October 2012

Contributing Physicians:Faisal Haq, MDMitchell A. Jackson, MDCynthia Matossian, MD, FACSJ.C. Noreika, MD, MBAJames J. Salz, MD

Sponsored by

Combining the Best Clinical & Financial Considerations

for a Winning Practice

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ne of the most important aspects ofprofessional growth for ophthal-mologists involves the adaptationof technology. Cataract surgery inparticular has been completelyrevolutionized over the past two

decades due to numerous technological advances. Newsurgical techniques, better IOLs and increasingly so-phisticated diagnostic equipment have all contributedto the cataract surgery revolution. With the advent ofthe baby-boomer era, the demand for our services andthe demands of our patients for precision will only in-crease. We all face the challenge to provide top-notcheye care while retaining efficient processes. Onceagain, technology has come to the rescue.

I work in a practice with multiple office locationswhere we see several hundred patients a day. Thetechnologies that we’ve invested in have enabled usto not only provide ever-improving patient outcomes,but have also been instrumental in optimizing our efficiency and improving our patient flow. The EPICrefraction system (Marco) has been a key addition toour practice that has helped us achieve this improvedquality of care while simultaneously improving ourefficiency. We purchased our first EPIC system 8 months ago and were so impressed with it that weadded a second unit 3 months later. The system, comprised of the TRS digital refractor and the inte-grated OPD-Scan III (Marco) component, gives us a reliable, fast refraction as well as a detailed cornealanalysis that aids us in multiple ways in the pre- andpost-operative management of cataract patients.

Refraction and Pre-Op ExamThe EPIC system allows our technicians to obtain anaccurate refraction in 2 to 3 minutes. The OPD takesabout 30 seconds for autorefraction, keratometry,pupillometry, corneal topography and wavefront aber-

rometry. Additionally, if the patient has a glare com-plaint, we can perform a quick glare test with the EPICsystem that takes another 30 seconds.

With the data obtained by the EPIC system, wecan quickly access information that is useful in determining a patient’s need and eligibility forcataract surgery or for a YAG capsulotomy. In addition, the OPD device provides me with a wealthof information that I can use to determine a patient’seligibility for a specific type of IOL. For example, ifthe corneal aberration profile shows significanthigher-order aberrations, I won’t recommend a multi-focal lens. Also, if the OPD shows a high anglekappa, I will be less likely to implant a multifocallens due to difficulty centering the lens over the visual axis. The OPD also allows me to separate theaberration profile of the cornea from the lens. It’shelpful to show patients the degree of their aberrationcoming from their cataract versus that originating inother parts of their eyes.

Some patients require “fine tuning” post opera-tively with laser refractive surgery to achieve thedesired refractive outcome. With the OPD axialcorneal topography, I can determine patients’ eligi-bility for laser vision correction. If they’re not goodcandidates, I can have a candid discussion withthem regarding their potential final outcomes.

Glare TestingConsistent, reliable and reproducible data derivedfrom the glare testing feature on the EPIC unit aids indetermining a patient’s eligibility for either cataractsurgery or YAG laser capsulotomy. Previously, weused the Brightness Acuity Tester (BAT, Marco) tomeasure the degree of glare related impairment in ourpatients. We found that there was significant techni-cian- and patient-related variability with this test. Withthe EPIC glare test, the patient and the doctor can both

Informative Tools for Cataract Treatment

Technologies that provide fast and accurate data guidekey treatment decisions.

OBY FAISAL HAQ, MD

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quickly ascertain how much impairment a patientfaces when exposed to glare in real-life situations.We’re in a better position to determine the level of impairment that the patient faces due to glare, and thisallows us to make better clinical decisions regardingthe need for cataract surgery or for YAG capsulotomy.

Post-operative AssessmentI perform an OPD and EPIC refraction on all of my pa-tients that have a presbyopia-correcting lens or a toricIOL. Beyond the obvious refraction and topographydata, the OPD provides an aberration profile that sepa-rates the cornea from the lens. That way, if a multifocalIOL patient is having difficulty with his vision, I canquickly determine if there are any significant aberrationspresent in the IOL itself (for example if there is subtlelens tilt or decentration) or if the problem is purely re-fractive in nature. This information helps me decide be-tween an IOL exchange or laser refractive surgery.

Similarly, for a Crystalens (Bausch + Lomb) patient, if there’s significant astigmatism that is lentic-ular in nature, I very carefully look for any asymmetricvaulting that may need to be corrected prior to anyconsideration of laser refractive surgery. For patientswith a toric IOL, I can quickly assess the level of their

corneal astigmatism and compare this to the level oflenticular astigmatism. In an ideal case, the two num-bers should be similar in magnitude and exactly 90°away from one another.

A Wise InvestmentThe EPIC system provides our practice with a diagnostictool that helps not only to improve our clinical outcomes,but also improves our patient flow and overall efficiency.It’s an investment that we feel easily pays for itself. Patient wait times have been reduced, we’re seeing morepatients than before and we’re performing more surgerythan we did in the past. Also, a larger percentage of ourpatients are choosing presbyopia-correcting lens implantsbecause we’re able to actually show them the results oftheir OPD scans and talk to them about customized lenschoices based on their unique eyes. The dual clinical andfinancial benefits of this technology have made it an inte-gral part of the pre-operative and post-operative manage-ment of our cataract patients.

Faisal Haq, MD, specializes in cataract, vision correction surgery, corneal disease and glaucomamanagement at Key-Whitman Eye Center in Dallasand Plano, Texas.

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An OPD-Scan III Q&A

QDoes the OPD-Scan III help you choosethe right IOL?

“I often speak on the three ‘hidden threats’ to pa-tients’ satisfaction with their IOLs: pupil size,spherical aberration, and angle kappa. The OPD IIImeasures photopic and mesopic pupil size, wave-front data to 9.5 mm, and angle kappa in easy-to-interpret mm or degrees, all in a single, fast sitting20 second bilateral diagnostic evaluation. Withthis data I will know if I should insert a multifocallens based on angle kappa data as I presented atthe recent ESCRS meeting in Milan, Italy. I can se-lect a lens implant based on spherical aberrationdata as well. I have all the data I need to choosethe most appropriate IOL implant based on OPDIII data, which relates directly to satisfied patientsafter surgery.”

QDo you use the OPD to educate patients?

“One great way to use the OPD III is to show a patient a map of the astigmatism created by boththe lens and the cornea, and then easily demon-

strate in the exam room what corneal astigmatismwill remain by removing the lenticular portionduring cataract surgery. The OPD III graphic in thissetting saves a lot of chair time especially whentrying to upgrade a patient to a toric IOL implant.I basically tell the patient, ‘After we remove yourcataract lens, we need to correct this remainingcorneal astigmatism. We could do it with glassesor a toric lens implant.’

QUsing one multipurpose device is efficient. Is there a clinical advantage?

“In addition to pupil size, spherical aberration, andangle kappa, the OPD III performs blue light cornealtopography and measures lenticular astigmatism,and it only takes 20 seconds for both eyes. Thathelps patient flow, but it also means we get greateraccuracy. With older (especially less mobile) and/ordry eye patients, using multiple devices can dessi-cate the ocular surface and eventually compromisethe accuracy of later diagnostic tests. In contrast,most patients are fine with keeping each eye openfor 10 seconds with the OPD III.”

By Mitchell A. Jackson, MD, Medical Director of Jacksoneye in Chicago and Lake Villa, Ill.

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maging and diagnostic technologies continuallyexpand our understanding of ocular pathologies.In just a few minutes, we can get more information than ever before about the state ofour patients’ eyes. The OPD Scan system (Marco)is just such a device, providing refraction, corneal

topography, optical path difference and wavefrontanalysis in one brief sitting.

The data, including mapping and other analyses,help us diagnose patients and make treatment decisions,particularly for patients who are candidates for cataractsurgery or laser vision correction. The visual nature ofthe reports also illustrates the situation for patients,which means their treatment makes sense to them andthey know what to expect in terms of outcomes.

Clinical AdvantagesThe OPD helps me achieve the desired outcomes forboth cataract and laser refractive surgeries. Before Ichoose an IOL or decide on limbal relaxing incisions, Ineed answers. Does the patient have astigmatism? Is itcorneal or lenticular? Is it symmetrical or asymmetrical?What size is the pupil? Are there corneal aberrations?

The OPD answers these questions. For example, ifa patient has astigmatism, I can plan to use a toric im-plant or limbal relaxing incisions with the femtosec-ond laser. Because the system arms me with all therelevant information, I’m very confident about myIOL choices, and outcomes are excellent. Patients paya premium for a premium lens, and they are happywith their resulting vision. The technology helps meachieve that primary goal of surgery.

When it comes to laser refractive surgery, the OPD’s routine refraction helps me identify candidates.If a patient is a candidate and has an interest, we alsocollect data on the patient’s higher-order aberrations(spherical, coma, trefoil and tetrafoil). The device’s ability to measure pupil size is as importantfor these patients as it is for those undergoing cataract

surgery who want multifocal IOLs. The instrument alsohas a printout that’s specifically for LASIK, so it’s con-venient for my evaluation and for carrying into surgery.

Teaming with PatientsThe OPD lets you educate patients graphically, bring-ing abstract or complex concepts firmly into theirgrasp. And when patients and surgeons are both on thesame page, we can all work toward the same goals.

For example, it’s most impressive to show patientswhat their astigmatism looks like on the topographicmap. Because they can visualize the astigmatism, theyhave an easier time understanding the decisions relatedto the problem. I explain the effect that the treatmentwill have, so they can see why we need to use a toriclens, or why we’ll use a multifocal lens and correct theastigmatism with limbal relaxing incisions.

The system also lets me show patients a map of theaberrations in their visual system. They see how muchspherical aberration they have, and I explain what thatmeans in terms of halos and glare, which helps usagree on an appropriate treatment.

After cataract surgery in which we’ve successfullycorrected astigmatism, it’s nice to show patients thedifference in the pre- and post-op topography. Theycan see how the aspheric lens has reduced sphericalaberrations. With a toric lens, they can see how astigmatism is still present in the cornea, but the lensnegates the total astigmatism. Patients understand andappreciate just how effective their surgery was.

Although much of this data was available beforethe OPD-Scan, it required us to move patients betweenfour different instruments. The system makes it practical to routinely use this high level of testing.

James J. Salz, MD, is clinical professor of ophthalmology at the University of Southern California and President of Laser Vision MedicalGroup in Los Angeles.

Clinical Advantages of the OPD-Scan

When a high level of evaluative technology becomes routine,outcomes for cataract and LASIK surgeries improve.

IBY JAMES J. SALZ, MD

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Time, Money, and the Patient Experience

Top technology purchases meet three strategic goals,while delivering a distinct clinical advantage.

BY ERIN MURPHY, CONTRIBUTING EDITOR

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eeling today’s economic pressures and facingchanging regulation, ophthalmologists havebeen forced to find ways to increase theirpractices’ profitability. There are many waysto approach this, including some relativelysimple changes with major benefits.

Dr. J.C. Noreika, the managing partner of Excel-lence in Eyecare in Medina, Ohio, has taken a verystraightforward approach. “I’m one of my practice’srevenue generators. The more tasks I can delegate, themore energy I can expend on high-level, well-compensated work and the more profitable the practicewill become. New technologies like the EPIC makethis possible,” he says. “I purchased the EPIC becauseit offers sophisticated clinical advantages while meet-ing my three strategic criteria for evaluating the purchase of new technology. The results have been rewarding and can be replicated in other practices.”

Achieving the Big 3Economic pressures make purchasing decisionsweightier than ever. Dr. Noreika approaches his deci-sion with a concrete set of criteria in mind. “For newtechnology to justify investment, first and foremost itmust improve patient outcomes compared to our exist-ing devices,” he says. “Beyond that clinical advantage,the investment only makes sense if it meets threemeasurable objectives: it saves time, saves money andenhances value and satisfaction for the patient.”

According to Dr. Noreika, the EPIC improves out-comes and it excels at all three goals. The clinical advantages include not only very accurate refractions,but also enhanced data for diagnosis, surgical decision-making and post-operative evaluation.

It’s clear to Dr. Noreika how the EPIC saves timeand money. “We use it on all new patients, saving timeover manual refraction. Surgical workups also takeless time because patients are afforded a variety oftests at a single workstation. The need to move

patients, a measurable source of wasted time, is kept toa minimum,” he explains. “Money is saved in manyways with the EPIC – most notably in time saved andthe ability to use staff with less expertise to performthe straightforward yet sophisticated procedure.”

The EPIC also meets Dr. Noreika’s third goal, enhancing the patient experience with the technology’s“wow factor.” When people come in for their exam andsee the EPIC, they recognize that the practice embracescutting-edge technologies. This helps differentiate itfrom the competition, particularly commercial visioncare providers. Dr. Noreika finds that this also results inreferrals, as patients tell their family and friends. In thissense, the EPIC is part of the practice’s internal marketing efforts. It impresses patients and attracts newcustomers through word-of-mouth without the addedcost of media advertising.

Opticians Performing Refractions“Staffing is my largest cost center,” Dr. Noreika observes. “Cross training is a way to make the most ofthat cost by enabling staff to work where they’reneeded during periods of downtime or when acoworker isn’t available. The ease of training and useof the EPIC has allowed me to take cross training to anew, more profitable level.”

Dr. Noreika has trained all three opticians in hispractice to perform refractions with the EPIC, a taskwhich they have readily adapted because of their fa-miliarity with optics. By performing the refraction, theopticians have an unprecedented opportunity to “own”the vision correction process from start to finish. Theyspend about 10 minutes preparing the patient and per-forming the EPIC refraction – 10 minutes in whichthey also establish a relationship and identify the pa-tient’s vision needs. Next, they hand the patient overfor the clinical examination, and then reunite afterwardto transition to the optical area.

By guiding the patient through the entire visit,

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Dr. Noreika has found that the opticians significantlyenhance the capture rate. At a time of decreasing reimbursement for clinical services, it’s an enormousbenefit to grow the dispensary’s economic contribu-tion in this way. Patients benefit as well because theopticians better understand their individual needs. Forexample, one optician is dedicated to refracting allpost-operative cataract patients, walking them throughthe process, from determining their optical needs, per-forming the EPIC refraction, selecting frames andlenses and finally to dispensing a product.

“The role of our opticians has become a key pieceof the practice’s efficiency,” states Noreika. “I’m sur-prised I didn’t implement this sooner, but I couldn’thave cross-trained opticians to do this with a manualphoropter. The EPIC creates this valuable opportunitywhile reducing the dependence on hard-to-find, highly

compensated technicians and optometrists who had performed our refractions in the past.”

Another advantage of this model is an increase inthe opticians’ job satisfaction. According to Noreika,other personnel who are cross-trained on the EPIC liketheir jobs better, too. “One of my most importantstaffers who had more than 20 years vested in our prac-tice needed a change from her administrative role. Sheis now our best refractionist. Her work has been revital-ized, and rather than losing her, I gained an asset.”

Premium ExpectationsAnother challenge facing ophthalmologists in all areasof practice is the entwined nature of technology andexpectations. For example, cataract patients have farmore choices today than they did even 10 years ago.Standard, toric and multifocal IOLs and limbal relax-ing incisions have the potential to deliver unprece-dented vision after surgery. Therefore, patients expectto be wowed by their vision after surgery, and theydon't want to encounter unforeseen issues. The highout-of-pocket price tag for premium IOLs cementsthose expectations. There is little margin for error.

Dr. Noreika has found that the EPIC is critical forpatients who choose premium IOLs because the pre-op-erative workup leaves little room for error. An accuraterefraction, corneal topography and wavefront analysis,combined with accurate A-scan axial length ultrasonog-raphy and OCT help him achieve the best outcomes.

To balance the clinical advantages of technologyagainst its cost, the practice prequalifies patients forpremium IOLs. “When we identify the need for sur-gery, we give patients a thumb drive that explains theirpremium lens options, the processes involved, and thecost. Our senior citizens have become digitally adept;they review the information at home and share it withfamily,” says Dr. Noreika. “Once a patient’s interest ina premium lens solution is determined, their decisionguides the next step in the process.”

At the cataract surgery workup visit, patients withan interest in premium lenses follow one protocolwhile patients who want standard lenses follow an-other. For example, premium lens patients get an OPDscan and more time for face-to-face discussion withthe doctor.

The high standards for outcomes change the post-operative model as well. In Dr. Noreika’s practice, opticians perform the post-op refraction, directing bothpremium and standard lens implant patients throughthe EPIC and the OPD, and then meeting up to assistthe patient in the optical dispensary after the clinicalexam.

Dr. Noreika says that this post-op visit is a keyjuncture in ensuring patient satisfaction. “The lastthing I want is to perform successful surgery and thenhave the patient experience issues with their eye-glasses,” he says. “If eyeglasses are required aftercataract surgery, our office will supply them, whichmeans the limiting variables are the quality of the refraction, the selection of frames, the lenses and theirfitting. The EPIC and the opticians remove these ques-tion marks. And I avoid the expensive proposition ofspending 20 minutes listening to a patient who haseyeglass problems.”

Positioned for the FutureIn addition to its significant clinical and financial benefits today, the EPIC is a keystone of Excellence in Eyecare’s strategic plan for future profitability. Dr. Noreika says that the Affordable Care Act meansthat vision care providers will have to accommodatemany more patients, while the newly insured patients will be younger and healthier because older patients already have health insurance through Medicare.

“The EPIC is an excellent fit for this situation. Not only does it help us see more patients efficiently,but the refraction is quickly performed on thoseyounger patients. At the same time, this patient cohort embraces technology and has high expectations. TheEPIC excels here as well,” he says. “All in all, I knowthat the EPIC has meaningful clinical and financial advantages today. I’m confident that it will be increasingly useful in a changing and unpredictable healthcare environment.”

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“The ease of training and use of theEPIC has allowed me to take crosstraining to a new, more profitable

level,” says Dr. Noreika.

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hen I purchased the OPD-Scan III (Marco), I realizedfrom the start that I wanted touse this technology on everypatient scheduled for cataractsurgery. I knew that without

the data it provided, I couldn’t accurately and consis-tently match the IOL to each patient.

However, Medicare and other insurance carriersdon’t cover the OPD III test, so I needed a way to gen-erate compensation from my patients to cover the costof the equipment and the cost of my technicians per-forming the test. I worked with the folks at Marco,who suggested charging a fee that was determined bycombining cost and patient volume. From day one, Ihad no problem getting patients to accept this fee, andI’ve always had them sign an Advance BeneficiaryNotice of Noncoverage (ABN) form to ensure that Ican bill them for payment.

The result: An indispensable clinical device thatpays for itself.

Getting the ABN SignedThe key to getting virtually all of my patients to acceptmy fee for the OPD III, $90.00, is in getting them to un-derstand the importance of the test and how it will bene-fit them. To do this, I stick to a very simple process withevery single candidate for cataract surgery.

At the time of the cataract consult, if there is a visually significant cataract and if the patient and Iagree that cataract surgery would be beneficial, I explain that he will need to return for biometry and avariety of additional tests, one of which is the OPD III.These tests are scheduled several weeks later, givingme time to optimize the patient’s ocular surface.

Moreover, I explain to the patient that the OPD IIIis not covered by insurance; the test has a $90.00 out-of-pocket cost for both eyes. (I emphasize that the costis not $90.00 per eye). In addition, I hand the patientan information sheet on the OPD III. I review how the

data are essential in helping me customize the IOL toeach of the patient’s eyes in order to obtain the bestpossible visual outcome. I also stress that without thedata, I can’t select the best IOL.

I explain that patients don’t need to pay this feeuntil their next appointment. I then ask the patient tosign the ABN. Because the ABN gets signed at thecataract consult visit, my staff and I don’t need to reopen that discussion at the biometry appointment.

This whole interaction takes less than 1 minute.It’s very successful; in a year, about two patients decline the test. Because my patients understand theimportance of the OPD III for their visual outcomeand they have lead-time to get their payment ready,they don’t object to the $90.00 fee.

Reinforcing the Test’s ValueWhen I have all the information from the OPD III, Idisplay it on a large-screen monitor in the exam roomto show my patients and their families. Not only isthere a huge “wow factor,” but the display also allowsme to demonstrate to patients the value of their out-of-pocket payment. I always say, “This is the $90 test,” asI point to the information from the OPD III. This reaf-firms that although the test costs some money, it’s anintegral part of their surgical planning.

Because I give patients this visual explanation,pointing to the various displays that help me choose atoric or multifocal lens, my conversion rate is veryhigh. We’re not talking about abstract concepts; we’relooking at tangible images and reports that prove pre-mium lenses will deliver better outcomes. For exam-ple, I can get many more patients to understandastigmatism by showing them the “bowtie” in agraphic display than I ever could by explaining thisdifficult concept verbally. My patients visualize theirastigmatism and agree to a toric lens.

Patients verify for themselves that they’re candi-dates for premium IOLs such as torics, multifocals oraccommodative lenses, or a procedure like a limbal

Cover Costs Using an ABNCollect a fee for the OPD-Scan III test, boost

conversion rates, and create positive word-of-mouth referrals

WBY CYNTHIA MATOSSIAN, MD, FACS

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relaxing incision. This makes them more confident infollowing my recommendation. The higher conversionrate to out-of-pocket procedures is another way thatthe OPD III creates additional revenue.

Implementing the ABN Offering advanced technology such as the OPD cre-ates added revenue opportunity. If the test isn’t cov-ered by insurance, the only way to charge is out ofpocket. And the only way to charge Medicare patientsout of pocket is to have them sign an ABN in advance,accepting responsibility for payment.

I follow my plan religiously with every patient, explaining the importance of the test, the fact that thereis a fee and the Medicare requirement that they mustsign an ABN form for any out-of-pocket fee. As I’mhaving the discussion, a technician hands me the form.I initial it, and the patient signs as well. The wholeprocess adds less than a minute to my cataract consul-tation. When patients return, the form is already in theirchart, and we proceed with the test and charge the fee.

Unlike some of my colleagues, I don’t selectivelyuse the OPD-Scan III; I use it for every cataract sur-gery patient. When I present this model for using anABN to colleagues, I think that some are hesitant because they aren’t familiar with the form. It’s verysimple when you make it a scripted part of yourcataract consultation. It’s also an absolute requirementof Medicare. With this model, we have very satisfied patients with outstanding surgical outcomes who become our goodwill ambassadors.

Cynthia Matossian, MD, FACS, is owner of Matossian Eye Associates, an integrated ophthalmology and optometry practice in Doylestown,Penn., Hopewell, N.J., and Hamilton, N.J. Contact herat Cmatossian@matossianeye.com.

Fee: I charge patients a fee for the test. Virtuallyno patient objects to the fee; I have them sign anABN during the consult to be sure that I can billfor it after the exam.

Conversion rate: The OPD III has increased myconversion rate for premium IOLs. I use it to helppatients visualize conditions such as astigmatismand show them the information I’m using to se-lect the best IOL for them. This boosts their con-fidence in my choice, and as such, more of themgo with the recommended IOL.

Word of mouth: Because I use the OPD III, I’mable to customize the best IOLs for my patients. Ialso use the information to ensure that patientswith pre-existing conditions don’t mistake theseproblems as results of surgery. Consequently, patient satisfaction is very high, and patients telltheir friends and families.

How the OPD III Pays for Itself

Editorial StaffEDITOR-IN-CHIEF, Ophthalmology Management: Larry E. Patterson, MD

EDITORIAL MANAGER, SPECIAL PROJECTS: Angela Jackson

EDITOR, SPECIAL PROJECTS: Leslie Goldberg

CONTRIBUTING EDITOR: Erin Murphy

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Ophthalmology Management is published by Springer VisionCare. Copyright 2012, Springer Science + Business Media. All Rights Reserved.

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