Prescribing keeps patients in an OD's practice, contributes to bottom line

Issue: November 1998

Now that optometry enjoys a clean sweep of therapeutic privileges in all 50 states, Washington, D.C., and Guam, more practitioners are realizing the impact that prescribing therapeutics has on the bottom line of their practices.

In addition to the financial benefits of prescribing, many practitioners also notice the intangible benefits of offering patients a single office to address all their eye care needs.

"To put a percentage figure on what therapeutics does for you is difficult, but it does give you a total scope [of practice]," said Bobby Christensen, OD, FAAO. "You an provide complete eye care for patients, and they don't worry about finding other practitioners to take care of them."

In this feature, Primary Care Optometry News interviewed five practitioners about the number of prescriptions they write each week, what they prescribe and how prescribing has added value to their practices.

Primary Care Optometry News: How much of your income is derived from therapeutics?

Ken Bumgarner, OD: It directly affects 30% of our annual income. However, there is a large, intangible benefit that comes from patients knowing you can treat disease. They will come to you for a routine eye exam because they know if there's a problem you can take care of it in the office. You're going to have more patients because they can "one-stop shop" and get everything from glasses to treatment for most pathology. I do about 2,070 scripts per year, which averages out to about 9.2 prescriptions a day or 46 a week, based on working 45 weeks a year.

Bobby Christensen, OD, FAAO: My practice income derived from prescribing, if you look strictly at office visits and procedures performed, was 13.5% for the first 9 months of 1998. This is fairly inaccurate, because therapeutics keep the patients in your practice. When you monitor patients for cataracts and perform the preoperative and postoperative work for their surgery, they will come back to you for glasses, and their families will keep coming to you. This also pertains to patients who come in for treatment of red eyes - if you take care of them and all of their needs, the likelihood of them coming back to you for contacts and glasses is much greater.

Michael Clark, OD: Approximately 30% to 40% of my practice's actual income is derived from therapeutics. For example, during the month of August, 18 doctor days were worked for a total of 130 medical office visits.

Steve Eyler, OD: It ranges from 8% to 12% of the gross revenues for the year. Those are gross revenues that are not tied to material costs. In this managed care era, you like that. The revenues are tied to health plans and Workers' Compensation, which are free from materials and a lot of the cuts you're seeing in some of the preferred-provider organizations and HMOs. That is a rough estimate and doesn't include routine eye exams for patients who have ocular disease related to a systemic condition, such as diabetes or hypertension.

Paula Newsome, OD, MS, FAAO: I would say that roughly 30% of my bottom line is related to therapeutics. My current practice comprises three optometrists, three opticians, one ophthalmologist. We are located in the greater Charlotte (North Carolina) area. Our patient demographics are 45% white, 45% black, 5% Asian and 5% Hispanic.

PCON: From which categories do you prescribe?

Dr. Bumgarner: Antihistamines account for about 15% of my prescribing; anti-infectives, 14%; anti-inflammatories, primarily non steroidals, topical, 7%; miscellaneous analgesics, antivirals and oral medications, 9%; glaucoma medications, 17%; and steroids, 18%.

Steroid-antibiotic combinations are about 20% of what I prescribe. Steroid-antibiotics are a big part of prescribing the combo-drugs. The more mature we get in therapeutics, the more you're going to see a lot of steroid-antibiotic combinations. It saves the patient money, and you're more likely to get patients to comply by using combinations when possible. My anti-allergy agents would include antihistamines, steroids and nonsteroidal anti-inflammatories.

Dr. Christensen: There are four doctors at Heritage Park Vision Source, and we all prescribe. The number one category, by far, is glaucoma. With glaucoma treatment, you have patients refilling prescriptions on a 3-month or 6-month basis, and that's a constant medication they're taking all the time. We have about 250 glaucoma patients, who refill their prescription at least every 3 months. It varies depending on the size of the bottle and number of drops they take per day.

Allergy medications prescribed for patients account for a fairly large number of prescriptions. During the spring and fall, we prescribe a lot. Scripts for allergy medications average two to three per day, but there might be some days where you write 15 and some where you write none. Over-the-counter medications are often prescribed and still produce revenue.

The steroids and anti-infectives run neck-and-neck as far as the number of prescriptions written. A lot of steroids are used after refractive surgery and cataract surgery - many are combination. You might write one or two a day in that category.

As far as writing prescriptions for NSAIDs, they are pretty low-usage drugs, even though they are handy. It's going to be less than 2 or 3 a month. We use oral analgesics quite a lot in conjunction with NSAIDs for eye pain and inflammatory processes, such as uveitis. I probably prescribe aspirin or ibuprofen once a day.

Oral steroids and oral narcotics are very low usage drugs. You just need to have them available when you have a patient who meets the needs for these classes of drugs. In our office, the least written prescriptions are antivirals for herpes simplex infections. We may use that drug once every 2 months, but it's a very important drug to have available.

Dr. Clark: I have been prescribing therapeutics since 1977. I prescribe from all of the drug categories and write 20 to 30 scripts per week (4 doctor days). Most of my prescriptions are for glaucoma, allergy agents and anti-inflammatories. The remaining scripts are for anti-infectives and analgesics. Only occasionally do I prescribe antivirals.

I believe the take-home message is to diagnose carefully and provide the most efficacious care for your patient. I would certainly encourage every appropriately certified OD to treat eye diseases, even though for many practitioners this involves shouldering new responsibilities. The key to treatment is to make an accurate diagnosis. I also believe that every OD treating eye disease should be familiar and comfortable with the documented guidelines for the use of all CPT evaluation and management (E/M) 99000 service codes.

Dr. Eyler: I have been practicing since 1977. On any given day, I'll write about 10 prescriptions, and our practice writes about 20 per day, so conservatively I'd say about 100 per week. These may be written or called in or refills.

The number of prescriptions written daily or weekly depends on the time of year. If it's allergy season, we'll write more, but if it's a typical time, the allergy medicines might range from 10 to 20 per week. The anti-infectives would probably range from 10 to 15 per week. Glaucoma would probably range from 20 to 30 per week. In one location in particular that has a substantial glaucoma practice, we probably see three to five patients in some stage of management a day.

We write one to three prescriptions for antivirals and analgesics per week. Nonsteroidal anti-inflammatories would probably be in the five-to-10 range. Steroids would probably be 10 to 15 per week.

Dr. Newsome: I have been prescribing for 14 years. My breakdown by category and numbers is 52% glaucoma agents, 23% anti-inflammatories, 10% steroids, 8% anti-infectives, 5% allergy, less than 2% analgesics and less than 1% antivirals. Glaucoma and allergy are big for me, but so is postop care for cataract surgery. The key for me is that there is little additional cost associated with prescribing. The overhead is the same.

PCON: How important is it for optometrists to have a Drug Enforcement Administration (DEA) number? How does having this number - or not having one - affect your relationship with pharmacies and insurance carriers?

Dr. Christensen: DEA license is required to be able to write schedule drugs. We are allowed to write schedule drugs for Schedules III, IV and V. When local pharmacies need the DEA number for filing the insurance, it's important to have. That doesn't seem to be too big of an issue, not as big as we all thought it was going to be.

Pharmacists view you as a member of the health care team. But the DEA number is important for some of the insurance plans. We don't print it on our prescription pads, and that's sometimes a problem because then when pharmacies register a drug into the system showing how many prescriptions we've written, it's not counted.

Dr. Bumgarner: Having a DEA license will become more important in managed care. In managed care contracting, different programs - discount fee-for-service, partially capitated and fully capitated contracts - will be available. Many times, with the group we're with, we will sign a contract to be on Workers' Comp that does not include eyeglasses and routine eye exams. But because we are on Workers' Comp we have to be certified to provide medical coverage for people on the plan. That's where I think our DEA license and therapeutic laws are going to be important for us in managed care. A lot of managed care programs require the practitioner not only to have a therapeutic license, but, also in some situations, to have hospital privileges. That's why it's important for therapeutics and hospital privileges to be a big movement in optometry over the next few years.

Dr. Eyler: We are provided with samples now that many of the large pharmaceutical companies have realized that detailing the optometrist is good business. On the weekend, it's nice to have a sample for a prescription antibiotic or anti-inflammatory. De tailing is a major factor in prescribing glaucoma medications. Nobody wants to buy a drug that's not going to work in a week.

We have good relationships with all of our local pharmacies. We don't really try to cut into their business [by sampling] unless it's an unusual circumstance: someone who doesn't have the funds to buy medications, or an emergency situation on the weekend or after hours.

PCON: Are you currently enrolled in a capitated managed care contract?

Dr. Bumgarner: Right now, we are not enrolled in a pure, fully medical-surgical, routine eye wear and eye care program. However, we belong to a management service organization with about 120 other doctors that has a network of about 300 doctors in North and South Carolina called the Carolina Eye group. We are fully prepared to negotiate for contracts. We are getting competitive in the managed care arena, but there aren't a lot of capitated contracts written in North Carolina at this time.

Dr. Christensen: No, we are not enrolled in any. We've been approached by a few and, to date, there have been no capitated plans in which we would make a profit. If we are to provide the care that we deem appropriate for the patient, we just can't break even.

Some doctors will always sign up for them. Patients will tend to go where their insurance plan is, even if they're a friend of yours. They will go to the provider who is on their insurance list.

Dr. Clark: I am enrolled in a managed care contract that includes comprehensive eye care and in contracts that are limited to glasses and contacts. Contracts that do not recognize the full scope of optometric practice really set back the profession.

Dr. Eyler: Yes, we are enrolled. They vary: some cover just eye examinations and emergency care, others provide for just glasses and contacts and many provide both. For some, you have to get approval to treat the disease once you've diagnosed it. It has its ups and downs. I think managed care from a disease standpoint or even from a glasses and contacts standpoint certainly reduces the net profits - your percentages aren't as high.

I suppose the upside is it helps optometrists who are starting solo practices in this day and age. You get on a few plans, and you can almost do it on your own like the old days.

Dr. Newsome: We are not currently participating in a capitated contract. We do participate in numerous managed programs. I actually lecture on managing managed care and several areas to consider when selecting a plan. It may not be a wise strategy to just sign up for a plan just because they send you the paperwork. You have to pick plans that work for you and your practice.

For Your Information:

Ken Bumgarner, OD, can be contacted at Spectrum Family Eye Centers, Optometric, P.A., 20 Commons Plaza, Southern Pines, NC 28387; (910) 692-3937; fax: (910) 692-5908.

Bobby Christensen, OD, FAAO, is in private practice and lectures widely on therapeutic pharmaceutical agents. He can be reached at Heritage Park Vision Source, 6912 E. Reno, Suite 101, Midwest City, OK 73110; (405) 732-2277; fax: (405) 737-4776.

Michael Clark, OD, may be contacted at Mt. Airy Vision Center, P.O. Box 348, 602 S. Renfro St., Mt. Airy, NC 27030; (336) 789-9031; fax: (336) 789-8343.

Steve Eyler, OD, president of University Eye Associates, can be contacted at 6604 East Harris Blvd., Suite E, Charlotte, NC 28215; (704) 536-6042; fax: (704) 563-5917.

Paula Newsome, OD, MS, FAAO, may be contacted at Acusight Eye Associates, 107 West Morehead St., Charlotte, NC 28202; (704) 375-3935; fax: (704) 333-7238; e-mail: paulanews@aol.com.