Article Date: 5/1/2005

Expand Your Practice
By taking prescription authority and clinical care to the next level in your practice, you can capitalize on profitable patient care opportunities.
BY J. JAMES THIMONS, O.D., F.A.A.O., Fairfield, Conn.


The Optometric Practice of the New Millennium is the most diverse, challenging and potentially rewarding of any era since our field's inception. With the advent of new technologies, advances in pharmaceutical therapy and expansion of clinical practice, we have the ability to create the ultimate model of the "Primary Eye Care Clinician." One of the challenges we face in moving the profession to this next level is how to incorporate these rapidly developing trends into traditional clinical care without losing the hard-earned ground that is the backbone of daily practice.

There are four key areas we must address in implementing therapeutics and developing new revenue streams for the office. These are acute/emergency care, ocular surface management, pre-/post-operative patients and chronic disease patients.

#1: Be there for emergencies

First and most important to achieving success is providing acute care services (corneal abrasions, keratitis, conjunctivitis, etc.). This service is invaluable in educating patients regarding your practice. And new drugs, such as the fourth generation fluoroquinolones (Zymar, Vigamox), enable you to treat safely and effectively. Practice revenue improves for two reasons. First is the office visit fee associated with the service independent of the annual examination and second is the development of a long-term relationship with the patient that creates loyalty and referrals.

#2: Surface change

The second area, treatment of the ocular surface, is one of the great untapped aspects of the primary care practice and has tremendous promise for growth. The reason for the rapid expansion in this arena is twofold. First, we now have therapeutic agents that are specifically designed to treat the underlying mechanism of dry eye which, in most patients, is inflammation.

The second and equally important reason is the marked shift in the demographics of the United States population over the next 25 years. By the year 2030, it's anticipated that almost one quarter of all individuals in North America will be over the age of 65. The impact of this age shift on the primary care practice should not be ignored. The therapeutic care of chronic disease should be and will be a major element of both patient care and revenue for the eyecare practice in the next decade.

Development of new drug classes such as immunomodulation (Allergan's Restasis), "designer steroids" (lotoprednol etabonate) and the explosion of nutraceuticals for the treatment of the ocular surface have revolutionized dry eye therapy. Used as stand-alone agents, or more frequently in combination, these drugs give clinicians the ability to tailor an approach that is unique to each patient. The revenue impact of this type of care can be enormous for several reasons.

First is the increase in the average number of office visits for patients in this category that translates into income without the overhead costs typically associated with a dispensing practice. Second is the ability, with agents such as Restasis, to effectively treat patients with intolerant contact lens syndrome and prevent them from exiting lenses. This allows you to maintain the revenue from the contact lens segment of your practice that many clinicians are concerned about and is lost when patients "drop" out. Third is the inherent increase in consumption of "optical." This happens because patients are in the office more frequently and have the opportunity to observe new frame selections and other items.

#3: Surgery isn't the end

The third area of therapeutic growth is the cataract and refractive surgery patients in your office. Refractive surgery has has meant new technology, better patient care and increased revenues to the optometric practice. However, after the procedure clinicians are sometimes baffled by the patients seeming lack of interest in returning for continued primary eye care. This can negate, to a large degree, the revenue obtained for the pre- an post-operative care of the patient and results in a lack of interest, on the O.D.'s part, in developing this aspect of the practice.

This outlook probably won't lead to prosperity, though. The reason is that with the development of new technologies such as intraocular contact lenses (made by Verisyse, Staar, etc., or phakic refractive lenses), wavefront lasers (VISX's Star 4, Alcon's Ladarvision, Bausch & Lomb's Zyoptics) and research in the areas of "surface ablation," Mitomycin C, "wafer" lenses, inlays and other technologies, it's clear that refractive surgery in whatever iteration it develops will not only be here, but will continue to grow over the next decade. It will impact our practices. The best approach to patient care and revenue in this area is to be proactive.

Patients who have refractive procedures still need care for allergies, dry eye, blepharitis and other common diseases of the anterior segment. Additionally, we routinely schedule our post-operative patients for yearly follow up examination of the fundus due to the high incidence of peripheral retinal abnormalities in the this predominantly myopic population. In our office, the post-LASIK patient is a regular part of the daily schedule and is a great source of continuing patient revenue from anterior segment therapy to extended ophthalmoscopy.

While most practices have been co-managing cataract patients for some time, I still speak to practitioners who manage these individuals as if they are eye care only and see them once a year or less. In truth the cataract patient is one of the mainstays of every ophthalmology practice and for good reason: Their surgical history typically places them on a two-visits-per-year cycle. And because most post-operative cataract patients are over 60 years of age, they need regular evaluation for not only the progress of their surgical procedure, but for other conditions such as glaucoma, macular degeneration, dry eye, blepharitis, etc. Given the marked increase in the presence of diseases like glaucoma and AMD with increasing age, it's more than appropriate to provide a level of service to your post-operative patients greater than that of the healthy, general eye exam patient.

#4: Caring for disease

The fourth area in making therapeutics work for you is glaucoma. There is no other patient population in your office that needs your care more and who at the same time is able to help your practice grow than this group. If you aren't as active as you would like in this area, or if you want to increase your rate of growth, the easiest way is to identify the patients already in your practice for whom you can assume care that has in the past been provided by others via your referral. Typically, this is the glaucoma patient.

For years, in large part due to lack of legislative authority, many practices referred their glaucoma patients to ophthalmologists who typically managed their medical needs and referred them back for their glasses. Today the care of the glaucoma patient is almost universal in optometry and the opportunity it provides is unparalleled for practice growth and revenue development. Beyond the comprehensive initial examination, the need to perform testing such as gonioscopy, visual fields, stereo photos, serial tonometry, optic nerve assessment and nerve fiber layer imaging on a scheduled basis is both important to increasing the level of care provided by your office, and to establishing a reliable source of significant income.

The most important step in creating success is to make the commitment to diagnose and then treat! Writing the first prescription for your patient's glaucoma therapy is a doctor-patient bond unlike any other and is the most important step in assuring the long-term growth of your office. The introduction of prostaglandins has given the primary care clinician a powerful weapon in the fight against blindness.

It's a start

While there's no single formula that works for all of us, these are some basic concepts that will increase the quality or your patient care and begin to develop the growth necessary to take your office to the next level using therapeutics.


Take It to the Next Level
by John M.B. Rumpakis, O.D., M.B.A.

According to the recently published American Optometric Association (AOA) report on optometric prescribing habits, it's clear that optometrists are becoming increasingly comfortable in managing and treating ocular disease. Yet we certainly haven't become masters of our own domain. Family practice doctors still write more prescriptions for glaucoma than we do, allergists still write more prescriptions for ocular allergy than we do . . . you get the picture. In fact, there's evidence that a significant number of patients still self treat for ocular allergy and dry eye rather than seek out professional assistance.

So what can the average optometrist do to take his prescribing habits to the next level? I have some simple suggestions that will make your patients happier and your practice healthier by changing your prescribing routine.

When routine is a problem

Recognize that what's routine for you can prove problematic for your patients. Many patients who have chronic problems such as dry eye and ocular allergy may never mention them to you during a routine visit. In their eyes, they deal with these problems on a daily basis and they don't view their malady as a problem. Be proactive in recognizing chronic problems and be able to provide a clear solution for patients to follow.

Record everything

Record everything in your medical records. They are the basis for recognizing and acknowledging patients' subjective and objective findings, our diagnoses and the resulting treatment plans. They also allow us to code and bill appropriately for the services we provide and they ultimately justify the need for us to prescribe for treating our patients.

Be brave, recommend

Many optometrists have a fear of recommending a specific product or treatment plan to a patient because of the fear of failure or commitment to a specific care plan. Yet patient studies repeatedly demonstrate that a recommendation is exactly what a patient is looking for. They may like to be presented with options, but ultimately are interested in what you, as the prescribing doctor, think will be their best option for resolution to their problem.

Sample vs. script

Many optometrists take the position that it's better to provide a sample to a patient rather than to write a prescription. I agree with that position, but only in the case of treating glaucoma. Samples play a specific role in our practices: emergency use (and for occasional use for the indigent patient while enrolling them in an indigent drug program). No one ever intended practitioners to provide samples to every patient for the purpose of testing the therapy's efficacy.

Think about what a written prescription represents to a patient: a solution to his problem. Studies have clearly shown that patients respect the treatment and perceive it as more effective when it's a written prescription rather than a sample. Don't be afraid to write a prescription for every condition that requires treatment.

When change is a good thing

These simple but effective steps will help you take your prescribing authority to the next level. Implementing a new behavior is often the most difficult step in the process because for most people, change is difficult. The changes I've described in this article are just as valid when prescribing oral agents as they are for prescribing topical agents. If you can implement what I've coined as the "Three R's of Successful Optometric Practice" (Record, Recommend and Rx), then you can not only take your prescribing habits to the next level, but at the same time, you're also benefiting your patients by taking the care that you provide to them to the next level as well.


The Value of Writing Prescriptions

"Writing prescriptions is the greatest advantage as well as actively marketing to individual patients as they visit the practice."

-- Walter D. West, O.D., F.A.A.O., Brentwood, Tenn.

"Perfect practice makes perfect. If you want to be a good prescriber of any medication, you first need a knowledge of the available medications, their uses and applications, their side effects and their potential interactions with other medications as well as the appropriate education and licensure. The second skill you require is the ability to properly diagnose illness. It sounds fundamental, but it's surprising how many physicians approach medication with a one-size-fits-all hierarchy. The last skill is practice. You can't replace practical application and experience. That's why internship and residency are invaluable. To learn under the wing of another who has garnered the experience and is willing to pass on the knowledge is the foundation upon which our system has been erected. Translating theoretical demonstrations into outcomes are what molds and shapes physicians' attitudes, values and philosophies."

-- Andrew S. Gurwood, O.D., F.A.A.O., Philadelphia


Dr. Thimons is a nationally and internationally acclaimed speaker and serves as medical director at Ophthalmic Consultants. He was awarded Optometry's Top Educator in 1999.



Optometric Management, Issue: May 2005