Economics of optometry and lasers/procedures

[Mirror Form]

I'm wondering if optometrists doing lasers/procedures is actually realistic from an economics standpoint. I work with some optometry students. They seem really excited by the idea of doing lasers, but have no clue what the economics are like. It seems to me like they're wasting their time and money campaigning for credentials that wouldnt' do them any good.

Given the economics of doing procedures, how would most optometrists actually be able to perform procedures? It's not like shave biopsies and chalazion I&C's reimburse much. If you're busy you could make just as much by fitting contact lenses during that time.

Lasers are very expensive to buy, lease, or even rent. You need a lot of patients to make it worthwhile. How many optometrists are really going to have enough patients with PCO's to make renting a yag worthwhile? Same goes for other lasers.

As an ophthlamologist, I have the credentials and training to do a lot more surgery than I actually do. I was trained very well to perform glaucoma surgery, strabismus surgery, and oculoplastics. It really doesn't make sense for me to do much glaucoma or strabismus surgery anymore though, and I don't do all that much plastics either.

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[KHE]

I'm wondering if optometrists doing lasers/procedures is actually realistic from an economics standpoint. I work with some optometry students. They seem really excited by the idea of doing lasers, but have no clue what the economics are like. It seems to me like they're wasting their time and money campaigning for credentials that wouldnt' do them any good.

Given the economics of doing procedures, how would most optometrists actually be able to perform procedures? It's not like shave biopsies and chalazion I&C's reimburse much. If you're busy you could make just as much by fitting contact lenses during that time.

Lasers are very expensive to buy, lease, or even rent. You need a lot of patients to make it worthwhile. How many optometrists are really going to have enough patients with PCO's to make renting a yag worthwhile? Same goes for other lasers.

I don't agree with that.

Yes, you may encounter some dippy students who think that "doing lasers" is fun and sexy but if you talk to most real world optometrists, we "get" the economics of it. In fact, because we've historically had somewhat of a retail component to our practices, we've "gotten" economics a bit better than most other health care professionals.

I've been saying that exact thing for a few years on this forum now and I don't quite get why it's taken this long for many of you to figure this out.

I've also been saying for years that these "scope of practice fights" aren't about these specific procedures. It's about who will ultimately control the profession of optometry. Will it be optometry or "someone else?"

Will optometry have go and grovel before some medical board every time a new prostaglandin analog comes out?

Will optometry have to go and grovel before some medical board when a product like Latisse comes out?

Will optometry have to go and grovel before some medical board when theraputic contact lenses are devloped?

Will optometry have to go before the medical board to pluck an eyelash that's irritating someone even though cosmeticians do it all the time? (and actually get paid more money to do it than either optometry OR ophthalmology though I guess that's a whole separate discussion.)

Well.....guess what? We have had those exact situations in a number of states.

And that's the issue. It's not about YAGs, or PIs. If I see 10 patients a year combined who need those procedures, I would be shocked and about 20% of my practice is nursing home based.

It's not about LASIK. That bubble has long since burst. I don't know how many times I can say that simply adding optometric providers while leaving demand the same is going to bottom out fees. We will be looking back at the days of the $299 per eye advertisements on the side of the highway as the "Golden Age" of LASIK. Trust me when I say.....optometrists GET THIS.

It's about self determination. Not the piddly income from 5 PIs a year.

 

[orbitsurgMD]

I don't agree with that.

Yes, you may encounter some dippy students who think that "doing lasers" is fun and sexy but if you talk to most real world optometrists, we "get" the economics of it. In fact, because we've historically had somewhat of a retail component to our practices, we've "gotten" economics a bit better than most other health care professionals.

I've been saying that exact thing for a few years on this forum now and I don't quite get why it's taken this long for many of you to figure this out.

I've also been saying for years that these "scope of practice fights" aren't about these specific procedures. It's about who will ultimately control the profession of optometry. Will it be optometry or "someone else?"

Will optometry have go and grovel before some medical board every time a new prostaglandin analog comes out?

Will optometry have to go and grovel before some medical board when a product like Latisse comes out?

Will optometry have to go and grovel before some medical board when theraputic contact lenses are devloped?

Will optometry have to go before the medical board to pluck an eyelash that's irritating someone even though cosmeticians do it all the time? (and actually get paid more money to do it than either optometry OR ophthalmology though I guess that's a whole separate discussion.)

Well.....guess what? We have had those exact situations in a number of states.

And that's the issue. It's not about YAGs, or PIs. If I see 10 patients a year combined who need those procedures, I would be shocked and about 20% of my practice is nursing home based.

It's not about LASIK. That bubble has long since burst. I don't know how many times I can say that simply adding optometric providers while leaving demand the same is going to bottom out fees. We will be looking back at the days of the $299 per eye advertisements on the side of the highway as the "Golden Age" of LASIK. Trust me when I say.....optometrists GET THIS.

It's about self determination. Not the piddly income from 5 PIs a year.

Yeah, OK. But exactly what is "self determination?" There are a lot of supervising bodies that have a say in what counts as adequate training for an ophthalmologist: the ACGME, the ABO, state licensing agencies, insurance companies, and the CMS and AAO also have a say. In Kentucky, it is open season on "lumps and bumps" for optometrists, according to the law. Got a little extra skin or prolapsed orbital fat? Looks like a "bump" to me, time for a blepharoplasty, no extra training required. In fact, unless the Board of Optometry forbids a procedure, what is stopping an optometrist from doing that procedure? Nothing, really. Next up, breast implants.

 

[200UL]

I am with orbitsurgMD - The Kentucky law dose create "open season" for most things in eye surgery.

Regarding the original point. I do not feel most optometrists do get the economic reality of most of the lasers. After all, one would have to do a lot of YAGs at $250 a pop to pay for that $25,000 laser. One could rent a laser - the rental company would get $150 from each laser.

This is what bothers me about the bill - It was sold as an access to care issue. The only optometrists who will use the lasers will be in the heavily populated centers. I am sure Ben Gaddie, OD will gladly charge some of his friends to use his laser (I promise you Ben Gaddie gets the economic reality). In other words, the lasers will not be placed in Martin, Clay, or Owsley counties (where over 40% of the populations live below the poverty line).

 

[Visionary]

I am with orbitsurgMD - The Kentucky law dose create "open season" for most things in eye surgery.

Regarding the original point. I do not feel most optometrists do get the economic reality of most of the lasers. After all, one would have to do a lot of YAGs at $250 a pop to pay for that $25,000 laser. One could rent a laser - the rental company would get $150 from each laser.

This is what bothers me about the bill - It was sold as an access to care issue. The only optometrists who will use the lasers will be in the heavily populated centers. I am sure Ben Gaddie, OD will gladly charge some of his friends to use his laser (I promise you Ben Gaddie gets the economic reality). In other words, the lasers will not be placed in Martin, Clay, or Owsley counties (where over 40% of the populations live below the poverty line).

Bingo! If Gaddie doesn't already have a laser (or 2), he likely has one on order. I'll give him this: he is a shrewd businessman. I would wager that he is planning on having some portable lasers that he can peddle to other ODs in the area as a revenue stream. I would also expect him to start a training program. You are correct, however, that the likelihood of such lasers being placed in the true counties of need is negligible. There's simply not enough volume to yield a good ROI. That's why the whole access to care issue is a sham. Gaddie will have the ODs in outlying counties referring in to him, rather than an ophthalmologist.

 

[KHE]

Bingo! If Gaddie doesn't already have a laser (or 2), he likely has one on order. I'll give him this: he is a shrewd businessman. I would wager that he is planning on having some portable lasers that he can peddle to other ODs in the area as a revenue stream. I would also expect him to start a training program. You are correct, however, that the likelihood of such lasers being placed in the true counties of need is negligible. There's simply not enough volume to yield a good ROI. That's why the whole access to care issue is a sham. Gaddie will have the ODs in outlying counties referring in to him, rather than an ophthalmologist.

I had to google who "Ben Gaddie" is. I think that what you're describing is incredibly unlikely.

In optometry, we still have huge numbers of doctors who manage nothing beyond refractive problems. While the number of ODs managing minor medical issues of the eye has increased, one complaint that has been universal in optometry is how little intra-professional referrals are made.

As such, if ODs won't refer to each other for the treatment of minor eye issues, do you really think we'll refer to each other for surgical care? Not a snowballs chance in hell.

Also to the issue of "need" in the various counties of Kentucky, how much actual "need" is there? Are there people who are NOT getting YAG's and PIs who live in these counties who WOULD if only that laser was 100 miles closer?

I'm skeptical of that.

 

[Frumps]

I had to google who "Ben Gaddie" is. I think that what you're describing is incredibly unlikely.

In optometry, we still have huge numbers of doctors who manage nothing beyond refractive problems. While the number of ODs managing minor medical issues of the eye has increased, one complaint that has been universal in optometry is how little intra-professional referrals are made.

As such, if ODs won't refer to each other for the treatment of minor eye issues, do you really think we'll refer to each other for surgical care? Not a snowballs chance in hell.

Also to the issue of "need" in the various counties of Kentucky, how much actual "need" is there? Are there people who are NOT getting YAG's and PIs who live in these counties who WOULD if only that laser was 100 miles closer?

I'm skeptical of that.

I beg to differ. You're right that the vast majority of optometrists are not going to be doing these procedures. It does not make economic sense to the OD in a rural community. People like Ben Gaddie know that he can count on referrals from various ODs in his area and bill himself as a optometric consultant (treating glaucoma with SLTs and PIs). If this bill was truly about access to care, the legislation should have included a "certificate of need" for an optometric clinic in a rural community to gain access to a laser. Anyone care to bet what the percent of procedures done by ODs in rural communities is going to be?!? Anyone care to guess why ophthalmologists don't live in smaller communites?!?

 

[Visionary]

I had to google who "Ben Gaddie" is. I think that what you're describing is incredibly unlikely.

In optometry, we still have huge numbers of doctors who manage nothing beyond refractive problems. While the number of ODs managing minor medical issues of the eye has increased, one complaint that has been universal in optometry is how little intra-professional referrals are made.

As such, if ODs won't refer to each other for the treatment of minor eye issues, do you really think we'll refer to each other for surgical care? Not a snowballs chance in hell.

Also to the issue of "need" in the various counties of Kentucky, how much actual "need" is there? Are there people who are NOT getting YAG's and PIs who live in these counties who WOULD if only that laser was 100 miles closer?

I'm skeptical of that.

I'll accept your first point regarding the number of ODs who will seek such privileges.

I'm not so sure about ODs not referring to someone like Gaddie, who has training in glaucoma lasers, though. You may be right, but if so, where would the referral base come from? I guess he could advertise as a glaucoma specialist and build his practice up as such. Heck, if he's not arranged a referral base already, perhaps he's not as shrewd as I thought. Given his background, I suspect he was a primary architect of the KY bill. After all, he is the KOA president-elect. If he wasn't going to benefit financially, why push for the lasers? As you've stated before, ODs are pretty well in tune with the business end of things.

I, of course, totally agree with your last point. That's why I said the access to care issue is a sham.

 

[SurgbySurgeons]

I'll accept your first point regarding the number of ODs who will seek such privileges.

I'm not so sure about ODs not referring to someone like Gaddie, who has training in glaucoma lasers, though. You may be right, but if so, where would the referral base come from? I guess he could advertise as a glaucoma specialist and build his practice up as such. Heck, if he's not arranged a referral base already, perhaps he's not as shrewd as I thought. Given his background, I suspect he was a primary architect of the KY bill. After all, he is the KOA president-elect. If he wasn't going to benefit financially, why push for the lasers? As you've stated before, ODs are pretty well in tune with the business end of things.

I, of course, totally agree with your last point. That's why I said the access to care issue is a sham.

We actually have an optometrist in our city who bills himself as a glaucoma consultant. He states that he did a glaucoma fellowship because he happened to be working with an MD glaucoma subspecialist in the past. He is very busy with referrals from ODs. I don't know what happens to these patients when they need surgery however.

 

[KHE]

I'll accept your first point regarding the number of ODs who will seek such privileges.

I'm not so sure about ODs not referring to someone like Gaddie, who has training in glaucoma lasers, though. You may be right, but if so, where would the referral base come from? I guess he could advertise as a glaucoma specialist and build his practice up as such. Heck, if he's not arranged a referral base already, perhaps he's not as shrewd as I thought. Given his background, I suspect he was a primary architect of the KY bill. After all, he is the KOA president-elect. If he wasn't going to benefit financially, why push for the lasers? As you've stated before, ODs are pretty well in tune with the business end of things.

I, of course, totally agree with your last point. That's why I said the access to care issue is a sham.

I can only speak for myself having practiced in 3 different states and for 11 years. ODs referring to other ODs simply doesn't happen for the vast majority of things other than MAYBE vision therapy or once in a while, some crazy keratoconus fitting.

I just don't see Dr. Gaddie has having any sort of referral base. I do not know him nor how many procedures he's done. I do not know any ODs in Kentucky nor do I know the state of optometry in Kentucky so I admit I could be wrong but to me it's inconceivable that anyone other than those working directly for him would refer to him for these procedures.

I can say that I would not refer to him. Why would I want to refer to him when there are probably 50 fellowship trained sub specialists who do the exact same thing?

If I was in the middle of the sticks, I probably STILL would not refer to him because there's virtually nothing emergent that requires those treatments.

In other words, referring to him offers nothing to me or the patient. Does it offer something to the profession of optometry? I guess it might in theory but I don't even think that.

 

[KHE]

I beg to differ. You're right that the vast majority of optometrists are not going to be doing these procedures. It does not make economic sense to the OD in a rural community. People like Ben Gaddie know that he can count on referrals from various ODs in his area and bill himself as a optometric consultant (treating glaucoma with SLTs and PIs). If this bill was truly about access to care, the legislation should have included a "certificate of need" for an optometric clinic in a rural community to gain access to a laser. Anyone care to bet what the percent of procedures done by ODs in rural communities is going to be?!? Anyone care to guess why ophthalmologists don't live in smaller communites?!?

I HIGHLY doubt that. I would not expect that he would get any referrals beyond those working directly for him, if even them.

 

[MR1]

I can only speak for myself having practiced in 3 different states and for 11 years. ODs referring to other ODs simply doesn't happen for the vast majority of things other than MAYBE vision therapy or once in a while, some crazy keratoconus fitting.

I just don't see Dr. Gaddie has having any sort of referral base. I do not know him nor how many procedures he's done. I do not know any ODs in Kentucky nor do I know the state of optometry in Kentucky so I admit I could be wrong but to me it's inconceivable that anyone other than those working directly for him would refer to him for these procedures.

I can say that I would not refer to him. Why would I want to refer to him when there are probably 50 fellowship trained sub specialists who do the exact same thing?

If I was in the middle of the sticks, I probably STILL would not refer to him because there's virtually nothing emergent that requires those treatments.

In other words, referring to him offers nothing to me or the patient. Does it offer something to the profession of optometry? I guess it might in theory but I don't even think that.

I have seen multiple (probably dozen in my residency) where an OD referred to another OD before the patient got sent to a MD. For multiple reasons as well, disc edema!!, delayed visual maturation, ET\XT, glaucoma. It happens, maybe not often but it does.

 

[Visionary]

I can only speak for myself having practiced in 3 different states and for 11 years. ODs referring to other ODs simply doesn't happen for the vast majority of things other than MAYBE vision therapy or once in a while, some crazy keratoconus fitting.

I just don't see Dr. Gaddie has having any sort of referral base. I do not know him nor how many procedures he's done. I do not know any ODs in Kentucky nor do I know the state of optometry in Kentucky so I admit I could be wrong but to me it's inconceivable that anyone other than those working directly for him would refer to him for these procedures.

I can say that I would not refer to him. Why would I want to refer to him when there are probably 50 fellowship trained sub specialists who do the exact same thing?

If I was in the middle of the sticks, I probably STILL would not refer to him because there's virtually nothing emergent that requires those treatments.

In other words, referring to him offers nothing to me or the patient. Does it offer something to the profession of optometry? I guess it might in theory but I don't even think that.

I'll admit that I don't know him or of what his actual referral base consists. I know he's in a 7 OD practice (one is his dad) with 5 locations in the Louisville area. If he could just get those in his practice to refer, he would probably do well.

I agree that there is no real need, even in rural areas, to refer to him or any other "optometric surgeon." There simply is no access to care issue. No patient in KY is more than an hour or so from an ophthalmologist, and Louisville itself has plenty of them.

 

[PBEA]

I have seen multiple (probably dozen in my residency) where an OD referred to another OD before the patient got sent to a MD. For multiple reasons as well, disc edema!!, delayed visual maturation, ET\XT, glaucoma. It happens, maybe not often but it does.

Uhhhh, I see alot of "delayed visual maturation, ET\XT, glaucoma", and I rarely refer them to an MD or OD for that care. Why in the world would I do that?

 

[MR1]

Uhhhh, I see alot of "delayed visual maturation, ET\XT, glaucoma", and I rarely refer them to an MD or OD for that care. Why in the world would I do that?

Never makes sense to me either (although I detect sarcasm in your post)

 

[KHE]

I'll admit that I don't know him or of what his actual referral base consists. I know he's in a 7 OD practice (one is his dad) with 5 locations in the Louisville area. If he could just get those in his practice to refer, he would probably do well.

I agree that there is no real need, even in rural areas, to refer to him or any other "optometric surgeon." There simply is no access to care issue. No patient in KY is more than an hour or so from an ophthalmologist, and Louisville itself has plenty of them.

I ask this in all seriousness, because I honestly do not know.

How many YAGs and PIs would you say that the average ophthalmologist out there in private practice does in a month?

 

[cme2c]

I ask this in all seriousness, because I honestly do not know.

How many YAGs and PIs would you say that the average ophthalmologist out there in private practice does in a month?

Will be pretty variable depending on how many cataracts the doc does obviously and also the ethnic makeup of a docs practice, but I would say a couple PIs, and 5-10 Yags per month would be aggressive estimates for the "average" comprehensive ophthalmologist.

 

[orbitsurgMD]

Will be pretty variable depending on how many cataracts the doc does obviously and also the ethnic makeup of a docs practice, but I would say a couple PIs, and 5-10 Yags per month would be aggressive estimates for the "average" comprehensive ophthalmologist.

1-2 PIs and on the low end of the capsulotomy range, most likely, even for a busy cataract surgeon. Visually-significant PCO just isn't as common with newer lens implants and the cohort of PMMA carriers is dying off or has already had their lasers done. The era of the day-91 YAG capsulotomy has rightly been driven from the pale.

 

[cme2c]

1-2 PIs and on the low end of the capsulotomy range, most likely, even for a busy cataract surgeon. Visually-significant PCO just isn't as common with newer lens implants and the cohort of PMMA carriers is dying off or has already had their lasers done. The era of the day-91 YAG capsulotomy has rightly been driven from the pale.

I agree that visually signficant PCO isn't as common, but I think YAG rate with premiums balances that a bit.

 

[KHE]

I agree that visually signficant PCO isn't as common, but I think YAG rate with premiums balances that a bit.

Ok,

I don't really want to talk too much about this Ben Gaddie guy's practice because I have no idea who he is nor do I know anything about his practice.

But if you're all saying that the average comprehensive ophthalmologist does 1-2 PIs a month and maybe 5 YAGs, then it stands to reason that an optometrist who is NOT doing cataract surgery and almost certainly doesn't have the same referral base and relationships among primary care MDs and internal medicine types who would be more likely to refer in "old people" that would have a higher likelihood of needing something like a PI would be doing something "much less" than that.

So even with a multi location, multi OD practice the chances of him being able to generate anywhere close to the volume needed to make having a laser worthwhile even with every OD in his group referring to him and him alone is slim at best.

And 82% of ODs out there are in solo practice, not a multi location multi OD practice.

So again.....I want to restate that none of this has anything to do with YAGs and PIs. It really really doesn't. I really understand why you're all wound up about it. I really do. But you're not looking at this the right way. It's not about YAGs.

 

[cme2c]

Ok,

I don't really want to talk too much about this Ben Gaddie guy's practice because I have no idea who he is nor do I know anything about his practice.

But if you're all saying that the average comprehensive ophthalmologist does 1-2 PIs a month and maybe 5 YAGs, then it stands to reason that an optometrist who is NOT doing cataract surgery and almost certainly doesn't have the same referral base and relationships among primary care MDs and internal medicine types who would be more likely to refer in "old people" that would have a higher likelihood of needing something like a PI would be doing something "much less" than that.

So even with a multi location, multi OD practice the chances of him being able to generate anywhere close to the volume needed to make having a laser worthwhile even with every OD in his group referring to him and him alone is slim at best.

And 82% of ODs out there are in solo practice, not a multi location multi OD practice.

So again.....I want to restate that none of this has anything to do with YAGs and PIs. It really really doesn't. I really understand why you're all wound up about it. I really do. But you're not looking at this the right way. It's not about YAGs.

The fact that there is not the backlog of patients that need these procedures is even more reason to limit them to do it. ODs claim that there are so many patients that will be helped by scope expansion..... There aren't. I practiced in the middle of nowhere. The reason it's the middle of nowhere is there is no one living there. Who wants a procedure done by someone who didn't actually do one on a live patient for their training and then does a handful a year? If they are only doing a weekend training course and then doing even less than the average general ophtho they will never get good at these procedures. That is the problem. If you had formal requirements where ODs had to do a set amount of these procedures in order to graduate, I wouldn't have a problem with them. But that's not what optometry is doing. They are saying "we are trained for it now", and that their boards will make the sole determination on competency to perform procedures. That is what ophthalmology has a problem with.

So I agree it's not about YAGs, why would ODs go through all this for YAGs, it's about a bigger agenda. YAGs and lid ditzels are small potatoes compared to cataracts and refractive surgery. Once you allow the boards of optometry to make that type of decision on it's own, it won't be long before the same minority of ODs say they are competent to perform intraocular surgery.

 

[SurgbySurgeons]

So I agree it's not about YAGs, why would ODs go through all this for YAGs, it's about a bigger agenda. YAGs and lid ditzels are small potatoes compared to cataracts and refractive surgery. Once you allow the boards of optometry to make that type of decision on it's own, it won't be long before the same minority of ODs say they are competent to perform intraocular surgery.

I agree as well. The ODs are positioning themselves for the future by being allowed to perform "minor" procedures now. The next thing on the agenda for ODs will likely be refractive surgery, and further down the line femtosecond assisted cataract surgery. When the ODs introduce new legislation in a few years, they will say, "we have been performing laser surgery for years and look at our complication rate." It's the same argument they used in Kentucky, because a YAG PC has a low risk of complications. Its the same thing with injections and minor lid surgeries. The only thing is, when they do finally get legislation to include some more advanced procedures, they better be prepared for the expert witness MDs who will see them in court. I'm thinking the first lawsuit is going to involve mismanagement of skin cancer (what do you think). Anyway, good luck with the increase in scope. You'll now get to pay higher malpractice and soon be required to take boards (not just sign up for fun like this year). Also, will learn the fun of needing hospital privileges to perform these procedures in the clinic. Have fun taking call boys and girls.

 

[Shnurek]

The next thing on the agenda for ODs will likely be refractive surgery,.........Anyway, good luck with the increase in scope. You'll now get to pay higher malpractice and soon be required to take boards (not just sign up for fun like this year). Also, will learn the fun of needing hospital privileges to perform these procedures in the clinic. Have fun taking call boys and girls.

Refractive surgery has been done by ODs in Oklahoma since 1998. (ever hear of anything going wrong?)

For those ODs that wish to proceed to learning surgery, they also impose upon themselves the additional responsibilities that come with the additional privileges. (Most of us do not want that)

I believe in the distant future, for the sake of compromise, a minority of exceptional ODs will go onto ophthalmology residencies.



Anyways, take my opinions with a grain of salt as I am not an OD yet.

 

[JMK2005]

Refractive surgery has been done by ODs in Oklahoma since 1998. (ever hear of anything going wrong?)

Are you saying there has not been complications leading to vision loss??

Must be a huge access of care issue in OK for refractive procedure.

 

[speyeder]

I believe in the distant future, for the sake of compromise, a minority of exceptional ODs will go onto ophthalmology residencies.

How will these exceptional ODs be admitted to ophthalmology residencies without first completing medical school?

 

[bungo]

Refractive surgery has been done by ODs in Oklahoma since 1998. (ever hear of anything going wrong?)

It really irks me whenever someone infers that there haven't been any complications from the expanded medical or surgical scope of optometrists. Plenty of glaucoma blebs and cancers have been inappropriately excised in OK, And I am sure any complications from PRK could be easily covered up.

I had to go see an optometry VA patient on call a couple of weeks ago who they had let slowly go blind due to glaucoma (I was seeing them for an unrelated issue). He told me they had him come in every month for a visual field and kept switching around his drops. He was slowly losing his vision and got frustrated. He asked about surgery or about seeing an ophthalmologist. They convinced him he didn't need anything different and now he is blind. I was pretty upset by what he told me. He basically said they refused to refer him. I doubt that, but I was still shocked. I found out who the VA ophthalmology chief was and I wrote them a long email at two in the morning detailing everything I had found out about the guy. I got back a one line response saying this happens all the time and he was free to switch his care.

Whenever anything does "go wrong", it doesn't slow down your schedule of pushing for more things you want. If anything, it accelerates it. For instance, proposed optometry legislature in California after all those VA glaucoma lawsuits came out.

 

[200UL]

bungo

Please tell me you are joking about glaucoma blebs being excised in OK. I can’t even imagine – “woops, now there is a hole in the eye and the pressure went to zero. Dr. Ben Gaddie didn’t tell us this one at the weekend course at the super 8”.

I fully would expect lid lesions to be inappropriately handled (I saw the recorded testimony in the OK statehouse where the optometry expert misdiagnosed basal cell / and a case of sebaceous cell where the history straight out of the textbook gave it away – either the guy felt very comfortable lying to the state representatives and wanted to pump his chest that he was trained to take care of everything or he had the medical knowledge that would get him fired in my clinic as he would not even be at the level of a newly trained technician), but an optometrist has no business excising anything on the globe.

I have never encouraged a lawsuit where a complication occurred because one never really knows what took place at the time. However, if an optometrist ever excises or attempts to excise a glaucoma bleb, this would not only be a situation of malpractice – I believe this would be grounds for an assault charge and that the doctor should end up in jail.

 

[Shnurek]

How will these exceptional ODs be admitted to ophthalmology residencies without first completing medical school?

Hypothetically they won't have to. Optometry is trying to emulate the dental model. But I am for vertical integration.

It really irks me whenever someone infers that there haven't been any complications from the expanded medical or surgical scope of optometrists. Plenty of glaucoma blebs and cancers have been inappropriately excised in OK, And I am sure any complications from PRK could be easily covered up.

...I found out who the VA ophthalmology chief was and I wrote them a long email at two in the morning detailing everything I had found out about the guy. I got back a one line response saying this happens all the time and he was free to switch his care.

Whenever anything does "go wrong", it doesn't slow down your schedule of pushing for more things you want. If anything, it accelerates it. For instance, proposed optometry legislature in California after all those VA glaucoma lawsuits came out.

Please find me proof of this malpractice, not just anecdotal tales and conspiracy theories. You might be right but I'd rather see proof.

I also do not believe he was not referred. In the VA that I shadowed an OD in, there was a glaucoma specialist literally across the hall. Do all VA's have at least one OMD?

I am not familiar with those VA Glaucoma lawsuits but were they caused by malpractice by ODs, OMDs or both?

Do you mean that care does "go wrong" for ODs performing it and this leads to expanded scope of practice for ODs? Seems counter-intuitive to me.

 

[Shnurek]

BTW, here's what happens when you use incompetent ophthalmic technicians to screen your patients to save some money:

http://www.youhavealawyer.com/blog/2008/07/14/laser-eye-surgery-lawsuit/

 

[200UL]

Shnurek - do you understand the difference in harming a patient and malpractice. Proving malpractice requires a trip to the court room. Patients have poor outcomes every day under the care of optometry and ophthalmology. You have been listening too much to Dr. Gaddie who believes everything he touches turns to gold. If any medical professional completes "250,000 procedures," there will be some patients with poor outcomes. The argument by optometry in OK and KY was that there were perfrect outcomes in 250,000 procedures because they did not end up in court. In reality, not going to court means nothing. Anyone who actually practices medicine understands this concept.

I repeat if an optometrist ever attempted to excise a glaucoma bleb, this would be grounds for a malpractice suit and they would lose. Additionally, this eye doctor should end up in jail for assault (In my medical judgment, hitting the patient in the head 3 times with a baseball bat would be a lesser crime).

 

[Shnurek]

I don't know about you but I believe there is a correlation between the amount of patients that get harmed and the amount that go to court for malpractice. Sure the numbers may not be equal and I agree with you that some of those 250,000 might not have been excellent but I'd rather speak in facts.

 

[JMK2005]

I don't know about you but I believe there is a correlation between the amount of patients that get harmed and the amount that go to court for malpractice. Sure the numbers may not be equal and I agree with you that some of those 250,000 might not have been excellent but I'd rather speak in facts.

Many claims may not even go to court but settle before that time. It is difficult to find out about those. Realize that it takes a lot for patients to decide to sue and find a lawyer to take up the case. It may get dragged out for years.

So, don't be naive to think that a lack of malpractice claims equal good outcomes.

 

[200UL]

So are you agreeing that not all 250,000 procedures were perfect? Your leaders say they were...

I am thankful that my profession's leaders do not have to lie directly to lawmakers (saying basal cell cancer carcinoma and sebaceous cell carcinoma are "benign" in order to impress) and misrepresent qualifications (ben gaddie telling local TV station that optometry students have just as much suturing experience as ophthalmology residents).

With leaders like Gaddie (leaders who lie and look stupid doing it), those in your profession who continue to push the envelope will be perceived as nothing more than quacks.

Have your leaders develop a training program and learn to speak as medical professionals (and not used car salesmen) - then you can ask for your surgical rights.

 

[Shnurek]

As optometrists have tried to go through ophthalmology for decades to increase scope of practice, they were continually shot down. So ODs had to resort to tactics that might not have been "ethically sound". Because OMDs were unreasonable so ODs became unreasonable too. And unreasonableness in politics is the name of the game. That's why I chose science as a major

Personally, scientifically, the word "perfect" has no bearing as there are countless variables. Politically, "perfect" or other extreme words are thrown around everywhere. Should it be this way? The common populace are not scientists and they do not know of what we speak of. Language has to be "dumbed down" for the layman. And sure it can be biased toward one side or the other.

I'd rather it not be this way but both sides are so antagonistic toward each other. We need to come together and do something about this issue instead of expending so much mental energy on battling over scope of practice turf like street gangs when instead we can be thinking more about how to improve our patient's lives.

I hope something comes out of qcy07 and CKliger's correspondence.

 

[bungo]

Google optometry va lawsuit or add in California if you want. It was an optometry only thing.

The bleb excision story came from the article linked in another one of these threads where Dr. Parke from Dean Mcgee was quoted.

The optometry clinic at this va doesn't like to refer to the ophthalmology clinic.

 

[taehong81]

Hypothetically they won't have to. Optometry is trying to emulate the dental model. But I am for vertical integration.



Please find me proof of this malpractice, not just anecdotal tales and conspiracy theories. You might be right but I'd rather see proof.

I also do not believe he was not referred. In the VA that I shadowed an OD in, there was a glaucoma specialist literally across the hall. Do all VA's have at least one OMD?

I am not familiar with those VA Glaucoma lawsuits but were they caused by malpractice by ODs, OMDs or both?

Do you mean that care does "go wrong" for ODs performing it and this leads to expanded scope of practice for ODs? Seems counter-intuitive to me.

Here is an article that talks about the cases from the VA optom.

 

[bungo]

Hypothetically they won't have to. Optometry is trying to emulate the dental model. But I am for vertical integration.

Please find me proof of this malpractice, not just anecdotal tales and conspiracy theories. You might be right but I'd rather see proof.

I also do not believe he was not referred. In the VA that I shadowed an OD in, there was a glaucoma specialist literally across the hall. Do all VA's have at least one OMD?

I am not familiar with those VA Glaucoma lawsuits but were they caused by malpractice by ODs, OMDs or both?

Do you mean that care does "go wrong" for ODs performing it and this leads to expanded scope of practice for ODs? Seems counter-intuitive to me.

As far as the dental model goes, I think I posted why this is a terrible comparison before. How many students are in an optometry class? How on earth would an optometry school provide enough cases to train all those optometry students as optometric surgeons?

There are over a hundred separate ophthalmology programs spread over the country to maximize surgical volume and exposure to pathology. Even then, some programs can't get enough volume for their residents.

The optometrists in California wanted to act faster to expand their scope before all the dirt coming out of the VA hit the news. Yes it is counterintuitive that after two optometrists let around a hundred veterans lose vision, their state organization continued to push for lower standards and less regulation over their ability to treat glaucoma.

read ophthalmology's perspective here: http://www.californiaeyemds.org/

It seems stupid to me to have optom and ophtho clinics totally separate. The situation you described sounds better. The relationship is just terrible right now. I wish it was better. Even CRNAs and anesthesiologists get along most of the time.

 

[speyeder]

Hypothetically they won't have to. Optometry is trying to emulate the dental model. But I am for vertical integration.

Meaning what? That ophthalmology residencies will train ODs alongside MDs? Why would they do that?

 

[VA Hopeful Dr]

It really irks me whenever someone infers that there haven't been any complications from the expanded medical or surgical scope of optometrists. Plenty of glaucoma blebs and cancers have been inappropriately excised in OK, And I am sure any complications from PRK could be easily covered up.

I had to go see an optometry VA patient on call a couple of weeks ago who they had let slowly go blind due to glaucoma (I was seeing them for an unrelated issue). He told me they had him come in every month for a visual field and kept switching around his drops. He was slowly losing his vision and got frustrated. He asked about surgery or about seeing an ophthalmologist. They convinced him he didn't need anything different and now he is blind. I was pretty upset by what he told me. He basically said they refused to refer him. I doubt that, but I was still shocked. I found out who the VA ophthalmology chief was and I wrote them a long email at two in the morning detailing everything I had found out about the guy. I got back a one line response saying this happens all the time and he was free to switch his care.

Whenever anything does "go wrong", it doesn't slow down your schedule of pushing for more things you want. If anything, it accelerates it. For instance, proposed optometry legislature in California after all those VA glaucoma lawsuits came out.

I'm not saying this is the case here, but its not always the best idea to take a patient's word about another doctor. I have patients say just awful things about me to other residents and vice versa - the reason involved not getting percocet. Had nothing to do with poor clinical acumen.

 

[200UL]

VA Hopeful Dr
I agree with you. The issue is quality of care. Difficult to measure no matter who is providing the care (OD/MD/DO). However, allopathic/osteopathic have decided to use a model where one must prove competency on actual patients and then take a series of boards - it is the best we can do. Then one gets to practice independently. Optometry in the states of KY/OK have used $ and their voices to just say they are competent – I guess in some parts of the country, if you shout loud enough people will believe you. While Ben Gaddie's dog and pony show can trick an unsophisticated 90 year old in the clinic because of his nice smile and gentle bedside manner, we will never know if he knows how to perform the lasers correctly or if he is using them in an appropriate manner. Sorry, just because he is not called to the courtroom means nothing.

What I do know is that Ben Gaddie is willing to flat out lie in order to gain surgical rights - kind of a bad way to start..... Therefore, how can he expect anyone to trust him? How can the field of optometry stand beside him and his fraudulent statements.

The problem is that optometry will never be able to train their people as well as ophthalmology training programs (ophthalmology training programs hold the pathology) (ophthalmology programs actually force each resident to graduate with minimal numbers)(today a ophthalmology program cannot graduate an "ophthalmologist" unless they are competent in surgery). Not a bad model and it gets more rigorous every years just like every residency training program in medicine.

Each year 3 new optometry schools are added - clinical experiences continued to be diluted so that schools can bring in more students and more money. When graduates leave and can only find work at wal-mart, people like Dr. Gaddie tell them they will become surgeons if they just donate enough money to their PAC.

A better strategy would be to reduce the number of spots and enhance clinical exposures. If the desire is optometric surgery, start a surgical training program in your school that involves patients. Good luck getting it done in 4 years of schooling - then again maybe ophthalmologists are just slow learners..

 

[bungo]

I'm not saying this is the case here, but its not always the best idea to take a patient's word about another doctor. I have patients say just awful things about me to other residents and vice versa - the reason involved not getting percocet. Had nothing to do with poor clinical acumen.

I agree with what you are saying here. Patients bad mouth their other doctors to me all the time. This story just seemed too terrible to be true. That is one of the reason's I contacted the chief. Some level of non-compliance had to be involved, but the basic parts of the story are true. A VA glaucoma guy who was seen in clinic every month by optometry eventually went blind and never saw an ophthalmologist.

 

[KHE]

You guys still keep thinking this is all actually about surgical procedures, eh?

 

[SurgbySurgeons]

VA Hopeful Dr
I agree with you. The issue is quality of care. Difficult to measure no matter who is providing the care (OD/MD/DO). However, allopathic/osteopathic have decided to use a model where one must prove competency on actual patients and then take a series of boards - it is the best we can do. Then one gets to practice independently. Optometry in the states of KY/OK have used $ and their voices to just say they are competent – I guess in some parts of the country, if you shout loud enough people will believe you. While Ben Gaddie's dog and pony show can trick an unsophisticated 90 year old in the clinic because of his nice smile and gentle bedside manner, we will never know if he knows how to perform the lasers correctly or if he is using them in an appropriate manner. Sorry, just because he is not called to the courtroom means nothing.

What I do know is that Ben Gaddie is willing to flat out lie in order to gain surgical rights - kind of a bad way to start..... Therefore, how can he expect anyone to trust him? How can the field of optometry stand beside him and his fraudulent statements.

The problem is that optometry will never be able to train their people as well as ophthalmology training programs (ophthalmology training programs hold the pathology) (ophthalmology programs actually force each resident to graduate with minimal numbers)(today a ophthalmology program cannot graduate an "ophthalmologist" unless they are competent in surgery). Not a bad model and it gets more rigorous every years just like every residency training program in medicine.

Each year 3 new optometry schools are added - clinical experiences continued to be diluted so that schools can bring in more students and more money. When graduates leave and can only find work at wal-mart, people like Dr. Gaddie tell them they will become surgeons if they just donate enough money to their PAC.

A better strategy would be to reduce the number of spots and enhance clinical exposures. If the desire is optometric surgery, start a surgical training program in your school that involves patients. Good luck getting it done in 4 years of schooling - then again maybe ophthalmologists are just slow learners..

Good post. I've read that some optometry programs might go to three years I just got done reading about the situation in California. It just makes me sick, it really does. I can't understand how the optometrists are becoming certified to treat glaucoma WITHOUT ever treating one patient. Are you serious. And even after the mismanagement at the VA clinic and the lawsuits, the legislators still feel comfortable giving optometry glaucoma privileges. I'm not against optometry treating glaucoma patients, but please get some proper training first. Or, please refer the patients when needed.

If you ask people if they would rather be paralyzed or blind, most people would rather be paralyzed. I don't know why the legislators don't find vision to be that important.

 

[SurgbySurgeons]

You guys still keep thinking this is all actually about surgical procedures, eh?

What is it about? It's obviously not about the patients.

 

[Shnurek]

I love how you just made a new screen name so you can bad mouth optometrists more anonymously. Yea you are right. All the hundreds of malpractice cases against OMDs don't matter. Those are just flukes because you guys are all "perfect" Lets just focus on a few ODs that should have their licenses revoked, if all the facts are true. I doubt that though because reading the publication it refers to ODs as "nonphysicians" when medicare refers to them as "physicians" lol. This biased attitude discredits the publication in my mind. Let the courts decide everything! Enough of this rambling.

 

[SurgbySurgeons]

I love how you just made a new screen name so you can bad mouth optometrists more anonymously. Yea you are right. All the hundreds of malpractice cases against OMDs don't matter. Those are just flukes because you guys are all "perfect" Lets just focus on a few ODs that should have their licenses revoked, if all the facts are true. I doubt that though because reading the publication it refers to ODs as "nonphysicians" when medicare refers to them as "physicians" lol. This biased attitude discredits the publication in my mind. Let the courts decide everything! Enough of this rambling.

First of all, I don't consider optometrists physicians. Optometric physician, sure. I actually never refer to myself as a physician either. When someone asks, I say I'm an ophthalmologist. I definitely don't think all MDs are perfect (whoever would say that). I am aware plenty of lawsuits involving ophthalmologists as well. I just get upset when legislation gets passed that does not provide the safety measures that have been in place for medicine for years. For some odd reason, I believe that prior to taking care of glaucoma patients, you should be required to actually train on glaucoma patients. Just as with surgery.

 

[200UL]

I love how you just made a new screen name so you can bad mouth optometrists more anonymously. Yea you are right. All the hundreds of malpractice cases against OMDs don't matter. Those are just flukes because you guys are all "perfect" Lets just focus on a few ODs that should have their licenses revoked, if all the facts are true. I doubt that though because reading the publication it refers to ODs as "nonphysicians" when medicare refers to them as "physicians" lol. This biased attitude discredits the publication in my mind. Let the courts decide everything! Enough of this rambling.

This is kind of scary- I do sound a lot like SurgbySurgeons. I do feel that the term physician should be reserved for someone with an MD or DO behind their name. Using it otherwise misrepresents. Don't worry, I am not into titles or degrees - I introduce myself by my first name to all my patients. I do get a kick out of people who want to be called "doctor" because they "earned it". These people need to get over themselves. Maybe the term "doctor" makes grandma and grandpa proud, but it doesn't impress me all that much as everyone is a "doctor" these days.

I do not want to bash optometry - I feel fortunate to work with several optometrists. They are not pushing for "laser enucleations" like the KY bill grants.

I do want to bash the Ben Gaddies of the world because they are scam artists.

I will be the first to say MDs mess up every day. Modern medicine has realized this for centuries. A system has been developed to minimize mistakes and create competent physicians and surgeons (medical school with clinical training and surgical training involving actual patients and world experts). This system will never involve people like ben gaddie.

 

[KHE]

Wow.

This thread has really gone off the rails here.

Why are people so obsessed with this Ben Gaddie guy? Someone should send him an email and ask him to join this forum. I doubt he knows he has such a "fan" club. He's getting more attention than Charlie Sheen.

All these silly anecdotes about this patient going blind or that patient going blind mean little. They are nothing more than anecdotes, most of them heard second, third, even fourth hand and no one has the full story as to what actually happened. I can tell all kinds of stories of patients coming to me for second opinions on cataract surgery and all they had was -1.25 oblique cylinder that was uncorrected. But this little tit for tat game is useless. Some OD misdiagnosed a skin lesion. Big frickin deal. What....that's never happened in the MD universe? No MD in history has ever missed an obvious skin lesion?

Someone asked if it's not about surgery, what it's about? I'll say it again for the 100th time.

It's about who will ultimately control the profession of optometry. Optometry, or "someone else?"

Optometry has grown tired and weary of having to grovel before the medical board or having some sort of bull**** hassle every time some new beta blocker comes out. Or Latisse. Or the issue of foreign bodies in New York. Or the issue of medicated contact lenses. Or epilation for Christ's sake.

Virtually no optometrists really care about YAGs and PIs. (yea, yea, I know....Ben Gaddie. Ben Gaddie.)

What we want is to not have to deal with the crap if they come out with an eyedrop for cataracts. Or presbyopia. Or Myopia.

How many more times can I say that it's NOT about surgery? It's not about cataracts. $600 and constantly going down from medicare. Yippeeeeee! Quick! Quick! Sign me up!

It's not about LASIK. For Christ's sake......LASIK fees are already through the FLOOR. Suddenly we're going to produce 1500 new OD Lasik surgeons so we can start doing them for $99 per eye instead of $299 per eye? Let's be serious now.

 

[PBEA]

Here is an article that talks about the cases from the VA optom.

that link did not work

If it has the juicy details of the individual cases, I'd be interested in reading them. It being the multivariant "glaucoma" as the issue, I'd want to know if the ODs are supposedly mishandling some rarer posner-schlossman, etc or if these are more generic "POAG" cases.

 

[Visionary]

Wow.

This thread has really gone off the rails here.

Why are people so obsessed with this Ben Gaddie guy? Someone should send him an email and ask him to join this forum. I doubt he knows he has such a "fan" club. He's getting more attention than Charlie Sheen.

All these silly anecdotes about this patient going blind or that patient going blind mean little. They are nothing more than anecdotes, most of them heard second, third, even fourth hand and no one has the full story as to what actually happened. I can tell all kinds of stories of patients coming to me for second opinions on cataract surgery and all they had was -1.25 oblique cylinder that was uncorrected. But this little tit for tat game is useless. Some OD misdiagnosed a skin lesion. Big frickin deal. What....that's never happened in the MD universe? No MD in history has ever missed an obvious skin lesion?

Someone asked if it's not about surgery, what it's about? I'll say it again for the 100th time.

It's about who will ultimately control the profession of optometry. Optometry, or "someone else?"

Optometry has grown tired and weary of having to grovel before the medical board or having some sort of bull**** hassle every time some new beta blocker comes out. Or Latisse. Or the issue of foreign bodies in New York. Or the issue of medicated contact lenses. Or epilation for Christ's sake.

Virtually no optometrists really care about YAGs and PIs. (yea, yea, I know....Ben Gaddie. Ben Gaddie.)

What we want is to not have to deal with the crap if they come out with an eyedrop for cataracts. Or presbyopia. Or Myopia.

How many more times can I say that it's NOT about surgery? It's not about cataracts. $600 and constantly going down from medicare. Yippeeeeee! Quick! Quick! Sign me up!

It's not about LASIK. For Christ's sake......LASIK fees are already through the FLOOR. Suddenly we're going to produce 1500 new OD Lasik surgeons so we can start doing them for $99 per eye instead of $299 per eye? Let's be serious now.

Agreed. Lots of activity within the last couple days. Have a new puppy at home, so have been out of the loop.

I understand your points about control and how only a minority will be seeking surgical privileges, and I'm glad you see why we continue to be irked by the surgery issue. The reason Gaddie keeps coming up is because he is the KOA president-elect and, presumably (I have no inside knowledge), one of the primary architects of KY SB 110. He did a fellowship in glaucoma lasers before returning to Louisville to join his father's practice, knowing full well that he would not be able to perform said lasers. Then, voila, he is elected KOA president and this bill goes through. Not likely a coincidence.

As far as numbers, I only have my practice as a reference. We have five docs who regularly do YAG caps. As a practice, we do about 45 per month or average 9 per doc. Don't know about PIs. Those are much less common. Another procedure to consider is SLT. We have 2 docs doing those for about 15 total per month. We lease the SLT, so it's likely underutilized. As a repeatable glaucoma laser, SLT would be a good revenue potential for someone with a glaucoma focus. There are multi-mode lasers available now for around $60k that will do YAG cap, PI, and SLT. ROI wouldn't be bad.