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The $1,000 Revenue Per Patient Model: Building a Specialty-Driven Practice | Dr. Patricia Poma
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Welcome to the Power Hour, Optometry's biggest and longest running show. I'm your host, Eugene Shotsman. And today's episode starts with a number that should get your attention. Over $1,000 in revenue per patient. My guest today is Dr. Patricia Poma. She's owned her practice for more than 20 years. She's built a specialty driven practice that includes, get this, medical eye care, vision therapy, myopia management, dry eye aesthetics, specialty contacts, optical supplements, and subscriptions. But this is not an episode about running from thing to thing or buying a machine and moving on to the next shiny specialty. Patricia's approach over the last couple decades has been very, very disciplined. And she talks about it. Build one thing at a time, make it sustainable, train the team, create systems, and then you can move to the next opportunity. And one of the big things in her conversation is this theme of non doctor driven revenue. Revenue that doesn't always require chair time. So Patricia talks about how she builds ambassadors inside the practice, or creating subscript prescription programs, or developing specialty services that and finding ways for the practice to keep delivering value even when she's not the only person delivering that every piece of care. So what I loved about this conversation is that Patricia is direct. She's practical, very clear about the mindset shift that's required. She talks about moving patients into daily disposable contacts, for example, or explaining dry eye in plain language to patients, training the team to carry the conversation forward. And why culture and patient trust are just as important as the service itself. Itself. So if you ever wondered how a practice gets to high revenue per patient model, especially given the challenges that are in the marketplace today, this episode should be for you. Before we jump in, quick reminder to subscribe on YouTube, Spotify, Apple Podcasts, or wherever you listen. And as always, reach out to me directly@eugene shotsman.com or through the Power Hour website with feedback, questions, ideas for future episodes, or if you want to explore working together. And now, here's my conversation with Dr. Patricia Palma. Dr. Patricia Poma, welcome to the Power Hour. Excited to have you on the show.
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Thanks for having me here, Eugene.
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B
All right, so I think in order for us to talk about how you get to over $1,000 revenue per patient, I think we need to get just a little bit of background on your practice and kind of how you grew it or what your journey has been. So let's do just like a little bit of, a little bit of context setting for the audience and then we'll go into the actual performance.
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Yeah, it it's definitely a journey. It doesn't happen overnight. And I think that the main thing is we need to realize that this was, you know, and the, and the journey continues. Right. It's never a dull moment when you own a private practice and when. And when you're practicing within a profession, that the scope continues to change and develop, which is really exciting. So I'm in metro Detroit area. I purchased my practice back in 2006. 7. And for those of you who are old enough to remember, the economy was at rock bottom. And back then, that's when the big three in Detroit were all claiming bankruptcy. So it wasn't the best time to purchase a practice. So, you know, purchasing a sinking ship, if you will, because retail wise, no one was buying anything back then was, was interesting, you know, so it, we didn't start off, you know, you know, just bouncing off the walls here. It started first with just sitting back and analyzing the practice and just looking at what the needs of the patient were, finding out what niches needed to be met. The practice I was with, you know, was thriving, it was doing okay. And it had some vision therapy components to it. But other than that, specialty wise, there wasn't much available in specialties back then. Optometrists in my state weren't really able to bill medically either because the ERISA plans discriminated against optometrists. So, you know, my little tangent is, you know, you know, continue to fight the fight for scope because it matters. So I came in as a new optometrist, hungry, ready to go. And the first thing I implemented was trying to keep the glacks and the immaculate degenerations and the red eyes within the office and fight for getting on insurance panels. So that was my step number one, trying to figure that out. So that was no small feat. I also, it was, timing is everything. And I think that's the other thing in, in, in the business world is knowing when to jump on board and when there's a fight that can be fought and when you need to kind of stop and wait. But the door started to creak open with billing medically. And that was step one was eliminating insurance plan vision plans slowly and increasing our medical billing.
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B
Yeah. And I think as you start kind of describing this journey, let's just go back for a second and let's, let's start with when you're, when you first purchased your practice. What did you know that you wanted to build a specialty practice? Did you know what business model you wanted to follow? Or did you kind of discover it over time.
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I'll be honest, I was just grateful to find a job that was within private practice at that time. I was commuting almost an hour to get to my office because I was not in the area that I grew up in, but just to find, you know, to me at the time, I did not want to work retail. I wanted private practice. I knew I wanted to be my own boss. But at the same time, I did work in my office. I took a gap year between undergrad and graduate school. And so I did have an idea of wanting to do pediatric care. And that vision therapy component was something I was attracted to. And then within that scope, I did do some rotations with some myopia management. So that was something I also wanted to develop. And mind you, this was about 20 years ago, so we were really at the forefront of myopia management. I know a lot of people are entering that now, but I was fitting orthokay slowly from the beginning. Yeah.
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B
Yeah. Okay. So now let's fast forward to what the practice is today. And it sounds to me like. And one of the things that I know you're well known for is, hey, you took a practice that is. It's a retail practice, but it's also, you've built a kind of a specialty practice. So explain to the audience what. What does that mean? What, in your words, what is a specialty practice? And. And really, like, the revenue per patient of over $1,000 per patient, which we. Which we sent in the intro, is a. Is definitely a remarkable accomplishment when you look at the rest of the industry. So we're going to talk about how you do that and what you specifically do, but just describe your practice to. To everyone listening. How many patients do you see per day? What's the. What's the vibe like? And also, what's the list of services that you even open?
- [07:10]
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Yeah, and the one thing I want to really, really express is, you know, because. Is that all this was done slowly with time. Right. What I noticed with a lot of the clients with that, when I do some consulting is they want to do everything now. So they're purchasing, you know, an IPL while they're hiring a vision therapist, and then they're doing myopia, and then they're doing. So I think that the main thing is, you know, finding one goal at a time, developing it, or finding those that can help you develop, because it's not like you have to do everything yourself, but developing it to the point where it's sustainable on its own and, or you know, referrals. Come on, you know, where it's just this beautiful beast within itself before you move on to the next project. Right. So I feel like as of late optometrists have all have ADHD a little bit. So you know, we buy the IPL and we're like oh wait, that's not working. So we're going to squirrel. I'm going to move on to this now. We're next. Right. So my practice, you know, where we are today is along the lines of lots of specialties. So we've developed the vision therapy to the next level where the therapists are trained and know how to, you know, lesson plan their own patients and they know when they see a diagnosis, what to do with it. We have a dry eye aesthetics practice that encompasses, you know, everything from oculif to LLLT to lipiflow to IPL and radio frequency. So we're doing quite a bit. It's not just one little thing, but we have and a nutritional aspect to it and esthetics with a whole skincare line and, and supplements and collagen and all the in subscription programs for that. We also have doctors in our office that fit sclerals so specialty lens fittings for patients with irregular corneas. We have a myopia management clinic, if you will. And I call them clinics but they're also, they're just factions or little pods within the practice. But you know, which the, the myopia management really, really is an adjunct and, or supplemental to, to the vision therapy. Right. We already have that patient base so why not add more to it? The, the, you know, now there's more, you know, that that's even changing because now there are lenses and spectacles that are involved. So the opportunities to keep adding revenue within that myopia management is, is, is there. What am I missing? Macular degeneration and glaucoma, obviously that's still, you know, medical and then contacts and glasses like we, we underestimate, you know, as optometrists we're always looking at exciting things and I think we need to keep the excitement within our contact lenses and our glasses. Also I think having product that is different. Having product and whether it's lenses, frames, finding niches and needs of patients, whether it's a pediatric patient that can't find good quality frames or brands that are just different. We're living in this vertical integration in which almost all the retailers have, and I'm not going to mention brands per se, but the same brand so if you're not a fan of that brand, there are people that are connoisseurs of specific little things and, or become connoisseurs because they don't want the same frames as everyone else, or they want multiple pairs and they have different looks and, and you know, we need to remember that that's our bread and butter. I do spend a lot of time fitting different contact lenses. Whether it's a multifocal Torque. We are 98% daily disposable in the office. It took time to get there, but taking the time to fit multifocal lenses, now a lot of doctors don't want to take the time to do it, but just charge accordingly. You know, charge for your chair time if, if, you know, if you feel like it's going to take six visits per fit, then charge for six visits per fit. If you feel, you know, look at the complexity of the situation and know your, your, your what your fee structure should be based upon that.
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B
So, Patricia, I want to zoom in on each one of these things. And you kind of started with contacts, so I'm going to go to contacts, and then maybe we'll talk about multiple pair or just the, the brand strategy or the optical strategy that you have. And then we'll go into dry eye. We'll go into some of the other specialties that you mentioned. But let's just start at contact lenses. So you mentioned you're 98 daily disposable. Talk about what you were before and how you got to 98%.
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Well, I graduated in 2005, so, so there weren't many daily disposable options at that time. Right. So, but I remember, and it was interesting because, you know, again, looking at the patient need, I think that's the main thing we can say. We want all the things, but listen to what people are saying. If there's, you know, my patients were saying, I hate cleaning these things. I hate how they get deposits on them. I hate how I have to wear the same lens for two weeks. I hate, you know, and, and, and my eyes are dry. These lenses are uncomfortable. I, I can't wear them more than eight hours. And so, you know, at the time, the only multifocal in the market was the Focus. I think it was called Focus Daily Multifocal. And mind you, the success rate was only 50%. And I just started throwing them on eyes and checking to see what would happen. And so the Elcon rep came in and he said, who's fitting these lenses? Like, you know, it just made this Mark. And slowly the sales were increasing, and they were there. It was a lens that was maybe to be discontinued. It wasn't the best optics, right, for. For, you know, considering, you know, what we have now, especially. But 50% of the people loved it. And, and so, you know, I had big conversations with Elkin at the time because I said to that they said, well, you know, it's only 50% success rate. Why are you still fitting it? And I said, well, if you think about sales in general, you know, if our opticians felt that way, they would never make a sale. You know, you're going to show that Gucci frame or that Prada frame or that whatever frame, and not everyone's going to spend that much money on a frame. But if you have that mindset of only, you know, 50% are going to buy it. But think about the 50% that you didn't show it to that maybe would have bought it. So again, I charged accordingly with my fees. I said, hey, I have this lens. 50% of the people like it, but it is a daily disposable. So you have a fresh lens every day. Would you like to try it? And if they said yes, I'd say, okay, well, it's X amount of dollars for this fitting fee. I'm going to hold your hand through it. It might not work, but being transparent and talking about the journey and the patient can decide whether that's something they wanted to do or not, right? And clearly, for those who wanted to spend the money, it told me they weren't happy. They were looking for a better solution. And so they knew at the very least that I was going to try. I was going to hold their hand and try. And I think as optometrists, we're so worried about failure. But again, if you say, I'm not sure, but I'm going to hold your hand through it, and I'm here for you. Thicker, thin. And so that the thing about my office now is patients telling me, Dr. Palma, I can't wait to see what you have that's new. You always have something new. So I've kind of earned this reputation for being this innovator, but also telling them that we're going to proceed with caution because I'm not going to just jump on the next train just because, you know, I. We're going to do some research and diligence about it too, but knowing that if there is something new, if I have a solution, I'm going to offer it, that I'm going to be at the forefront of my profession.
- [14:26]
B
So that's, it's interesting and it kind of answered the question of how you got to daily disposables or how you got started with it. But, you know, now I feel like patients have a lot of choices and especially with the ability to buy contacts online. Right. They're sitting in your chair and they're likely asking their AI assistant, how much are these contact lenses that Dr. Poma just prescribed to me in, you know, on the Internet? And then they're getting, they're getting wild answers because many of those, and I, I think I covered this in an episode once where we kind of discuss, we talked about the misperception or kind of the trick that people use on Google to make their products seem cheaper than they really are. And I won't name any brands either, but they start with numbers and they have a technique that makes it look like the box is at least 20 to 30% cheaper than what the actual retail is. So what's, you know, how do you, how do you keep that contact lens patient in your office now? And how do you keep them buying daily disposables if that's, you know, and how do you convince a patient that's where they want to be?
- [15:50]
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So that's just where I start, you know, I, you know, when they want to start with a monthly lens or a two week lens, I say, okay, well why don't we trade in your phone for a flip phone? So, and you know, and I do it in jest, like, and I laugh just like you did as I say it. But then they're like, oh, like, you know, no one's doing this anymore. This is healthier for your eyes. The optics are better. Like, get on board, let's go. You know, and of course, if someone doesn't want to, you know, they want to be put back to a monthly lens for whatever reason. The funny thing is most of the time they end up coming back and returning them just because with staring at screens all day long. I mean we, we do need the hydration of a daily. You just have to believe in it too. You can't feel bad. I'm very passionate about the recommendations I make. So I think that's 90% of it too is I don't, I walk the walk and talk the talk like I believe in what I'm saying. It's when the doctors stop making eye contact and they're like, yeah, well it's a thousand dollars. Well, and then they're done, right? They just, you know, I wear daily Disposables also. But it's interesting because when I, when I lecture and I ask, you know, doctors, you know, what's the lens that they prescribe? They're all talking monthly lenses. And then I ask, go around the room and ask what they're wearing and they're all wearing the best daily disposable. And I, and I think to myself, well, why are we, you know, start at the top and you can always go down. They can, oh, you can always go to a cheaper daily disposable. You know, my staff will sometimes do the breakdowns with solutions and things. But, but you know, the reality is that the cost is pretty, pretty equivalent, you know, with some of the lower end daily disposables. But back to your question on, you know, the combating the number game, right. Of, you know, why do they choose my office? I don't have a perfect, you know, for purchasing, purchasing versus online versus AI and, and all those things. You know, not every person spends their money in my office. And that's the reality. And sometimes things have to, they are what they are. But we do our best to provide, you know, make it easy convenience. We try to sell out the door. So I'm not that doctor that makes the patients come back for 17 contact lens checks. You know, personally speaking, I'm a very busy individual. So I'm one of those, be brief, be bright, be gone. I'm going to make a decision quickly. And I, and I, and I, let's just get this done. I want to check a box, right? I'm a working mom. I have better things to do even if I'm, you know, I don't want to spend my days off running errands. Right. So we allow people, if they feel comfortable with the lenses you can just purchase today. If there's a problem, you use your trials first. If there's a problem, we're gladly exchange boxes. So there's a convenience factor there. I also think that, and I hate to say this out loud, but it's a reality in optometry. There are a lot of alliance groups and, and there's a lot of competitive purchasing. Right. So, so, you know, this group here isn't aligned with this contact lens company and this one's aligned with this contact lens company and it used to not matter. You could pick Cooper, Elkon, J and J like and just do this mortgage board of whatever lens. Just pick one, it's fine. And I do think that every company has really good product. But I also think that strategizing within Your office. And aligning with a portfolio that meets your patients needs and sticking to that portfolio allows you for better pricing, better, you know, because now that we're in the days of everybody wants to, you know, the strategic partnerships and, and things. And, and so there's something to be said about, you know, finding a company that, that meets your needs, that provides customer service, that will return boxes, that'll, you know, the rep answers their phone, but also provides really good pricing to you and really good rebates so you can be competitive so that when that patient does have their phone in hand and then you blow that number, they already have it in. They're already like, like, nope, I'm not buying here. And then when you have that person at checkout that's very highly trained, mind you, that can have that conversation and they see that your lenses truly are cheaper.
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B
Okay, hold on, Wait, wait, wait. You just, you just said it and I, it's, it's just like your other matter of fact state. It's like, oh, you just want to flip.
- [20:01]
A
It is matter of fact. It's just fact.
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B
Yeah, it's great. But let's, but that's your trick. I was waiting. I was waiting. And that's it, right? It's the person at checkout. So what is that person at checkout doing?
- [20:14]
A
The per. Well, it starts with the chair though. It's not just I will sell at the chair. Also, I'm okay with pressing create that lab order, you know, because some people, it's like, you know, they love these lenses. It's great. I love this. I'm like, okay, here's your annual supply. And that makes it easy. But sometimes I'll do that and they'll get the checkout and get buyer's remorse just a smidge. Or they'll, by the time they get to check out, they're on their phone. Right? But that checkout. So again, finding a company that'll help train your checkout person so you don't have to do it. And they provide whatever it is that your office needs, whether it's a scratch pad with a breakdown or conversation or, you know, but that checkout person will say, well, where is it that you wanted to buy your contacts? Well, let me show you how we're better, how we're cheaper, how if you don't like your contacts, we'll help you return them. How? You know, providing customer service and the easy button. Because yes, shopping online is great. I do it all day long, right? But returning those Amazon packages when I buy, when I'm doom scrolling at 3am and then I have to go to Whole foods and return 17 packages. That is not a good time, right? And then I think to myself, why did I do that? Why did I buy that thing that I didn't need? I already have four of it, you know, and so to know that all they have to do is text the office or call and say, and, and, and it, it's that we can make it easy for them so they don't have to call the 1-800-number or they don't have to do it. And having a rep that helps, that is, is, is priceless. Like knowing that we have their backs from beginning to end. But then you have to deliver on that. You can't make false promises. You have to really, really show the patient that you care because we're in a world where no one really gives a crap about you anymore. So, so finding that is, is key.
- [21:55]
B
And Patricia, what, what about the, the experience in your practice that primes the patient? Is there anything in particular about your practice that makes them kind of that, that puts them in, that, in, in the mode of, hey, I'm going to get my care here and I'm going to really. And like, I don't know, something that focuses on the patient experience? Because hearing you talk, the more, the more I hear you talk, the more I realize that maybe your practice is everyday sort of, you know, for you. But there may be some really unique things that are happening in your practice that prime the patient to make more buying decisions.
- [22:40]
A
I think the first thing that there's so many first things, but one thing that's element, that's really important is culture. Having a culture in which you do the best you can to ensure happiness, that they can feel the energy. Patients love coming to our office because everyone has a genuine smile. The joke is that we're a dysfunctional family. So your front desk person, my front desk person, she has, I call it that Janet Jackson smile. She comes in and she's just happy and warm and inviting. And the patients, even if they're grumpy, they just look at her smile and her happiness. It's interesting because this, this poor woman gets asked out probably four times a week, right? Because she's just so warm and inviting. But it is not uncommon to see my staff dancing as they're helping people and just creating an ambiance in which people can be themselves and they can feel comfortable in their skin and being who they are and empowering them to make decisions and to be part of our culture, I think, also gives everyone. And it's not, again, not easy to do. It takes time, it takes energy, it takes getting rid of people that may be amazing in some aspects, but yet still don't fit the vibe. Again, very hard to do because it's really, really tough to find people that want to be, you know, that want to work, that want what we want. But that culture creates a connection with the patients, a comfort that, a trust that we have their best intentions, that we care about them. And so there's a warm energy that comes within our walls that's very inviting, very inclusive. I have a very diverse staff, so no matter who walks through the door, they're comfortable. That's also.
- [24:36]
B
Are you hiring for culture or are you training culture?
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A
Both. Okay, right. Because some people have it right away, and that's great. Some people have potential. And, you know, and so, you know, and then you say, this is how we do it here. This is how I'd like it, you know, if someone is not that smiling, Janet Jackson, smile, girl. Like, I can't make you into that. And so maybe you're not the first face when you walk through the door, but maybe you're pleasant in other ways or you have a skill set that's great in other, you know, but overall, we have to. We're there for the patients. And, and so you have the dedication to the patient is. That is a deal breaker. If you don't have that, then. Then. Then. Then we're done. But that dedication can look differently amongst different personalities.
- [25:29]
B
And so you said culture is number one. Is there a number two? That's part of the patient experience.
- [25:40]
A
Again, the dedication. You know, we can make mistakes, and we all will make mistakes. And the larger my practice grew, the more mistakes were made. Right. Because there's too many cooks in the kitchen. And so maybe someone started something on Tuesday and then they were off on Wednesday and someone tried to complete that task. Right. The busier you get, systems can fail. There are things. Things that happen, but it's all about having genuine intent and knowing when to say you're sorry. Knowing when to take care of a person and knowing that. That you. You really care about that patient is. That's just as important as. As, you know, the fun, loving environment.
- [26:17]
B
Okay, when we come back from break, I want to dig into your specialties. So we're going to talk about. Well, we'll. We'll talk about. We'll start with dry eye and aesthetics and then see where the conversation goes. We'll be right Back in the power hour. Hey there, it's Eugene and I want to let you. So you've been to conferences before. You come home fired up and then Monday morning hits and it's back to the grind. The ideas don't stick, the plan never gets made, and six months later your practice is in the same place. So I know that pain. I've been to those conferences with you and that is not happening. At this new event called I Care Boss Live. You've heard the story of Icare Boss, and now there's an event. I Care Boss Live. It's September 16th through 18th in Cleveland. Two and a half days. We're bringing together 200 of the best practice owners in eye care for a one of a kind event that combines speakers, peer learning, mastermind groups and industry innovation, all designed around one goal. You leave with a 90 day plan and you can actually execute it and get stuff done. And we're going to tackle some real stuff. Exam only rates, revenue preparation, people problems, leadership, AI and technology specialty growth, the things that keep people up at night. We're going after it and we're doing it in a room full of practice owners that are just as serious about growth as you are. This is not a conference, it's not a seminar. It's something different. There are only 200 spots, so if you want to be in on this, this is not publicly announced, just on this podcast. Go to thepowerpractice.com click events, click apply now. This is invite only. It's not for everybody. So you have to apply. We'll ask you a few questions and if it's a fit, we'll invite you to register this event. I Care Boss Live is going to sell out. Do not sit on it. I invite you to apply right now. All right, we're back on the Power Hour with Dr. Patricia Poma. And Patricia, I want to jump into your specialties. You mentioned you are a heavy specialty practice. You talked about kind of your centers of excellence. I don't know that we'll cover all of them, but at the very least, let's touch on one and maybe zoom into your dry eye practice. So how did you build it? What did you try? I like what you said earlier in the episode, which is that, and I've heard this all the time, which is that people kind of buy the machine and then they start trying to use it and they got, nobody's buying this, whatever. And then the machine just kind of becomes as a. It becomes a coat rack, a very expensive coat rack in some Closet. And you have clearly gone in a different direction. So I'd like to hear you talk a little bit about is how your dry eye practice came to be, how it evolved into the aesthetic side, and then we'll try to find ways that we can incorporate that into things that everybody can do.
- [29:11]
A
Yes. So there are a lot of coat rack IPLs out there. I've seen a lot of doctors, you know, purchase, because that's what everyone's doing without a plan. They just were like, you know, I need an ipl. They expect patients to come in and say, I need. What's that instrument right there? Can you put that on my eye? Because I have dry eye.
- [29:33]
B
And can you charge me $2,000 to do that?
- [29:35]
A
Yes, yes, yes. And then. Yes, exactly. And I think that just, that comes from the roots of optometry, because I think that patients do that with glasses sometimes, right.
- [29:46]
B
They.
- [29:46]
A
They will come in and saying, I need a new pair of glasses. My glasses broke. My glasses are uncomfortable. My lenses are scratched. Right. So the mindset of optometry is, yes, we want to sell them two pairs, three pairs, six pairs, maybe a computer pair. But. But the reality is a lot of times patients come in already with a preconceived notion of like, this is the year I'm getting a pair of glasses. Right. But I think medicine has changed. I think that there are some patients that go on TikTok and listen to some influencer about, talk about red light therapy or dry eye or that sort of thing. But the reality is that dry eye isn't something. It's something we can live with. Well, some people can, some people can't. Right. So that's the problem is dry eye is a spectrum, and it can get worse over time. So I am a very big holistic medicine, preventative medicine person. I'm really into fitness and health and that sort of thing. And I'm a root cause kind of person. So when it comes to health. So dry eye is something that if you don't look at those glands and if you don't identify the patients ahead of time, then the process can get progressively worse. And then, you know, and most dry eye patients are being treated when their glands, their meibomian glands are at zero, they're atrophied, and you have a dry eye patient that. That is barely surviving. They're taking, you know, 17 drops a day, doing all the things. And that's when the doctors look at me and say, ipl doesn't work. I've tried it on four patients and all of them still had dry eye. And, you know, that's like looking at a chronic cancer patient who's at stage four and they're, you know, on death's door, and you're trying to get them, you know, vitamins, you know, like so. And I'm over exaggerating a little bit, but I think I want to drive that point in, is that we need to look at, you know, and look at the patient's journey and anticipate what their problems may be. So I'll give you another example. I start talking about presbyopia around age 38, because you don't know if that patient's coming back right away, if they're going to come back in a year, two years, four years. And I say to them, around age 40, you're up close is going to start to change. But don't worry about it now. You're okay for now, but I'm just letting you know that I will hold your hand through it. So we proactively screen every other year. We take pictures of the meibomian glands. We have the oculus keratograph, and as part of our eye exam, we screen and we talk about dry eye. We ask those questions. If a patient's on Accutane, we're gonna talk about dry eye. We're gonna talk about what's gonna happen to them, not wait for them to come in and say, my eyes are burning. You know, don't leave it to the dermatologist to give them drops. You be at the forefront of it and let that patient know what they're gonna experience and offer a plan so that they don't have symptoms. Any. Any woman that's, you know, and this is a lot on birth control. Perimenopausal or menopausal or postmenopausal, on the computer all day. That's something that just needs to be addressed. And so a lot of people will say, I am fine. No, I don't have a problem. And maybe they don't, but isn't it fair that they should know that they will have a problem soon enough because their glands are starting to atrophy? So step one is identifying the patients. Find out, you know, who is out there, be comfortable talking about it, understand what you're talking about, and then go slow again. I have all the instruments at my disposable right now, but I started off with fish oil and brooder masks. If you're going to offer supplement, though, make sure you understand what you're offering. Do Your homework, you know, do you believe in the natural triglyceride versus the ethyl ester? Do you think it should have gla? Do you? Or are you just going to blink? Is a Costco version. Okay, Be prepared, because some of your patients, again, are very highly educated and they'll say, my other doctor, you know, they said I should take this one. So are you going to be the expert and a leader in dry eye in explaining omega threes? Are you prepared for a vegetarian version just in case, if someone's vegan, you know, be poignant about the decisions you make and have a little backbone so that you can have discussions about what you're recommending. So our Office has Omega 3 testing that we do. So when someone is on an omega or on a fish oil or Omega 3, I'll say, well, that's great. Would you like to test to see if you're buying expensive urine or if that fish oil is actually working? And so they look at me kind of funny. I'm like, well, has everyone. Anyone ever quantified your Omega 3 levels to make sure that you're getting enough for your body? Because the recommendation is two grams a day. That's what we all say. Well, if I came into the office, do I need two grams? But what if Shaquille o' Neal came in? Does he need two grams? I mean, there's a big difference there. So we have a skin poke test and we. We test Omega 3 values, and then if they're not good enough, we have discussions about why I think the Omega 3 I recommend is best. Why don't we try this one and see if your numbers change?
- [34:52]
B
Wait, wait, wait. Hold on. You. You just said so much. So if they're so. First of all, we'll back up and talk about the fact that I love that you are future pacing your patients by knowing correlated, you know, essentially anything that is a correlated or a causal symptom or lifestyle component for them. And then you can say, okay, I expect you to have this symptom. And then immediately they start saying, oh, number one, this person is an expert. Number two, I, maybe I will be a little bit more mindful of scratchy, itchy eyes. And, oh, yeah, like, now that I'm thinking about it, I guess that does kind of happen. You know, just.
- [35:35]
A
Or fluctuating vision or, you know, and again, some people are. Their personality type is I never have a problem. Fine. Yeah, that's okay.
- [35:43]
B
But even on days where I never have a problem, well, my doctor told me to look out for this. So it kind of feels like, you know, maybe, maybe it's starting to get a little worse, but. Okay, fine. So that's one. And then you talked about the skin folk test. I bet that's pretty unique to most practices. So talk a little bit. Expand that a little bit more. Do you charge for this? How much do you charge for it? And is it like, what? Patients like really do this a lot.
- [36:10]
A
So the capture rate's pretty good. I mean, I would say about 75%. It's about $55. I want to say we charge the same price. It's available on Amazon also, we have it in the office. The caveat is, is in my state, we're not allowed to break skin, so the patient has to do it themselves. You know, so they take it home, but we register them. There's not a lot of money in it, you know, as far as like revenue. But again, you're looking, people start to trust, you know, you and your opinions and because you're putting science behind what you say and you know, and they're not gonna, they're like, oh, she really knows what she's talking about. And when they see that their doctor's fish oil, that Costco fish oil is not as good, and then all of a sudden they take ours, Then they see their numbers go up. And so again now you've captured that individual and no matter what recommendation I make, they start to listen. And it's that slow. Trust. Now you have to be careful. It's okay to tell someone they don't need a pair of glasses. Right. You know, don't take advantage of that either because they need to trust you. But when they start to see that what you say and your authority is meaningful and you can back what you say up and you have knowledge, I think. So use it. Don't be a know it all. Don't use big words. You know, I see some doctors will start talking, you know, words that I have to find the medical dictionary to look up, like just straightforward everyday jargon. But once they do this testing again, it's. You just do a little skin poke, you fill the cart, there's three circles, you fill it with blood, you send it in, the results come in. It tells you in the spectrum what an ideal amount is for that patient. And then you can up their dose or you can change what they're taking, and then you do another follow up if you'd like to. Um, once some patients see that what we offer is good, then we offer a subscription program. So I have A subscription programs of, you know, Omega so they again, convenience that they don't have to go to the store. That and it also makes them accountable to maybe take their omega 3s every day because that next shipment is coming. Right. So we keep credit cards on file. You can use a company. Some people use companies for script subscriptions. We do it in house. I don't feel the need to pay for someone. I have someone in charge of that. You know, their credit card numbers are under password lock and key that only one individual has besides myself. And, and then every quarter the patients, you know, there's a discount involved a little bit. But we ship out hundreds of boxes of Omega 3s.
- [38:50]
B
So it's doing directly from your office?
- [38:53]
A
Direct from the office, Yep.
- [38:55]
B
Do you make money on it?
- [38:56]
A
Yes. Yeah, it's passive income. So it doesn't matter whether I'm there or not that day. And that's the beauty. And that's how you get more revenue per patient. Finding ways in which the office is sustainable whether you're there or not. Now I still need to be there sometimes, but you know, patients need to be seen, but at the same time finding needs and niches in which, you know, you can continue care without the doctor always having to be there. So we, with all our supplements, we have a subscription program in which we can ship them out and, and patients are really, really like it.
- [39:33]
B
So just, you know, because I hear this all the time is like, people don't want to talk about supplements because supplements don't make them any money. And I understand if you have a subscription program. Well, okay, you're making money, I guess, you know, whatever, 12 times a year or 99, four times a year off of that patient where they would have bought that from Costco. So like how much? And I don't care about the revenue. I'm caring, I care about the profit. So how much profit drops down to the bottom line from each patient for supplements?
- [40:05]
A
Well, the main thing is shipping and time. But there's always time, you know, when we have a slow day or a bunch of people canceled or that sort of thing. I mean you can, you know, you're paying that employee anyways, right? So, so as far as like hours and salaries, I'm not worried about that. The shipping can. So we do it. Some supplements that we don't make as much on twice a year versus every, we don't do monthly or you know, so it's either quarterly or twice a year that they get the six month supply. So, you know, every little bit Kind of counts, right? So even If I make $10 a bottle, but I'm shipping four bottles at a time, that's 40 bucks. And I, maybe I'm paying the employee $20 an hour and then there's some shipping, but at the same time I am selling hundreds of bottles versus, and versus. Well, you're 40 bucks once these twosies
- [41:02]
B
and you're 40 bucks times. If that's your net profit, multiply that times four quarters, that's an extra $160. What did you make again on selling them a pair of glasses? Right? Like what was your ultimate net profit on selling a pair of glasses? For most practices, you know, if the revenue per patient's, I don't know, four or five hundred bucks, that was what they made on the frames, right. And so like you just, it's as if you sold them another pair of frames. But profit, right? Like that, that's the, so that, that's one.
- [41:35]
A
In most supplements I'm making more than $10 a bottle. Right. But I was going on the low end of things, but I was tired of hearing. And so again listening to what the patients say and doing something about it, I think it's really critical. So this all came about with, I was having too many patients say to me, you know, I gave them whether it was macuhealth or an omega 3 or name that supplement. And they, I said, well, are you still taking that supplement? Well, I bought the bottle from you guys and then once it was out, I was just, I ran out and I thought to myself, well, I mean again, most people go on Amazon. Some people are proactive and go on Amazon, some people are. But at the same time I have a solution. Let's make it. Or it was snowing and you know, it's an elderly person that didn't want to get out or we go to Florida for the winter or so they could have it and pack it and use it. So, so if you have utilization or if it keeps coming, then they're going to, you know, it just, it's, it changes the whole thing.
- [42:31]
B
Yeah, that makes perfect sense. So you're solving problems that patients have. Let's talk about your dry app packages. So when I am a patient in your office and I did because you, you mentioned you're gonna, you're gonna do the LIPA scan or you're gonna, you know, get, get imaging my, my well being glands. And at every other year you mentioned. And then what, so then what, what is the conversation like in the office? What is the Conversation like in clinic. And I mean I heard that you future paced me, you helped me increase my expectations that this is something we'll be talking about today. But now I'm in your chair. So what is it that you do? Again, trying to help the audience understand how to get to over $1,000 revenue per patient. So what are some of the things that you do that work well for you?
- [43:22]
A
So again, being comfortable with the conversation and guiding the patient to where you want them to go. And it's again, I always compare to optical. How do you get, how do you. When do you sell a 167 or a 174 versus a polycarbonate versus Trivex? Right. Some patients. And so it's complicated. It depends. Right. But yet again we expect our opticians to make poignant decisions because they look at the prescription and they say, okay, this patient's a minus 12. We're going to go to 174. But what about that minus three patient? Are they okay in a 167? When do you do a 167 versus when do you do a polycarbonate lens? Is polycarbonate okay for that patient? It depends on who you talk to. Right. Doctors have a really hard time when they have more than one thing to do for dry eye. Do they pick the lipiflower or the, you know, name that thing. Do they do the lllt do the ipl. And I say look at the patient, look at their glands, look at their symptoms. Yes, you can present all the packages to them, but push the one that you think when you look at those glands and their symptoms and other factors, push the one that you really think that they need. There are some people that I look at them and say, listen, I'm not going to take your money for anything less than ipl. These glands are horrific. This is not going to do anything for you. You need the most expensive one. I'm sorry. Just like you're going to tell that -17 patient that they need 174 in their glasses, you know, because it's going to hurt their nose and they're not going to see well. And those, I mean, there's just non negotiables. Negotiation starts in when you have someone who is either again preventative medicine or the glands aren't that bad or you're doing, you know, they're not symptomatic with it. So we talk about, you know, so I joke around with them. I say, you know, here are your glands. I use the word constipated. A lot with glands. You know, I don't use the word atrophy. I say these glands are dying. Again, it's harsh, but patients don't know what atrophy means. They know when you say these are receding and they are slowly dying. Do you see how this is empty? Right? No one likes that word. It's a strong word. But when they see the image, it's powerful and they want to see their images later. Or I say they're empty. And so I tell them, I said, you have a bunch of options. One is you can do nothing. And that's always an option. And I will be here for you if you choose nothing, but I'd rather you not choose nothing. Option the lowest is the minimum that you're going to do is Omega 3s and a brooder mask. Then I say, there's two other levels that are not covered by insurance. And I said, I am so sorry, unfortunately, because they're in. And to make a negative, a positive, I say these two procedures I'm going to tell you about have aesthetic qualities or they make you. They're used in a lot of spas for anti aging. And I said, so the good news is your side effect is anti aging. The bad news is that because of that, insurance will not cover it. So we talk about LLLT and we talk about ipl. Some people are like, nope, I want the best. Give me that one. Some people who am in ha. And I'm like, okay, well, why don't we start with the Omega 3s in the, in the mask and I'll see you back in six weeks and let's see how you're feeling. And if they're not feeling better, if their glands don't get better, if they're non compliant, then we do a dry eye workup and we talk about the LLT and the, in the, and the IPL again
- [46:55]
B
when you, when you see them in six weeks. Patricia, Is that a medical visit? Is that.
- [46:59]
A
It's a medical visit. Absolutely. We do, yeah, we do a medical visit. We bill for, you know, the screening photos. We do, you know, the keratograph has this whole program of tests that you can do. And you don't necessarily need all that either. You can do, you know, the, there's so much t butt on your own. You can do Shermer's, you can do, you know, whatever it is that you need for those practices that maybe can't afford some of these gadgets that I have. But at the same time, and some of These people don't show or they don't come back. And they come back in a year and then want to talk about it in a year. It's their journey again. Back to what I was saying earlier. Your, your, your capture rate's not always going to be that good, but you're planting seeds and educating. And then as these people live life and realize that, hey, maybe she was right or maybe she was wrong, maybe I don't care. But then a lot of times they'll come back either in six weeks, a week later, a year later, whatever that looks like for them. You did plant a seed and some. And that seed will germinate sometimes, sometimes even three years later. That happens with all the specialties. You might not win right away. You know, the myopic patient might wait two more years for the patient to. Maybe there's a certain number they're looking for. Or the VT patient might be when their kid gets headaches. You know, you make recommendations and they, or maybe they have to save money for it. That happens a lot too.
- [48:20]
B
Do you find that there's a, when you talk to patients, is there a mechanism that you use to track that that conversation's been had? Is there some follow up that you do? And do you find that there's somebody else in your practice that needs to say it again? Whether it's like a counselor or like that same highly trained checkout person. How do you manage the. You did the recommendation in the chair and then there's some. Something that happens afterwards.
- [48:51]
A
Yeah. And I think this is really key to have what you call, I call them an ambassador for each specialty. So a go to person. What I noticed in the practice is that the more specialized we became, you know, I'll give you an example. Even as an optometrist, I don't do everything. You can't be jack of all trades because you're, you know, master of none. So what I specialize in in my office is vision therapy, dry eye and orthokay. Right. I have others that do glaucoma MacDigen. I have others that do scleral lenses. And I refer within my office because I can't stay up to date on the latest of everything and all the things. So I can't expect my staff to be good at everything also. And I want to make sure that we are the experts in what the patient is looking for. So after. And let's be honest, I also don't have all the time in the world to talk in great detail about a lot of these things, I'll plant the seed and then I find what I call as my ambassador, my dry eye ambassador, my vision therapy ambassador, whoever that, my contact lens ambassador. That will talk some about, you know, prior authorizations for sclerals and all those things for billing and you know, so I go to that, go to person who has the time, whether it's that day or they do a follow up call to talk about all the questions. So maybe they talk about the, you know, more about the Omega 3 testing. Maybe they talk about, you know, the side effects of ipl. They go through the checklist on the do's and don'ts when you do it, what medications you shouldn't be taking. You know, don't get a vampire facial five minutes before your ipl. Right. So you have that expert within your office. And what's really cool about that is it gives your back to the culture piece going full circle, is that it empowers your staff to feel like they're a part of things, that this is, it becomes a career and not a job. When they specialize and see purpose within their job, then they're happy. They feel an importance and a belonging and part of the community and culture that they are the expert in something that patients look for them and say, where is. I'll give you an example. Carrie. Is Carrie here today? One more question about. And it's funny because I'm walking by and they're asking me where Carrie is because they're going to ask her the question and that's awesome because guess what? I don't want to talk to you anyways. I have to go. You know, so it's really good when you have these mini experts that, that are just as passionate as you are and are able to seal the deal and educate and do all the things that you don't have time for.
- [51:28]
B
Yeah. And I mean, and it sounds like. And you have different ambassadors for each of the specialties in your practice.
- [51:36]
A
Yes.
- [51:37]
B
So there's somebody who's in charge of myopia, there's somebody who's in charge of vt, there's somebody who's in charge of. And those people are kind of the local specialists for that.
- [51:46]
A
Yes, yes. And we have the backups too because sometimes that person's on vacation or they're sick or maybe they actually quit. You know, it happens. Maybe someone steals them for their expertise and offers them $5 an hour more because they're already trained and ready to go. Which happens.
- [52:05]
B
You mentioned aesthetics and you kind of talked about the aesthetic Upside, I guess, of, of the, of the dry eye treatment. But I know that you have some patients that are like dedicated aesthetic patients. So how does that happen? And is it. Usually the path is I do some dry eye and then I like the aesthetic effects and so I do. So I come in for aesthetic related services. What services do you offer and how do patients find out about them? How do they get started?
- [52:33]
A
Well, it varies from state to state. First and foremost, again, you need doctors need to know what they're allowed to do in their state. I don't have much wiggle room in my state to do. I'm allowed to treat around the eyes. I have some justification for a full face because, you know, to keep things nice and even, but other than that. So, you know, outside of, you know, maybe getting a medical. I can't think of the word I'm looking for right now, but, you know, an MD to sign off on all the things and an esthetician and somebody, you know, working off of their license, you know, keeping it simple in my office. I didn't want all that headache. I'll be, I'll be honest. And I didn't want to become. I still wanted to maintain my medical reputation. Cause I work so hard to be able to build medical insurances. And I, and I'll be honest, I went to the dentist once and here I am to get my teeth clean. And he's like, you know, pulling on my face and telling me, you know, we could do Botox here and there. And I was like, I'm not here for this. You know, I also think that, you know, it's important to not lose sight of understanding again, what that patient need is. So we put posters up in every exam lanes and every exam lane and throughout the office of befores and afters. I don't want to offend anyone and saying, hey, I can make you look a little better. But this way the patient will ask, what is that? I'll say, well, any questions? And I'm thinking we're going to talk about glasses or macular degeneration. And they're like, what's that? And so that gives me an end to, to talk to them about it. What I'm finding with optometrist though, again is they're all purchasing these aesthetic instruments that cost over $200,000 a piece. And they're purchasing. And I was taught, I had a conference with this doctor who was probably like 55, and he said, yeah, I'm going to get one of these because patients are going to Want it? And I said, okay, well, how are you going to present this? What are you going to do? And he looked at me and he said, well, I'm not comfortable. I don't know anything about face, skin, and all those things. And I said, well, then why? Who's going to present it? He said, you need to find someone who's either a key staff person that's going to do that legwork for you. He's like, well, I'm just going to hire an associate doctor, a young female that'll do that for me. And I said, well, do you have that person in mind? He said, no, I'm just going to buy the instrument and I'm going to figure it out. And I stopped him. And I think that the company that I, Mikhail Wilfer, wasn't really happy about this, but I was like, you know, hey, get your plan first. Figure out if there's a patient base, Find out who's passionate about it, find out who's going to do it, and then. And. And have your packages ready to go, your pricing ready to go, what you're going to say, what your script looks like, and then purchase, because then it becomes that coat rack. And then you're. You have ill will against that company. You see it all the time on Facebook and all our little forums. Yeah, I hate them because I purchased this instrument and it's worth nothing, but they didn't plan for it. So, you know, be prepared for things like, how long is this gonna last? If you can't answer that question, then you have no business doing aesthetics. Be prepared for the worst. Be prepared for what happens if you burn a patient. What is your protocol again? Because what's happening is the doctors are buying it and they have zero confidence. All a patient has to do is ask one question that's not on the script, and the doctors falter. You know, do you understand the aging process? Do you understand inflammation? Do you understand what it takes to combat that? The answer is no. In anything with an optometry, know what you're doing, just like you do with a contact lens. If a patient sleeps in their contact lens and they have an ulceration, what do you do? You have that plan. You have your plan A, plan B, plan C. If something happens right, have those same plans and have your vision of what could go wrong. What could they ask? What could you know? And be prepared and have those scripts ready for your ambassador and for your staff and for yourself even.
- [56:35]
B
Yeah, it makes perfect sense, is that if you go into anything without making A plan, your results are likely to be subpar because you're likely to get distracted, you're likely to have a commitment phobia, and you're also likely to give up at the first sign of failure. Right. Like that's the. Or you're likely to at least put it to the side. If you, in the process of making a plan, you're basically anticipating everything that could go wrong, and you're. And, and so you're more prepared for that mentally, even if you go through that process for a short period of time. One thing I, you know, I, I was talking to a doctor who kind of was in a similar situation, and he was looking to bring in a, to bring in a piece of equipment, and we were talking about it, and I said, you know, why don't just talk to, like, three people that, you know who have this particular equipment, and why don't you ask them what mistakes they wish they didn't make upfront? Because I bet you that's going to help you go a lot faster and, and hearing it from other people, you can hear it from me, but, like, if you hear it from other people who have made those mistakes, I think you'll be far better off and, you know, just make a couple calls and invest the, you know, half hour so that you don't have to. Or half hour times three, maybe, so that you don't have to worry about $80,000, you know, getting old, aging, and then frustrating you because that capital could have been deployed in a completely different way if that solution wasn't for you.
- [58:08]
A
Sure. And hopefully you find someone who's transparent and we'll tell you. Right. Like, and that's, you know, and, you know, we'll tell you what the mistakes they made, because that's that. And that's the, the thing is finding your community, finding a community to belong, that, that you can be trusted. You know, you can trust those people, and they trust you, and you learn from one another. I think we're, we're beginning to, you know, I'm seeing all these trade shows and how the tenants is low, and we're starting to lose a little bit of that. You know, CES online people don't like to go to meetings anymore, dinners and all the things. And I think finding that those people is, you know, that you can bounce ideas off of is really important. Also, a lot of the experts, and I use it lightly, experts online that claim to be dry, experts aren't treating dry eye. The reality is, is that they. Maybe if they do one IPL a week. But they're, you know, but they're talking about it like they know what they're doing, but really maybe shadow someone that. That really is doing a lot of dry eye and aesthetics. We have a whole schedule just for dry eye. I mean, my dry eye coordinator is doing procedure. She's doing the oculift procedure. She's doing lipiflow. She's doing lllts. She has her own schedule. So each doctor has a schedule, and she has a schedule of things lined up, you know, so you can hear those conversations and you can see those things. But I do think that asking people and taking things worth a grain of salt is also important because there are a lot of people, you know, and asking for full disclosure, too. You know, who do you work for? You know, because everyone's, you know, and I love that some. Some forums require that, you know, full disclosure. Who do you, you know, who's. Who's paying your bills? Because I think that's important, too. Yeah.
- [59:48]
B
Yeah. That's why I say it's conversations with people you trust, not like a comment on. In. In some sort of forum or group. Patricia, we. Unfortunately, we're at the end of the episode. There's so many more things I have to ask you, but it will probably have to be in a future episode. Thank you so much for sharing some of your wisdom, and also thank you for helping people understand that $1,000 or more per patient is possible. And it's possible not overnight, but with this kind of transitional mindset of going from where you are in a day to where you want to be, and the idea of working on culture, but also the idea of being transparent but direct with your patients and not being afraid to sell it. Sounds like all of these are core levers that you pull on every single day to make your practice successful. So thank you so much for joining me on the Power Hour. It's been a really fun conversation.
- [60:43]
A
Thank you. It was fun.