Bumpy "ROAD" ahead

[Visionary]

Well, as predicted in prior threads about the decline of ophthalmology appeal amongst the "ROAD" specialties, radiology is now about to get chopped.

http://www.ama-assn.org/amednews/2011/07/18/gvl10718.htm

The spotlight tends to find those who are pulling in the biggest numbers from the Medicare coffers. Dermatology may avoid it, due to the prevalence of cash-on-the-barrelhead cosmetic procedures. Anesthesia is already losing out to nurse anesthetists. No one is immune. My advice is to choose your specialty primarily based on interest in the field, not potential compensation. You will still do better financially than the vast majority of hard-working Americans, but clearly the money is going anywhere but up.

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[speyeder]

Good advice indeed. Choosing a specialty by trying to anticipate which fields will be 'hot' is foolish. I have friends in radiology and the job market is terrible. Jobs in larger cities are hard to come by and many residents who can't find a job are doing one, sometimes two fellowships hoping it will make them more marketable.

 

[echinoderm]

thanks for this interesting post.. how do we interpret the "projected 2012 spending"? is a larger value good or bad? (and is a positive change good or bad?)... surprised to see that the "spending" is so high for ophthalmology, in comparison to all the various subspecialties.... e.g. in comparison to neurosurgery which has a small fraction of the spending.

 

[Visionary]

thanks for this interesting post.. how do we interpret the "projected 2012 spending"? is a larger value good or bad? (and is a positive change good or bad?)... surprised to see that the "spending" is so high for ophthalmology, in comparison to all the various subspecialties.... e.g. in comparison to neurosurgery which has a small fraction of the spending.

It is what it is. The spending is the projected outlay by the CMS in millions of dollars for care of Medicare participants in 2012, based on current numbers and estimates of growth in participation. The larger the number, the more that specialty gets from CMS. If you think about it, the numbers make sense. We are talking Medicare here. The highest payouts are, collectively, to the gatekeepers: internal medicine (10,737 mil) and family practice (5,640 mil). Those are followed by cardiology (6,778 mil), ophthalmology (5,316 mil), radiology (4,722 mil), and orthopedic surgery (3,572 mil). The rest are all in the 2k mil or less ranges. What services do Medicare participants utilize most? That would be basic medical care, subspecialty cardiac care, cataract surgery, imaging, and bone & joint repair/replacement. Naturally, there is variation depending on volume versus cost of services. As for neurosurgery, most of that occurs in younger folks, such as head trauma victims.

 

[KHE]

Good advice indeed. Choosing a specialty by trying to anticipate which fields will be 'hot' is foolish. I have friends in radiology and the job market is terrible. Jobs in larger cities are hard to come by and many residents who can't find a job are doing one, sometimes two fellowships hoping it will make them more marketable.

What opportunities, if any are there for radiologists to be in business for themselves?

That's a big problem to me. If you're relying on someone else to "give you a job" I think you're at a very significant disadvantage.

I would never try to do something to make myself more marketable to an employer. I would do something to make myself more maretable to patients, customers etc. etc.

 

[speyeder]

What opportunities, if any are there for radiologists to be in business for themselves?

That's a big problem to me. If you're relying on someone else to "give you a job" I think you're at a very significant disadvantage.

I would never try to do something to make myself more marketable to an employer. I would do something to make myself more maretable to patients, customers etc. etc.

Not sure if this answers your question but not all radiologists are employees of hospitals. There are many private practice radiology groups that have their own imaging centers. Radiology is a field that is almost 100% referral driven. They don't market themselves directly to patients, nor do they really deal with patients directly. They are more like consultants to other physicians. When was the last time you saw your radiologist? Probably never. They interpret the imaging tests ordered and send a report to the ordering physician, not to the patient.

 

[echinoderm]

on the flip side of the coin, how often are doctors (i.e. primary care and emergency med docs) nowadays relying on radiologists for a diagnosis or differential? quite often... except for ophthalmologists, of course.

 

[KHE]

Not sure if this answers your question but not all radiologists are employees of hospitals. There are many private practice radiology groups that have their own imaging centers. Radiology is a field that is almost 100% referral driven. They don't market themselves directly to patients, nor do they really deal with patients directly. They are more like consultants to other physicians. When was the last time you saw your radiologist? Probably never. They interpret the imaging tests ordered and send a report to the ordering physician, not to the patient.

Well, the reason I was asking was that in your previous posting you mentioned radiology residents doing two fellowships sometimes to make themselves more marketable. I read that to mean more marketable to a hospital. If that's not what you meant, I apologize.

What options are there for a radiologist to open a practice? How would one go about doing something like that?

 

[speyeder]

Well, the reason I was asking was that in your previous posting you mentioned radiology residents doing two fellowships sometimes to make themselves more marketable. I read that to mean more marketable to a hospital. If that's not what you meant, I apologize.

What options are there for a radiologist to open a practice? How would one go about doing something like that?

They do fellowships to make themselves marketable to both hospitals and private practice radiology groups. When jobs are harder to come by, employers can be pickier and select candidates with more skill sets. As far as opening up a solo practice, I'm not sure how feasible that is. I'd imagine the startup costs of having your own imaging center are astronomically high. It seems that most radiologists who go into private practice join already established groups.

 

[orbitsurgMD]

What opportunities, if any are there for radiologists to be in business for themselves?

That's a big problem to me. If you're relying on someone else to "give you a job" I think you're at a very significant disadvantage.

I would never try to do something to make myself more marketable to an employer. I would do something to make myself more maretable to patients, customers etc. etc.

True. It seems to me that many radiologists have difficulty climbing into the equity-holding rungs of the employment ladder, with restrictive covenants and limited employment venues in some communities. Some get hit with astronomical and unaffordable "buy-ins" when it is time for partnership offers. This is particularly unreasonable when tied to a hospital, where an entire group can be replaced with a change of contract with the hospital.

 

[Visionary]

What opportunities, if any are there for radiologists to be in business for themselves?

That's a big problem to me. If you're relying on someone else to "give you a job" I think you're at a very significant disadvantage.

I would never try to do something to make myself more marketable to an employer. I would do something to make myself more maretable to patients, customers etc. etc.

I agree with what has been stated above. There is no way one goes solo as a radiologist. The start-up costs would be prohibitive. You don't have to be a hospital employee, though. There are private groups that own their imaging equipment. You have to be a more shrewd business person and market heavily, for that to work. I frequently get fliers/call-backs from the primary non-hospital imaging group we use. They are bending over backwards to keep their referral sources. Since most hospitals have in-house imaging/radiology, it's terribly difficult to compete, especially since so many potential referral sources (e.g., primary care) are becoming hospital employees themselves. If these severe cuts go through, I think private practice radiology will quickly die off.

 

[KHE]

I agree with what has been stated above. There is no way one goes solo as a radiologist. The start-up costs would be prohibitive. You don't have to be a hospital employee, though. There are private groups that own their imaging equipment. You have to be a more shrewd business person and market heavily, for that to work. I frequently get fliers/call-backs from the primary non-hospital imaging group we use. They are bending over backwards to keep their referral sources. Since most hospitals have in-house imaging/radiology, it's terribly difficult to compete, especially since so many potential referral sources (e.g., primary care) are becoming hospital employees themselves. If these severe cuts go through, I think private practice radiology will quickly die off.

I think that that highlights something I've said for a long time now....

The only way to make any "real money" in just about any industry but particularly in health care is to be in business for yourself. No doubt that that is getting harder and being in business for yourself doesn't lend itself well to all specialties but as long as you're relying on someone else to give you that job and paycheck, you're in a danger zone.

 

[Visionary]

I think that that highlights something I've said for a long time now....

The only way to make any "real money" in just about any industry but particularly in health care is to be in business for yourself. No doubt that that is getting harder and being in business for yourself doesn't lend itself well to all specialties but as long as you're relying on someone else to give you that job and paycheck, you're in a danger zone.

True.

 

[davidjones]

IR docs can go to into business for themselves, especially if they leasy c-arms, CT, and own US (in office procedures are extremely lucrative) and many join smaller groups of cardiologists/vascular surgeons or large multi-specialty groups.

Many are even opening Fibroid Centers with OB/Gyns and raking it in.

Also as a soapbox sort of statement, CMS is targetting the wrong group of people for imaging costs, radiologists are not the direct cause of increased costs, but it's actually the self-referrers (ortho/cards being the worst offenders) or the ER (who order a head to toe CT for every thumb fracture that comes in) ;

 

[KHE]

Also as a soapbox sort of statement, CMS is targetting the wrong group of people for imaging costs, radiologists are not the direct cause of increased costs, but it's actually the self-referrers (ortho/cards being the worst offenders) or the ER (who order a head to toe CT for every thumb fracture that comes in) ;

But in that case, what does that ER doc get paid for ordering the head to toe CT scan?

 

[davidjones]

the ER reference was regarding to the almost complete dependence on radiology to come up with a diagnosis or at least with a differential with almost absolutely no prior clinical evaluation or a lack of understanding of how to use imaging.

Where I am training there on an almost daily basis there are multiple CTPEs ordered on patients with low Wells scores and very good explanations; CT and MRI of the heads are ordered to evaluate LOC in patients >65, when in this population the most common etiology is cardiac, and a cardiac workup is initiated only after the head is cleared. Additionally many of the studies are determined by a triage nurse before the ER guy/gal even sees the patient (which is an entirely different story)


This being an ophtho forum, a recent exam I had to look over was for a woman with bilateral periorbital edema and some sort of spectre of pain, who got a CT w contrast of the orbits to look for cellulitis (not unreasonable) but this was stone cold negative, and an MRI of the orbits shortly followed. What was the final diagnosis? nephrotic syndrome.

This is not to lay blame at the feet of other physicians (except the ones who self-refer) but to highlight the problem with the system, an ER doctor knows the a 16 year old with costochondral pain reproducible on exam is not an MI or PE, but those are actively rule out on the off chance they are there and doc gets sued, same story with ophtho, and with rads who hedge relentelessly on reports. It's to protect ourselves. I know I'm preaching to the choir, but the solution isn't to cut reimbursement, but to have tort reform to allow physicians to practice medicine without the constant threat of litigation.

 

[Radonkulous]

But in that case, what does that ER doc get paid for ordering the head to toe CT scan?

Aren't they bringing in RVUs to the hospital by ordering imaging tests?

 

[speyeder]

the ER reference was regarding to the almost complete dependence on radiology to come up with a diagnosis or at least with a differential with almost absolutely no prior clinical evaluation or a lack of understanding of how to use imaging.

Where I am training there on an almost daily basis there are multiple CTPEs ordered on patients with low Wells scores and very good explanations; CT and MRI of the heads are ordered to evaluate LOC in patients >65, when in this population the most common etiology is cardiac, and a cardiac workup is initiated only after the head is cleared. Additionally many of the studies are determined by a triage nurse before the ER guy/gal even sees the patient (which is an entirely different story)


This being an ophtho forum, a recent exam I had to look over was for a woman with bilateral periorbital edema and some sort of spectre of pain, who got a CT w contrast of the orbits to look for cellulitis (not unreasonable) but this was stone cold negative, and an MRI of the orbits shortly followed. What was the final diagnosis? nephrotic syndrome.

This is not to lay blame at the feet of other physicians (except the ones who self-refer) but to highlight the problem with the system, an ER doctor knows the a 16 year old with costochondral pain reproducible on exam is not an MI or PE, but those are actively rule out on the off chance they are there and doc gets sued, same story with ophtho, and with rads who hedge relentelessly on reports. It's to protect ourselves. I know I'm preaching to the choir, but the solution isn't to cut reimbursement, but to have tort reform to allow physicians to practice medicine without the constant threat of litigation.

Your last sentence says it all. Without tort reform, the practice of 'defensive medicine' will never end.

 

[KHE]

the ER reference was regarding to the almost complete dependence on radiology to come up with a diagnosis or at least with a differential with almost absolutely no prior clinical evaluation or a lack of understanding of how to use imaging.

Yes, but you said in an earlier posting that CMS was targeting the "wrong group" and that radiologists were not the source of increased health care costs. You've implied that ER docs or triage nurses ordering CT scans are a significant problem.

The tacit implication there is that you think that CMS should be going after ER docs. By doing what? Reducing THEIR reimbursement? Their reimbursement for what? If they don't profit directly by ordering CT tests, how would you "target" them?

 

[davidjones]

re: RVUs for hospital: In a hospital (where hospital owns equipment) the doc ordering a test has no financial incentive to order a particular test; though frequently hospitals do encourage the performance of high RVU procedures (including imaging) by other means, i.e. perks for the doc, or bonuses if they generate a certain amount of RVUs

the problem is PP: an orthopod who owns an MRI machine is much more likely to order an MRI for knee pain or back pain right away then going through a whole work-up (even though a rad reads the images) the technical fee (which is in the thousands of dollars) goes to the orthopod, likewise with cardiac imaging; rads who own their own imaging do not order the imaging and while they collect the technical fee and the professional fee, what gets imaged is ultimately up to the referrer.

A similar situation is seen with rad onc, there are urologists and breast surgeons who own IMRT equipment and collect the technical fee, while a rad onc (who may or may not be part owner of the equipment) does the actual therapy. Even within IR when we treat things like fibroids and liver CA which need advanced imaging costing thousands of dollars there is a push to have a DR read the study, even though we are credentialed and trained to do it ourselves.


re: the ER thing: I made the ER point to highlight the effect of defensive medicine; i.e ordering a CTPE/EKG/full blood work in a 16 year old with clear costochondritis (happens often) this is a thousand dollar workup for something that can be treated with OTC ibuprofen; this means that until there is reform that protects physicians in cases where they miss a 1 in 100,000 case of SAH in a person who comes in with a mild head ache or an MI in a young female who comes in with mild chest pain and no family or past medical history health care costs will continue to go up because unecessary tests will be ordered by physicians who do not want to be sued in those instances.

For a self-sustaining health care

 

[KHE]

re: the ER thing: I made the ER point to highlight the effect of defensive medicine; i.e ordering a CTPE/EKG/full blood work in a 16 year old with clear costochondritis (happens often) this is a thousand dollar workup for something that can be treated with OTC ibuprofen; this means that until there is reform that protects physicians in cases where they miss a 1 in 100,000 case of SAH in a person who comes in with a mild head ache or an MI in a young female who comes in with mild chest pain and no family or past medical history health care costs will continue to go up because unecessary tests will be ordered by physicians who do not want to be sued in those instances.

For a self-sustaining health care

Ok, I understand that and I agree with you.

But you said the CMS is targeting the wrong group of people for imaging costs.

Who should they target? Your assertion is that the CMS should target lawyers? I'm not sure they have that sort of power. Does CMS have an official position on "tort reform?"

 

[davidjones]

I don't believe CMS has any say in tort reform, that has to be made into law by congress, refuse to pass such a law because a lot of support of the democratic party comes from lawyers, and many of them are lawyers, even John Edwards was an ambulance chaser. The republicans also have interests that will keep them from supporting a provision that limits frivolous law suits. There are patient advocacy groups that lobby to prevent such a thing from happening as well, because they fear that families in which mistakes happen will not be properly compensated.

The lack of tort reform is a very very long conversation that is out of the scope of both my knowledge and this thread though

As far as who the cuts should be targeting, I'm not sure, the Stark law is supposed to limit physician referral to facilities that they have a financial stake in, i.e. imaging or rad therapy equipment, there is a huge loop hole that says if you are in a multi-specialty group then that is ok, so ortho join with cards or urology and by up these things, turf out the actual reads or performance of therapy to a rad or rad onc, and collect the technical fee. If the stark law was enforced then there would be a drastic drop in utilization. There is a study that shows that 25% or so of imaging centers are owned by non-radiologist/non-hospital owned imaging centers, however, they acount for 50% of cardiac and MSK imaging performed in this country.


however, cutting a radiologists salary will not prevent overutilization of imaging since radiologists are not the ones ordering the scans; CMS wants to not only cut the technical fee for performing the imaging, but also the professional fee that goes directly to the radiologist (usually around 10% of the technical fee). The other thing they want to do is if a patient is going to get multiple imaging in one day, only the first study is fully compensated, so if a guy walks in with left hemiparesis, gets a head CT (let's say with 500 reimbursement) and then gets an MRI with 6 different sequences and about 3000 images (usually technical fee about 3000 and profesional fee about 150) the MRI which takes up to 20 minutes to read (longer if it's abnormal) will be compensated for a fraction of the cost.

Instead of limiting imaging use, it will actually increase because docs will think "ooh I can get a head CT an MRI of the liver and the head all in the same day and it won't cost the patietn that much more then just the CT so I'll just go ahead and do that"

Ultimately this will lead to radiologists limiting the performance of those studies unless they are truly indicated to only one a day, so areas will completely lose access to advanced imaging because it won't be cost effective.

 

[200UL]

Tort reform will not impact the number of imaging studies ordered. Often times imaging studies are ordered to assist in diagnoses. Doctors like to actually have the correct diagnoses....This will never change even if there is zero threat of litigation. Sometimes imaging studies are ordered for inappropriate reasons (nephrotic syndrome) because the doctor has poor clinical skills in a particular area - this too will never change.

However, Medicare and third party payers will continue to target "high use tests" that are UTILIZED too frequently. OCTs in ophthalmology were targeted (and will continue to be targeted) because of the increasing UTILIZATION associated with anti-vegf therapy for AMD/diabetic retinopathy. I do not order these because I am worried about getting sued. I order these because I want the best care for my patient.

Also, imaging studies are often big business for hospitals (this is unfortunate). Hospitals often make there money off of ER visits, CT scans, lab studies, and oncology care (and everything that comes with that). With the current reimbursement rates for imaging studies, a hospital can help its bottom line if the CT scanner/MRI machine crank non-stop.

Finally, don't kid yourself, reimbursement rates for radiology have been impacted by big business. Do you think Seimens or GE don't want big reimbursement rates for these procedures. If they were not paying big $, what would be the stimulus for hospitals spending millions on purchasing the latest and greatest machine. Hospitals care about the bottom line just as much as patient care.

 

[Visionary]

I agree with a lot of what has been said here. I think imaging is overutilized because of a decline in clinical skills and/or an increase in laziness, rather than for purposes of defensive medicine. CMS is definitely targeting the wrong group, as they do with most cost-saving cuts, . . . if they were actually trying to reduce overutilization. They aren't, however. The CMS just focuses on the cost and utilization of procedures and services, in order to balance the bottom line. It's a money issue, rather than a patient care issue. By dinging radiologists, they aren't saying you order too many tests. They're saying you cost too much money. Yes, the current culture of medicine, and of hospitals in particular, is the reason for it. Doesn't matter, though. Why did OCT reimbursement get cut? It wasn't that we started overutilizing them. It's because our treatment methodology was radically altered by anti-VEGF treatment, necessitating more frequent OCTs. Fact is, though, that the volume and cost of OCT went up enough to draw the attention of CMS. Cut a highly utilized procedure/service, and you save a lot of money. It's all about the Benjamins, my friend.

 

[echinoderm]

regarding overuse of imaging:
http://www.nytimes.com/2011/06/18/health/18radiation.html?_r=2&ref=health

 

[200UL]

regarding overuse of imaging:
http://www.nytimes.com/2011/06/18/health/18radiation.html?_r=2&ref=health

This map is very interesting. I am sure the local radiologists in the "scan twice" camp were heros at their local hospitals until this came out.

 

[orbitsurgMD]

I agree with a lot of what has been said here. I think imaging is overutilized because of a decline in clinical skills and/or an increase in laziness, rather than for purposes of defensive medicine. CMS is definitely targeting the wrong group, as they do with most cost-saving cuts, . . . if they were actually trying to reduce overutilization. They aren't, however. The CMS just focuses on the cost and utilization of procedures and services, in order to balance the bottom line. It's a money issue, rather than a patient care issue. By dinging radiologists, they aren't saying you order too many tests. They're saying you cost too much money. Yes, the current culture of medicine, and of hospitals in particular, is the reason for it. Doesn't matter, though. Why did OCT reimbursement get cut? It wasn't that we started overutilizing them. It's because our treatment methodology was radically altered by anti-VEGF treatment, necessitating more frequent OCTs. Fact is, though, that the volume and cost of OCT went up enough to draw the attention of CMS. Cut a highly utilized procedure/service, and you save a lot of money. It's all about the Benjamins, my friend.

True enough. The problem with what CMS has done is that it has reduced the payments for OCT so low that unless you are running a constant stream of patients through a machine, as would only be possible at a multi-physician group or a busy retina practice, the costs of the devices cannot be reasonably recouped in the expected life of the device. Most of the machines, Zeiss Cirrus, Topcon, Optivue and Heidelberg, are priced in the $70,000 and up range, for the market and reimbursement that prevailed ten years ago, when a two eye, one patient procedure paid nearly four times what it does now. I have calculated that I would need to do at least five scans a day every day I am in clinic in order to just cover the machine, never mind the cost of technical time and physician interpretation time. And unlike other capital purchases, like lane equipment, OCT is like computer equipment, requiring replacement or very substantial and costly upgrades every 3-4 years. Adding a modality that cannot ever cover its costs is a non-starter.

There is a significant price/payment misalignment with OCT. For what the procedures pay, the machines ought to cost less than $20,000, in line with what perimeters and biometers cost.

 

[Visionary]

True enough. The problem with what CMS has done is that it has reduced the payments for OCT so low that unless you are running a constant stream of patients through a machine, as would only be possible at a multi-physician group or a busy retina practice, the costs of the devices cannot be reasonably recouped in the expected life of the device. Most of the machines, Zeiss Cirrus, Topcon, Optivue and Heidelberg, are priced in the $70,000 and up range, for the market and reimbursement that prevailed ten years ago, when a two eye, one patient procedure paid nearly four times what it does now. I have calculated that I would need to do at least five scans a day every day I am in clinic in order to just cover the machine, never mind the cost of technical time and physician interpretation time. And unlike other capital purchases, like lane equipment, OCT is like computer equipment, requiring replacement or very substantial and costly upgrades every 3-4 years. Adding a modality that cannot ever cover its costs is a non-starter.

There is a significant price/payment misalignment with OCT. For what the procedures pay, the machines ought to cost less than $20,000, in line with what perimeters and biometers cost.

Couldn't agree more. The cuts in OCT reimbursement will not only hurt the industry and our ability to care for patients, but it will stifle innovation. The adaptive optics SD-OCTs that are being developed now will never be more than research tools. We have a 6-mode Spectralis here and, thankfully, managed to pay it off before the cuts, but we also have 8 docs. The price of the current SD-OCT machines will have to come down, if the companies want to sell them. Hopefully, we will be able to avoid further cuts from the current CMS imaging evaluation, since we've already been hit hard.

 

[Shnurek]

I mean an OCT is still fairly useful even if it pays 1/4 of what it used to. It takes less than 3 minutes per patient for both eyes in the hands of a skilled tech. Also, because of the demand going down now, I'm sure the prices of the machine will go down as well.

 

[Visionary]

I mean an OCT is still fairly useful even if it pays 1/4 of what it used to. It takes less than 3 minutes per patient for both eyes in the hands of a skilled tech. Also, because of the demand going down now, I'm sure the prices of the machine will go down as well.

Dude, what are you talking about? Of course an OCT is useful. That has not been questioned. The demand is going UP, not DOWN. The acquisition time is not a factor, if you can't perform enough scans per day to justify it. Hopefully the prices will go down, but no signs of that yet, despite the fact the reimbursements were slashed. As orbitsurgMD stated, if you are looking to purchase an SD-OCT now, the ROI is terrible, unless you have very high utilization (e.g., large group practice or high volume smaller practice). You'd be better off buying a used Stratus 3.

 

[orbitsurgMD]

Dude, what are you talking about? Of course an OCT is useful. That has not been questioned. The demand is going UP, not DOWN. The acquisition time is not a factor, if you can't perform enough scans per day to justify it. Hopefully the prices will go down, but no signs of that yet, despite the fact the reimbursements were slashed. As orbitsurgMD stated, if you are looking to purchase an SD-OCT now, the ROI is terrible, unless you have very high utilization (e.g., large group practice or high volume smaller practice). You'd be better off buying a used Stratus 3.

I would have a hard time recommending buying a used Zeiss anything, especially their electronics. The quality and features are not at issue, but their sunset policies and their refusal to allow third-party parts or service makes them a riskier company to do business with. When they decide to stop making parts and repairs available for one of their devices, that's it, you are told to buy a new device.

I can understand that it isn't possible to continue to manufacture boards on older machines which have chips that are obsolete and discontinued, but the decision not to sell spare parts to servicing companies keeps you hostage to their planned obsolescence timetable. All that does is give me reason to look more at other companies' offerings.

 

[Visionary]

I would have a hard time recommending buying a used Zeiss anything, especially their electronics. The quality and features are not at issue, but their sunset policies and their refusal to allow third-party parts or service makes them a riskier company to do business with. When they decide to stop making parts and repairs available for one of their devices, that's it, you are told to buy a new device.

I can understand that it isn't possible to continue to manufacture boards on older machines which have chips that are obsolete and discontinued, but the decision not to sell spare parts to servicing companies keeps you hostage to their planned obsolescence timetable. All that does is give me reason to look more at other companies' offerings.

Valid points, indeed.

 

[Shnurek]

The demand is going UP, not DOWN. The acquisition time is not a factor, if you can't perform enough scans per day to justify it. Hopefully the prices will go down, but no signs of that yet, despite the fact the reimbursements were slashed. As orbitsurgMD stated, if you are looking to purchase an SD-OCT now, the ROI is terrible, unless you have very high utilization (e.g., large group practice or high volume smaller practice). You'd be better off buying a used Stratus 3.

I meant that since the ROI is going down therefore less offices can afford it so the demand will go down. Sorry for any confusion.

 

[orbitsurgMD]

Dude, what are you talking about? Of course an OCT is useful. That has not been questioned. The demand is going UP, not DOWN. The acquisition time is not a factor, if you can't perform enough scans per day to justify it. Hopefully the prices will go down, but no signs of that yet, despite the fact the reimbursements were slashed. As orbitsurgMD stated, if you are looking to purchase an SD-OCT now, the ROI is terrible, unless you have very high utilization (e.g., large group practice or high volume smaller practice). You'd be better off buying a used Stratus 3.

I have observed that the equipment sales pitch made by device companies differs between the ophthalmology and optometry markets. I have seen a much more aggressively commercial presentation of OCT to optometry, with the usual ROI calculations and "assumptions" of medical necessity for imaging procedures that might have difficulty passing legitimate scrutiny. At times, it has seemed that some of these companies expect practitioners to turn their practices into Olan Mills-style tomography studios, where patients are funneled into the OCT en masse and the OCT becomes a profit center.

 

[KHE]

I have observed that the equipment sales pitch made by device companies differs between the ophthalmology and optometry markets. I have seen a much more aggressively commercial presentation of OCT to optometry, with the usual ROI calculations and "assumptions" of medical necessity for imaging procedures that might have difficulty passing legitimate scrutiny. At times, it has seemed that some of these companies expect practitioners to turn their practices into Olan Mills-style tomography studios, where patients are funneled into the OCT en masse and the OCT becomes a profit center.

Well, I don't currently own an OCT and I've never sat through an "ophthalmology sales pitch" by an OCT salesperson.

What optometry presentations have you sat through? In what context where those presentatijons made?

I also don't quite get the reference to a "profit center." Should most things, if not everything in your office be a profit center on some level? Is that not the whole point of being in business?

 

[200UL]

I have no comments on the "profit center." However, if the 30% medicare cut goes into effect, there will be many things I do that will become gauranteed losses.

I find this current discussion very interesting. I have thought about the fact that it may eventually become challenging to pay for a new OCT machine when the rates fell this year. Such a trend will lead to lower quality care as Visionary points out above.

Our technology available today is unreal. The best care (no costs spared) has been available to all in this country. However, we are currently at a tipping point in healthcare - the problem is there is not enough money available to give the best quality care to all. When the real cuts come (and they will as our country cannot spend 100% of GDP on healthcare), quality of care will suffer.

In other words, just like the children of today will have a lower standard of living compared to the baby boomers, medicare recipients of tomorrow will have a lower standard of care compared to today's medicare recipients.

 

[orbitsurgMD]

Well, I don't currently own an OCT and I've never sat through an "ophthalmology sales pitch" by an OCT salesperson.

What optometry presentations have you sat through? In what context where those presentatijons made?

I also don't quite get the reference to a "profit center." Should most things, if not everything in your office be a profit center on some level? Is that not the whole point of being in business?

I own and run my own private practice. Of course I know it is important that new technologies be able to cover their costs. If they do better than that, great, I am all for that. But there is a difference between presenting a product as being useful in advancing clinical decision making while also being a sustainable asset to a practice business and presenting it as an opportunity to open up new revenue streams and well, it is also good for finding CME. That is the difference in presentation I have noticed between the two practice communities. And I have seen it up close and in person as done by large famous German medical device companies.

 

[orbitsurgMD]

I have no comments on the "profit center." However, if the 30% medicare cut goes into effect, there will be many things I do that will become gauranteed losses.

I find this current discussion very interesting. I have thought about the fact that it may eventually become challenging to pay for a new OCT machine when the rates fell this year. Such a trend will lead to lower quality care as Visionary points out above.

Our technology available today is unreal. The best care (no costs spared) has been available to all in this country. However, we are currently at a tipping point in healthcare - the problem is there is not enough money available to give the best quality care to all. When the real cuts come (and they will as our country cannot spend 100% of GDP on healthcare), quality of care will suffer.

In other words, just like the children of today will have a lower standard of living compared to the baby boomers, medicare recipients of tomorrow will have a lower standard of care compared to today's medicare recipients.

If the 30% cut goes into effect, Medicare Part B will be done. Anyone with brain tissue can figure that out. Primary care, which is already on the ropes in many parts of the country with Medicare will probably lead the way, and that is likely all that it will take to collapse the program. Even a large minority of primary care doctors closing to new Medicare patients while a smaller number opting out will be all that it will take to upend the Part B program.

Right now, opting out is a threatening process. It requires forgoing all participation with Medicare for two years thereafter. When many doctors participate, opting out carries the possibility that all your patients will go to other doctors who do participate. So few opt out. For now.

But if you slap a 30% cut on payments (remember, that is this coming year; there is yet another big cut coming the next year under the infernal SGR,) you have made Medicare an outright across-the-board losing proposition: surefire business failure. The decision becomes very clear and easy then: drop Medicare, drastically re-structure your practice business to reduce overhead, and the easiest thing to cut is the whole billing-coding-collection apparatus that doctors have had to adopt to use Medicare. But to do that, it makes no sense to have contracts with private carriers either, since that same apparatus is necessary to file and collect with private insurance. What will result is the end of third-party interaction with the doctor, that all will get thrown back on the patient to deal with their insurer and with Medicare.

But there's more. If you don't have to deal with Medicare or their price caps, you also don't have to deal with HIPAA or with PPACA, with CPT codes or ICD-9 or ICD-10, or having to do e-prescribing of having to buy an EHR, unless you want to, unless those things actually show themselves to make your job easier while being efficient and affordable, like anything else you might buy, and not like something the government tells you you have to buy.

In some ways, it doesn't have to be so awful. CMS will hate that. They live for the power to control prices and to make medical practice bend to their will. To save Part B after shoving out a 30% cut, the only thing they will have is to lift the ban on balance billing. That is the only thing that will keep Part B alive in a large reduction scenario. Otherwise it is dead, and they know it.

Just imagine the outrage of the American public then. I am sure they can.

 

[doc4444]

I hope to god people in this particular forum actually like medicine. You will NEVER be filthy rich doing Ophthalmology. Even if you do Plastics, the way this economy is going, you had better like orbital surgery. Word to the wise from someone who knows - orbital surgery sucks.

so give up your formulas and just do what you like. There is no way to predict right now what is going to happen to medicine, but it is a fair shake that most of us will see our reimbursements going down.

Finally, don't do Ophthalmology unless you enjoy being surrounded by self-important primadonnas, who like nothing better than hearing themselves talk. I've had a decade of it, as an attending. It doesn't go away. There's a reason why that stereotype exists, people. If that's who you are though, you'll be quite happy.

 

[Mirror Form]

Finally, don't do Ophthalmology unless you enjoy being surrounded by self-important primadonnas, who like nothing better than hearing themselves talk.

It's pretty hard to avoid that in many fields of medicine. Ophtho might be one of the worst though.

 

[OjoCinco]

Who the heck are you guys talking to? Ophthalmologists have been among the nicest people to be around among medical professionals.

I think in medical school we have our heads shoved so far up the ass of an academic center that we forget that's not what life is like. I find that the only real personality rule is that if a physician of any specialty is an attending at your academic center they have a very good chance of being a condescending jerkwad. Go meet some private practice Ophthos before you judge them all.

You know, it's sometimes fun to carry out a generalization without having some moralistic fellow slap us back to reality.

you, sir, make the internet less fun.

 

[fakelyfakester]

1

 

[Mirror Form]

Who the heck are you guys talking to? Ophthalmologists have been among the nicest people to be around among medical professionals.

I think in medical school we have our heads shoved so far up the ass of an academic center that we forget that's not what life is like. I find that the only real personality rule is that if a physician of any specialty is an attending at your academic center they have a very good chance of being a condescending jerkwad. Go meet some private practice Ophthos before you judge them all.

You do realize I am an ophthalmologist right? Sure private practice is different, but you can never escape the ABO. My guess is that you'll have a different opinion while you're preparing for your oral boards.