SHARED CARE IN TODAY’S DRY EYE PRACTICE counselors really does save time in the clinic. I’d be remiss if I didn’t recom-mend Dry Eye University for all staff and providers. REDUCING BACTERIAL LOAD WITH HYPOCHLOROUS ACID → A RECENT CLINICAL STUDY authored by Stroman and colleagues 1 looked at the magnitude of bacterial load reduction on the periocular skin using pure hypochlorous acid cleanser (Avenova, NovaBay). Looking at 71 eyes across four sites, the study concluded that Avenova reduced the bacterial load significantly without altering the diversity of bacterial spe-cies remaining on the skin under the lower eyelid. The study introduced the periocular skin as an ecosystem of diverse habitats and niches that support a wide array of microorganisms, includ-ing bacteria, fungi, and viruses. Meibomian gland dysfunction (MGD) was referenced as a well-recognized cause of tear instability — an important contributing factor in dry eye disease — and a cause of chronic meibomian gland inflammation and vascular changes around the eyelid margin. The authors discussed Avenova’s broad spectrum of activity and rapid kill kinetics because it acts as an oxidant. Its bactericidal effect is the result of lipid peroxidation or halogenation. The most prevalent strains, Staphylo-cocci and S. epidermidis had reductions in colony forming units of 99.6% and 99.5% respectively. Additionally, Avenova removed staphylococcal isolates that were resistant to multiple antibiotics equally well as those isolates that were susceptible to antibiotics. REFERENCE 1. Stroman DW, Mintun K, Epstein AB, Brimer CM, Patel CR, Branch JD, Najafi-Tagol K. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol . 2017;11:707-714. Carrie Jacobs, COE: I would like to ask the physicians on our panel how they respond when a patient asks how much a therapy will cost. Even though costs should be addressed by the counselors, I know every doctor hears that question. Dr. Yeu: I may mention a round-about figure, but I usually say I don’t know the exact cost. I tell patients, “We are a comprehensive dry eye practice, and we offer the entire spec-trum of services that are available to take care of you. Some are covered by insurance, but some are not.” I refer the patient to our counselor after that. I think most patients understand that ours is a highly specialized practice. I should mention that just as we have refractive package options for cat-aract surgery, we have package options for patients who need dry eye care and maintenance. Therapy may start with LipiFlow, but patients may have several BlephEx treatments during the year to extend the effect, particularly if they have moderate to severe disease. The package option provides value, and it involves one-time CareCredit financing. Dr. Robben: I also tell patients that I don’t know the exact cost of a treatment. I let them know that I am recommending the best treatment for them and that my staff will cover the financial component, and I refer them to our counselor, who discusses the financing straight away. The initial price point that patients hear is the financing price point. Ms. Barkey: Treatment recommen-dations should be based on care, not on finances. Physicians should let staff handle the financial discussions. Some practitioners believe patients cannot afford certain services. However, we have found patients often can afford them. They just need to be educated, so 12 Discussing Non-covered Costs they can make an informed decision. Practitioners who assume a patient cannot afford something, and, thus, bypass some portion of the discussion of recommended therapies, are not being fair to the patient. Dr. McDonald: Never prejudge a patient’s ability or willingness to pay for a therapy. I see patients at three different offices: one is in a wealthy neighborhood, one is in an upper mid-dle class area, and one is in a lower-income neighborhood. I have the high-est conversion to LipiFlow by patients at the lower-income office. I practice in what I believe is now the largest private ophthalmology practice in the United States. We have 600 employees. Every day, I have different scribes and technicians with me. The scribes have been trained to do counseling, but I make the recom-mendations, and I have my speech edited down to the shortest possible impactful speech. I leave the scribe in the lane to explain everything. Almost every patient at all three offices uses CareCredit. The surgical coordinator, the same person who books our cat-aract surgeries, reviews the details of CareCredit with patients. Our approach may be somewhat different because the practice is huge. Dr. Robben: Your approach is essentially the same as ours, in that you present the evidence, make the recommendation, and then have a team member answer questions related to costs. Utilizing this technique and utilizing the people around you in this way can make it possible for busy physicians to treat dry eye effectively. Ms. Jacobs: The physician’s word is gospel, so patients aren’t likely to choose a treatment unless the physician recommends it. On occasion, however, after the physician leaves the room, patients may question the need for a therapy or the cost. The role of the support staff — whether it’s a counselor, technician, or scribe — is to reinforce what the physician recommends. Ms. Barkey: In comprehensive practices, continuity is important. All caregivers need to speak with a unified voice. ●
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