipiFlow (Johnson & Johnson Vision) or TearCare (Sight Sciences), which use heat to remove the blockages. LipiFlow and TearCare are one-time in-office procedures that can be repeated annually as needed. I set up the device, and a technician attends to the patient for 12-15 minutes while I see other patients. The profit for each treatment is between $300 and $600.

In our practice, we’ve found patients are open to having in-office DED procedures, and they’re very pleased with the results. The added revenues are substantial, with less time commitment than surgery and much lower risk and liability. In addition, other eye care providers may be permitted to perform the treatments, depending upon state regulations. Because there are so many patients with DED, many of whom are undiagnosed, you can replicate this success in your practice by screening for DED and putting in-office treatments in place.

Screen Everyone for DED
A big part of our role as physicians is to detect problems before patients know they exist, such as a retinal abnormality, cataracts, or glaucoma. That goes for DED as well, which is why every patient who comes into my office has to be screened, regardless of whether they complain of symptoms. We ask directed questions, and all comprehensive exam patients get meibomian gland imaging. If the screening questions are positive, I can do other tests such as tear film osmolarity (TearLab Osmolarity System, Trukera Medical) and MMP-9 assay (InflammaDry, Quidel).

Once I identify DED, I educate patients about the problem and potential treatment options. With the right language and meibography as a visual aid, this becomes a very efficient, routine process.

By addressing dry eye head-on, there is no doubt that you will grow your patient base. Our profession has gone through a paradigm shift over the last 10 years where both patients and physicians now understand that DED is a real disease that affects patients’ quality of life, not just a nuisance condition, and that there are effective treatments beyond over-the-counter lubricants. Some physicians are still reluctant to manage these patients with advanced treatments due to the time, effort, and expense in identifying and treating them. Those are the frustrated patients who find their way to our office. Positioning myself as a doctor who listens, who understands DED, and treats people effectively has helped the practice expand by word of mouth. Even patients searching online for help with DED find us, often because they’re searching for specific procedures that we offer.

Choose the Appropriate Procedures
I take a multifaceted approach to treatment, with basics like environmental and behavioral modifications, high-quality omega 3 supplements, lid wipes, and prescription immunomodulators. But in-office procedures are the cornerstone because they offer significant results and can reduce inconvenient at-home care. We selected OptiLight, LipiFlow, and TearCare based on the literature and positive discussions with colleagues who were seeing good results and satisfied patients. We also chose well-established manufacturers who are very invested in our success.

When tailoring an individualized treatment regimen for each patient, I carefully evaluate the lid margin, the quality of the gland expression (if any), and meibography. I often recommend OptiLight because this light-based therapy addresses inflammation, the underlying cause of most DED. LipiFlow and TearCare are both thermal treatments that allow us to mechanically remove inspissated meibum from the meibomian glands. I recommend thermal treatment for patients who cannot have OptiLight because their skin tone falls outside Fitzpatrick skin types I-IV and for less common cases with blocked glands only. Some of my patients with inflammation and blocked glands have both treatments.

Convert Patients to the Treatment They Need
Before purchasing any in-office treatment device, I ask if patients will recognize the procedure’s value. Will patients be willing to pay out of pocket for this treatment? I’ve been pleasantly surprised to find that patients across socioeconomic lines are open to paying for the DED treatments they need. Manufacturers support the process, investing in our success with promotional materials for the office and our website. The marketing team at Lumenis was invaluable in helping us market the OptiLight procedure on social media. But the strongest way to ensure financial success is consistent screening, patient education, and doctor recommendation. DED is common, so we find it consistently, make treatment recommendations, and perform a significant number of procedures as a result. For those patients who have a financial barrier to treatment, we offer low-interest financing.

It’s important to note that because we’re screening for DED rather than waiting for patients to complain about symptoms, about half of our in-office treatments are done on asymptomatic patients with identifiable meibomian gland dysfunction and inflammation. That means patients who feel fine are agreeing to an out-of-pocket procedure in order to proactively treat a chronic, progressive condition.

Once I recommend a procedure, I’m very upfront about the cost. I’ve found that patients appreciate hearing about that directly from me, rather than delegating to other staff. This allows us to start the scheduling process immediately and ensure successful conversion.

Track Your Numbers
How long does it take for your investment in DED procedures to pay off? We don’t track ROI religiously in my practice, but our revenues from OptiLight will soon exceed the investment. ROI for the system is enhanced by the higher price of treatment compared to other procedures, the absence of disposable costs, and cosmetic results that patients appreciate so much we’ve been encouraged to expand our use of the device to other facial treatments, particularly for patients with rosacea. After we purchased LipiFlow in 2017, we recouped the cost in a little more than 4 months. Today, we’re doing fewer LipiFlow treatments after adopting OptiLight.

Diagnosis and root-cause treatment of DED, including performing procedures, have also raised our conversion to premium IOL cataract surgery because improving the ocular surface enables us to acquire highly accurate preoperative measurements and better identify candidates for premium IOLs. Due in part to effective management of the ocular surface, almost 90% of our patients are within .50 diopters of the refractive target after cataract surgery. These refractive outcomes have led to more word of mouth and optometric referrals, as well as increased confidence in recommending premium IOLs.

Overall, the revenue generated by dry eye procedures has amounted to about 5% of our total practice revenue. By keeping track of your procedure volume and conversion rate, it becomes quickly apparent that building a dry eye practice will increase overall patient volume and enhance your practice’s bottom line, hedging against the declining reimbursements for covered procedures.

Michael A. Farbowitz, MD, is medical director, cataract and refractive surgeon and dry eye specialist at Short Hills Ophthalmology, a multispecialty group in Short Hills and Clifton, New Jersey. Dr Farbowitz discloses that he is a consultant for Lumenis.