Building Allergic Conjunctivitis Into Your Medical Practice Model

Diagnosing and treating the large number of patients with ocular allergies increases patient satisfaction and highlights your role as a primary care practitioner.

By Ian Benjamin Gaddie, OD, FAAO

Medical eye needs, such as glaucoma treatment and cataract comanagement, are good ways to grow a medical practice, but we should take advantage of all the medical practice- building opportunities that come through our doors. My doors just happen to be in Louisville, Ky., in a region known for having the highest pollen counts in the country. I see many patients with allergies all year long. The treatment of allergies represents an opportunity to increase medical billing, make my patients more comfortable and spread the message that I take care of medical eye problems in my practice.

The key is to ingrain allergy treatment into the practice identity and patient experience by identifying and treating all allergy patients, regardless of whether their primary complaint is allergy. This can represent additional medical billing, and patients are satisfied when they get relief from a problem they may have begun to accept as part of life. And treating allergy, especially when we use our power to prescribe, reinforces the idea that we don't just prescribe eyeglasses, we treat disease.

Medical Practices Prescribe Tell patients to fill their allergy prescription at the pharmacy and use the medication according to your instructions. You want them to get results. You want them to see and feel immediately that the best way to get relief for ocular allergies is to go to the optometrist. That means you need to use the power of the pen to prescribe the best allergy medications. There are some comparable over-the-counter drugs, but they aren't as effective as prescription medications. And if you direct patients to OTC drugs, you're encouraging them to self-treat ocular allergy, rather than seeing you. Some medical prescription plans exclude certain allergy medications in favor of OTC drugs, and your staff should be prepared to handle that situation. They should know the ins and outs of various plans. If I know that a patient's insurance won't cover a prescription drug, I explain that an OTC drug may not offer the relief he needs. I write the prescription and let him make his own financial decision. Either way, patients should know that they will only get the best treatment for ocular allergy from an eye doctor.

Reinforce Your Medical Role ● Review medical insurance cards for patients up front. ● Relieve common, maddening problems such as ocular allergy and dry eye through medical visits and prescription medication, if indicated. ● Incorporate messages in the practice experience about your disease treatment services and the idea that patients should see you first for any eye-related concerns — not just every 2 years for eyeglasses.

Transitioning to a Medical Visit

It's common for patients who schedule an exam for new eyeglasses or contact lenses to have allergy symptoms and complaints. Some patients' allergy symptoms may not interfere with refraction, so you can treat the vision and allergy issues in a single visit. If you can't get achieve a good refraction because allergies have diminished the status of the ocular surface, you should turn the initial exam into a medical visit, treat the allergy, and have the patient return in a few weeks for refraction.

Many practices are not ready for a medical exam. In fact, one of the biggest pitfalls of some practices' medical treatment is that they're not agile enough to switch and bill medically while the doctor is seeing the patient. Whether the patient in the chair is a healthy 6-year-old or a 60-year-old with multiple eye diseases, you should have the flexibility to move the exam in the direction it needs to go.

My advice: Make it easy to make that change quickly and seamlessly.

The best way to achieve this seamless flow is to keep both vision and medical insurance on file for all patients. If your staff reviews patients' medical cards up front, you won't have to stop mid-stride and go through that process if a patient has allergy (or any other medical complaint). The process is more efficient. What's more, asking everyone for their medical insurance plants the seed in patients' minds that you handle medical problems — not just eyeglasses and contact lenses.

To increase practice efficiency after the exam, make sure that once you notify your staff that you've made the switch, they know to follow a standard schedule for setting follow-up appointments. Also, keep medical coding information at their fingertips.

According to Dr. Gaddie, when a patient comes in for new eyeglasses but has clear allergy symptoms (as shown here), you and your staff must be able to seamlessly switch to a medical visit.

How Does Bacterial Conjunctivitis Fit the Medical Model? Bacterial conjunctivitis is certainly a medical evaluation and treatment event. It requires an initial visit and prescription, as well as at least one follow-up visit to make sure the disease has resolved. However, most patients see their primary care practitioner or urgent care center for this problem. And because it affects so many more children than adults, pediatricians see the bulk of the cases, and most of those children have never visited an optometrist's office. This doesn't make bacterial conjunctivitis a very good basis for your medical practice model, but again, as with allergy, don't overlook the opportunity to reinforce your medical expertise. Choose a subtle way to let patients and parents of young patients know that you treat "pink eye," such as with a poster describing the signs and symptoms of the disease. Emphasize that they can see you for this problem immediately without a long wait for an appointment, but they should always see a medical professional as soon as possible. Also make patients understand through your questionnaires that you want to know every problem that they have had with their eyes, including any type of conjunctivitis that was treated elsewhere. This reinforces your role in handling this potentially dangerous infection.

"Next time, see me first."

Generally, patients aren't referred into or out of an optometry practice for allergies. We can treat ocular allergies on our own, as well as prescribe a systemic medication. When patients with allergies seek help from a doctor, they typically look to a primary care physician.

We see something of a trickle-down from the primary care doctors because they often put patients on an older class of medication that hasn't been used in the ophthalmic world in decades. They usually treat systemically, not specifically for the eyes, and systemic medications can make ocular symptoms even worse in terms of surface dryness. Patients find their way into our offices because despite taking allergy medication, their eyes are still feeling terrible. If they wear contact lenses, they're probably unable to wear them for very long.

This is a key teaching moment for our patients. We try to set up our whole office environment to speak to the idea that we are a primary eye care, �first-stop" practice, but no one hears it more clearly than patients who've already seen their regular doctors for an eye problem without success. We tell patients, "The next time you think you have a problem with your eyes, come to us. We have all the specialized equipment needed to diagnose and treat most eye problems because our primary focus is your eyes."

Identifying Every Allergy Patient To really offer our patients relief, get the best refraction from eyes free of allergy symptoms, and grow the medical side of our practices, we need to identify all of our patients with allergies. Some patients are easy because allergy is their primary complaint or their symptoms prevent an effective refraction, while others may just "get by" with itching and watering and expect no relief. Most of my allergy patients fall into two groups: 1. Eyeglass wearers with a vision change. These patients often come in for new eyeglasses because they think they've had a change in vision. We can't get a good refraction because allergies have diminished the status of the ocular surface. These patients need an allergy treatment prescription. Then, they should return in a few weeks for refraction to see if they do, in fact, need a new prescription. 2. Contact lens wearers with comfort and possibly vision issues. Contact lenses and allergic conjunctivitis are an inflammatory combination. Patients may be so uncomfortable that they can't wear their contact lenses, and many have vision issues. They need to get out of their contact lenses, use prescription allergy medication, and later return to contact lenses, wearing a short-term lens modality, such as a 1-day disposable, to avoid buildup of allergy proteins. Other patients may have allergy symptoms that don't interfere with the exam, so we can treat the vision and allergy issues in a single visit. Although there's no additional medical visit, the unexpected relief patients experience increases their satisfaction and reinforces your role in treating allergy. Questionnaires do wonders for identifying allergy patients with questions such as: Are you having trouble with allergy eyes this year? Do you experience any itching, burning, watering or redness? I see many positive responses, and I teach patients that they don't just have to live with allergy eyes. Allergies are a part of life, but the symptoms are treatable. Finally, be sure not to overlook patients whose questionnaires say "no allergies." Patients may be unaware that their symptoms are allergy-related simply because they've never been tested for allergies. Also, I've been seeing more and more patients who are experiencing allergies for the first time during their middleage to senior years.

Measuring the Rewards

A good prescription allergy drop takes care of allergic conjunctivitis, so the payoff in terms of additional medical office visits is low compared to a problem such as glaucoma. One additional visit is usually all it takes. Some doctors do two additional visits — medical for allergy, medical follow up, and then refraction — but that can sometimes inconvenience patients. Others bill a single visit medically and charge out of pocket for refraction, but that can mean perceived higher copays for patients.

I stick with what's necessary in terms of revenue from medical visits and take a larger view of the rewards of widespread allergy treatment, which offers us:

● The opportunity to raise awareness of our medical practice identity among patients
● Increased patient satisfaction with comfort that exceeds expectations
● Some additional medical visits (usually one, but more for patients who have concurrent blepharitis or inflammatory dry eye)
● Added marketing and advertising appeal in a market where all people talk about allergies.

If you live in an area with a sky-high allergy rate, widespread allergy treatment is mandatory. However, even if you live in a blissfully pollen-free zone where only 30% of patients have allergy symptoms, you have a good practice opportunity. Identify all of your allergy patients, prescribe the best treatment and emphasize the capabilities of your medical practice.

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Dr. Gaddie is CEO of Gaddie Eye Centers and president of Gaddie Consulting in Louisville, Ky. In addition, he is vice president of the Optometric Glaucoma Society and President-elect of the Kentucky Optometric Association. E-mail Dr. Gaddie at ibgaddie@bellsouth.net.