glaucoma
Putting an Economic Spin on Glaucoma
Glaucoma is a profitable segment of eye care. Just look at the numbers.
BY JOHN M. B. RUMPAKIS, O.D., M.B.A., Lake Oswego, Ore.

What are we afraid of? Yes, you heard me right. Why is our profession so afraid of embracing primary care? For the past 30 years, we've fought in just about every legislative arena imaginable for the privilege of having prescriptive authority to diagnose and treat disease within our practices. Fortunately,we've been successful in our efforts.

But for all of those efforts, we still barely register on the radar as far as number of prescriptions written for treating various entities, particularly glaucoma. Despite all of our legislative and educational efforts,we still account for less than 10% of all glaucoma scripts written within the United States.

Where are the patients?

I can understand that most O.D.s are reluctant to treat glaucoma because managing the disease can be a clinically challenging aspect of primary care optometry. But also realize that glaucoma is a slow, insidious disease that affects more than three million people in the United States. And we aren't taking the active role in their care that we fought so hard to obtain.

Interestingly, I've heard other practitioners say, "We don't have many glaucoma patients in our practice." Really? So where are these patients? Do they have the innate ability to self select their practitioner based on a disease that they don't even know they may have? Approximately two-thirds of all first encounters with an eyecare practitioner occurs with an optometrist. I believe the problem more likely lies with us, not with the patient. And believe it or not, it most likely has nothing to do with our clinical ability to diagnose and treat glaucoma within our clinical settings.

Despite having the clinical ability to diagnose and treat, our pattern has primarily been to diagnose glaucoma and to refer the treatment out of our practices. Additionally, we're unsure of the appropriate manner in which to code and bill for our services. In fact, we often simply don't realize just what treating glaucoma can do for our practices economically. Why do you think the fight to gain prescriptive authority for treating glaucoma was so hard? I think it had more to do with the economic aspects of the disease and the impact that it may have on M.D. practices, rather than their argument regarding our education and clinical ability, as glaucoma has often been referred to as the "bread and butter" of the typical ophthalmologic practice.

All signs point to glaucoma

Why all the excitement about glaucoma? Let's look at some facts from the Glaucoma Research Foundation.

• It's estimated that more than three million Americans have glaucoma but only half of those know they have it.
• Approximately 120,000 are blind from glaucoma, accounting for 9% to 12% of all cases of blindness in the United States.
• About 2% of the population between 40 and 50 years of age and 8% older than 70 have elevated IOP.
• Glaucoma is the second leading cause of blindness in the United States and is the first leading cause of preventable blindness.
• Glaucoma is the leading cause of blindness among blacks and is six to eight times more common in blacks than in whites.
• Blacks between the ages of 45 and 65 are 14 to 17 times more likely to go blind from glaucoma than whites in the same age group who have glaucoma.
• The most common form, open angle, accounts for 19% of all blindness among blacks, compared to 6% in whites.
• Other high-risk groups include: people who are older than 60, family members of those already diagnosed, diabetics and people who are severely myopic.
• Estimates put the total number of suspected glaucoma cases at around 65 million worldwide.

Sixty-five million glaucoma suspects worldwide? This is a staggering number, and is exactly why I have a hard time believing those who say they don't have many glaucoma patients.

Every patient who crosses our thresholds and presents for general ophthalmic care has the potential to develop glaucoma. That's why we have so many clinical tests and technologies available to us for diagnosing it early in the process.

A look at the numbers

Let's examine the financial impact that a glaucoma patient can have on a practice. For our discussion, we'll examine the total financial impact of the patient from the time he makes an appointment in your office for a general exam throughout his cycle of care within your practice. We'll assume he's new to the practice and use the 2004 Medicare Maximum Allowables for Portland, Ore. as the basis for our fees. (See "First Visit.") Note: Medicare is considered a discount medical plan. Most fees that you'll charge and collect will be significantly higher than the fees I'm presenting here.

Once you've identified and diagnosed the patient as either a glaucoma suspect or as having glaucoma during your initial exam, present your findings to the patient and schedule a follow-up evaluation for further testing (See "Second Visit"). If the results of the tests from the second visit are consistent with those of patients who have glaucoma, then schedule a third visit to perform additional tests. At the third visit, perform tests indicated in the "Third Visit" sidebar. Explain the results of these tests and confirm the diagnosis with the patient.

Review the need for treatment and the consequences of not following through with treatment. Once you've decided to begin treatment, select your medication and explain your choice to the patient based on his particular presentation. Review the use of the medicine(s) and give him a sample. Schedule a follow-up appointment to evaluate the efficacy of the medication ("Fourth Visit").

At the patient's fourth visit, educate him regarding the importance of maintaining stability of IOP and of complying with the medication. Schedule the patient for yet another follow-up visit (See "Fifth Visit") at the three-month interval. At this visit, you'd again perform serial tonometry to evaluate the diurnal efficacy of his existing medication regimen. Make adjustments in his medical therapy as needed.

Again, counsel the patient on the importance of complying with the medication you prescribed and schedule him for a three-month follow up. The next two visits (which span the remaining six months of the first year of care) would most likely be similar in nature (See "Sixth Visit" and "Seventh Visit").

This would complete the patient's first year of care and you'd then repeat the cycle.

There's no denying the facts

Expect slight differences in the frequency of visits within the second and subsequent years of providing care to your glaucoma patients. While slightly more routine, the key to successfully managing glaucoma is diligent follow-up care. Refer to "First Year Revenue" for a break down of the total revenues generated for the first year of care on a per-visit basis. Comply with your local carrier's local coverage determination (LCD) regarding tests and testing frequency.

This table clearly demonstrates the annuity value of treating glaucoma patients. Using these numbers, a glaucoma patient can and will generate about $995 in revenue for the first year of care and $610 for the second and subsequent years. This is purely service revenue and excludes optical goods and their subsequent cost.

Keep in mind: Providing both refractive and medical care aren't mutually exclusive. You're entitled and fully capable of performing both services. You're not giving up one to provide the other. While the actual amount of physician time spent is incrementally greater for medical services, you can effectively delegate most of the actual testing to your staff. Applying this same philosophy to the regular routine conditions that optometrists see every day, such as allergic or infective conjunctivitis, inflammatory keratitis, corneal foreign body removal and lash epilation, allows you to provide full-scope care to all of your patients.

Use what you've been given

Our scope of practice and prescriptive authority allows us to perform these services. That's why it's important to reinforce the fact that we're primary providers with our patients. Something as simple as writing out a prescription for medications that a patient has to fill at the pharmacy rather than just giving him a sample can cement our role with our patients, as well as with the general medical community, as their eyecare provider rather than just where they go to get their glasses or contact lenses.

Embrace our increased scope of practice, exercise your prescriptive authority and provide the best care that you're capable of providing. Both you and your patients will benefit. I wish you success!