Kentucky: The Latest Battleground for Optometric Scope Expansion

[Dusn]

Twice in 7.5 years?

Is that including post-intravitreal injection? Do you not give double-dose 0.1cc injections?

Personally I hate doing post-injection paracentesis and would like to avoid them. I end up doing far more than I'd like, however.

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[Visionary]

Twice in 7.5 years?

Is that including post-intravitreal injection? Do you not give double-dose 0.1cc injections?

Personally I hate doing post-injection paracentesis and would like to avoid them. I end up doing far more than I'd like, however.

Yep. The two times were for a Macugen injection (0.1 cc) in fellowship in a patient with already higher than desired IOP and a patient in my own practice who accidentally got part of a sub-Tenon's Kenalog in the vitreous ( ). The first case I probably could have watched, but the patient was very concerned about the vision drop. The other I estimated got 0.2 cc. That had to be tapped. Both turned out just fine. I don't give 0.1 cc of anything nowadays, but we did back in residency and fellowship. Still, IOP always came down. The way I see it, doing an AC tap just increases your risk of endophthalmitis.

 

[MullerCell]

I completely agree with Visionary. I've done thousands of injections and have never needed to do a post-injection AC tap when injecting 0.05cc. If they are NLP after the injection, just look at the nerve. Even with double dose Avastin or Lucentis (0.1cc), the IOP will go up higher, but the CRA always seems to at least be pulsating post-injection. If the CRA is completely closed, I would tap (I've never seen this with a 0.05 or 0.1cc intravitreal injection, only after injecting gas for a pneumatic or at time of a scleral buckle), otherwise just given them a few minutes and they will be fine.

 

[VikingFavre]

I completely agree with Visionary. I've done thousands of injections and have never needed to do a post-injection AC tap when injecting 0.05cc. If they are NLP after the injection, just look at the nerve. Even with double dose Avastin or Lucentis (0.1cc), the IOP will go up higher, but the CRA always seems to at least be pulsating post-injection. If the CRA is completely closed, I would tap (I've never seen this with a 0.05 or 0.1cc intravitreal injection, only after injecting gas for a pneumatic or at time of a scleral buckle), otherwise just given them a few minutes and they will be fine.

I've seen it once already with 0.05 Lucentis where the CRA closed off, IOP 70.

We probably tap more than we should but 2 in 7.5 years seems crazy low.

 

[MR1]

With injecting 0.05 I never have tapped. Only with pneumatics or buckles

 

[Visionary]

I've seen it once already with 0.05 Lucentis where the CRA closed off, IOP 70.

We probably tap more than we should but 2 in 7.5 years seems crazy low.

I'm just that good.

 

[Hightide12]

As an optometrist, I really wish the optometry STUDENTS (probably 1st or 2nd years?) would stfu... You are embarrassing our profession. You don't know what it's like to practice optometry, and definitely not ophthalmology. 97%+ OF OPTOMETRISTS DO NOT EVER WANT TO PERFORM SURGERIES!!! and this whole debate has been blown out of proportion by the AOA and AMA. PS Shnurek, please complete the curriculum before you start yapping. 1 year of general pathophysiology in optometry school does not equate to what medical students have to learn (I've compared my brother's med school notes to ours). During my 4th year externship at a VA hospital, both optometry and ophtho res/attendings would arrive at 8 am. At 4:30, the ENTIRE optometry clinic had closed shop for the day, while the Ophth were there often til 9:00 pm. I'm not sure what optometry STUDENTS are arguing about. I'm quite content with my 30 hour work week and $150K. Ophtho residents/attendings...please ignore the troll. He does not speak for all of us

 

[Visionary]

this whole debate has been blown out of proportion by the AOA and AMA.

True. Brings in the dough, though.

 

[ophthope]

I'm quite content with my 30 hour work week and $150K.

Can I take over your job when I'm out of Ophtho residency? I thought Ophthalmologists barely made that much!

 

[MstaKing10]

My sister in law is an optom and she does very well for herself, takes no call, has none of the litigation/malpractice issues to deal with, makes her own hours, and has a lot less to stress about. Honestly, I don't understand why SOME optoms want to increase their chances of law suites and added headache and stress of a surgical field. For what? A small increase in pay that ultimately, if health care continues on its present course, will be negligible after calculating overhead, malpractice insurance etc. Most of my older partners are trying to wind down their surgical practice and ramp up their medical practice due to these issue. Why would you want to reverse that?

 

[Visionary]

My sister in law is an optom and she does very well for herself, takes no call, has none of the litigation/malpractice issues to deal with, makes her own hours, and has a lot less to stress about. Honestly, I don't understand why SOME optoms want to increase their chances of law suites and added headache and stress of a surgical field. For what? A small increase in pay that ultimately, if health care continues on its present course, will be negligible after calculating overhead, malpractice insurance etc. Most of my older partners are trying to wind down their surgical practice and ramp up their medical practice due to these issue. Why would you want to reverse that?

Exactly. Just listened to a talk last night from Nancey McCann, the government liaison for ASCRS. Very eye-opening (no pun intended). If changes proceed as currently laid out, it will be very bad. We're talking massive cuts in reimbursements. Already, cataract surgery is up for another $100 per case cut next year. Very scary stuff. Almost makes me wish I hadn't gone into medicine.

 

[orbitsurgMD]

If changes proceed, I can see a lot of ophthalmologists dropping out of Medicare and all other third-party payers entirely and going cash-pay with a much reduced overhead and small office staff. Prepayment for surgery and payment at time of service for office services, no coding requirements(ICD or CPT), no audits, no waiting to get paid, no needing to buy an EHR unless it promises to save you time and money.
One could probably survive on a much smaller patient census, need a much smaller office and staff and an easier workday. Dentists make it work.

 

[dantt]

Exactly. Just listened to a talk last night from Nancey McCann, the government liaison for ASCRS. Very eye-opening (no pun intended). If changes proceed as currently laid out, it will be very bad. We're talking massive cuts in reimbursements. Already, cataract surgery is up for another $100 per case cut next year. Very scary stuff. Almost makes me wish I hadn't gone into medicine.

To play devils advocate some of it makes sense. For example OCT reimbursement is excessive. We can't expect medicare/insurance write a blank check when we OCT everybody walking through the door. We likewise can't be doing "weck cell vitrectomies" on every cataract surgery to upcode. We are our own worse enemies.

 

[dantt]

If changes proceed, I can see a lot of ophthalmologists dropping out of Medicare and all other third-party payers entirely and going cash-pay with a much reduced overhead and small office staff. Prepayment for surgery and payment at time of service for office services, no coding requirements(ICD or CPT), no audits, no waiting to get paid, no needing to buy an EHR unless it promises to saye you time and money.
One could probably survive on a much smaller patient census, need a much smaller office and staff and an easier workday. Dentists make it work.

I'm strongly in favor of the cash model. Only in this free market model does the cost and value of the services we provide become apparent. One walks into the doctor's office these days and has no idea how much it will cost walking out. The doctor does everything they can to maximize payment with unclear benefit.

 

[ophthope]

To play devils advocate some of it makes sense. For example OCT reimbursement is excessive. We can't expect medicare/insurance write a blank check when we OCT everybody walking through the door. We likewise can't be doing "weck cell vitrectomies" on every cataract surgery to upcode. We are our own worse enemies.

I thought that max reimbursement for 2011 was on posterior segment imaging and it was only $45. I fail to see how that is an excessive fee for a technician to take an image of your eye with a precision manufactured $250,000 piece of medical equipment and then have a physician interpret the reading.

And who is coding vitrectomies on that many cases? You'd be slammed with Medicare fraud charges. This isn't 1994.

 

[orbitsurgMD]

To play devils advocate some of it makes sense. For example OCT reimbursement is excessive. We can't expect medicare/insurance write a blank check when we OCT everybody walking through the door. We likewise can't be doing "weck cell vitrectomies" on every cataract surgery to upcode. We are our own worse enemies.

Excessive compared to what? The devices cost $60K and up. The recoupment for small practices is lucky to pay for the machine let alone any of the technician time and physician time needed for interpretation. (and if you have two offices, it is way cheaper to buy a new van and drive one OCT back and forth than to have a second machine.)

Carrying cost of the machine exceeds $1K/mo on a 60-month recoupment, which is about as long as you would want to go on a device that is basically a laptop computer integrated with a laser/scanner/camera. I figure they are reimbursed at about half the rate they should be.

 

[dantt]

I thought that max reimbursement for 2011 was on posterior segment imaging and it was only $45. I fail to see how that is an excessive fee for a technician to take an image of your eye with a precision manufactured $250,000 piece of medical equipment and then have a physician interpret the reading.

And who is coding vitrectomies on that many cases? You'd be slammed with Medicare fraud charges. This isn't 1994.

Right. Just the year prior it was over 50/eye and who only scans one eye? Medical value notwithstanding, Oct now racks in over a billion in Medicare charges a year.

http://www.octnews.org/articles/2844561/ophthalmic-oct-reaches-1-billion-per-year-but-reim/

I personally know people who perform wreck cell vitrectomies...

 

[ophthope]

Right. Just the year prior it was over 50/eye and who only scans one eye? Medical value notwithstanding, Oct now racks in over a billion in Medicare charges a year.

http://www.octnews.org/articles/2844561/ophthalmic-oct-reaches-1-billion-per-year-but-reim/

I personally know people who perform wreck cell vitrectomies...

You can't say 'medical value notwithstanding' when the conversation is about valuation of a diagnostic test. I still think I'd argue that it is very medically valuable, requires professional interpretation to be valuable, requires a technician to perform, and is performed on a very expensive piece of equipment - so it *should* be reimbursed well.

 

[dantt]

You can't say 'medical value notwithstanding' when the conversation is about valuation of a diagnostic test. I still think I'd argue that it is very medically valuable, requires professional interpretation to be valuable, requires a technician to perform, and is performed on a very expensive piece of equipment - so it *should* be reimbursed well.

People used to be able to bill separately for both eyes and would do nerve as well as retinal imaging.

Bottom line: there is a limited number of available health care dollars. We are having cuts in reimbursement because it has been decided that the dollars are better spent elsewhere and the cost of eye care (or any other health care) cannot keep increasing just because we have a better diagnostic tool available. Arithmetic.

 

[MullerCell]

OCT reimbursement has been cut significantly in recent years, and both eyes are now bundled (i.e. you are paid the same for 1 or 2 eyes). Part of the problem is that reimbursement is based on utilization. With the explosion of anti-vegf injections being performed for multiple indications, we are doing tons more OCTs to monitor treatment response. Additionally, many unneeded OCTs are done that provide no useful information and are not being used to guide management. This too results in decreased reimbursement for those of us who are using the data an OCT provides to better care for our patients. Financially, it doesn't really make sense to buy a new $60,000 machine unless you are using it quite a bit.

 

[orbitsurgMD]

The OCT manufacturers have an enviable market. While a small practice might never recoup the costs of an OCT on the fees from utilization, doing without increasingly places the practice in a position of relative professional and competitive disadvantage to those practices that have the devices. Although one can still rely on established technologies such as stereophotography, perimetry, and tonometry to diagnose and follow glaucoma, increasingly there is a requirement for additional technologies to identify early disease and to at least resolve whether ocular hypertensives may be watched without treatment with reasonable confidence of stability or should require treatment as suggested in the OHTS results. Until now, there has been the option of relatively less expensive options--GDxVCC and HRT2 and HRT3 (relatively meaning $25K to $44K per unit, still costly, and if you visited their displays at the most recent AAO, you wouldn't have even guessed they existed) but the manufacturers of these devices are devoting their development and marketing efforts to their higher-cost and more profitable spectral-domain OCT products. Instead of speaking of ROI, we may be crossing the threshhold of having to have these devices whether they earn their keep in procedural revenues or not. Given the cost of one of these OCTunits, their eventual need for replacement with both computer and diagnostic product development cycles and the general and projected trends for third-party reimbursement, it is one more burden that makes small practices less viable. In my own community, Zeiss has very aggressively pushed its Cirrus products, with several optometry practices purchasing them. I receive many consults with pages of the OCT reports appended (but no apparent interpretation, go figure) and the report nicely rendered in black and white so that even the colorscale is masked. It seems that many patients of these practices are coaxed into having OCT studies (and made to sign ABNs for them) for the most tenuous of reasons. From my retina colleagues I am hearing there is pushback from insurers on paying for OCT at all, in cases where the study actually is being used to drive a significant decision on antiVEGF treatment. Cost is really the issue. I don't think it always makes sense to justify a capital equipment expenditure entirely on its revenue generating capacity, but when it costs a multiple of what the next most expensive piece of capital equipment a practice typically has to buy in order to be equipped to operate, some of that cost certainly does have to be justified by and recouped from procedural revenues. That is just simple business.

 

[Visionary]

If changes proceed, I can see a lot of ophthalmologists dropping out of Medicare and all other third-party payers entirely and going cash-pay with a much reduced overhead and small office staff. Prepayment for surgery and payment at time of service for office services, no coding requirements(ICD or CPT), no audits, no waiting to get paid, no needing to buy an EHR unless it promises to save you time and money.
One could probably survive on a much smaller patient census, need a much smaller office and staff and an easier workday. Dentists make it work.

I can really see that happening. Honestly, we are doing patients a major favor by doing the claim submission ourselves. If patients had to pony up the cash at the time of the visit, then submit their own claims for reimbursement, our overhead would drop tremendously.

 

[Visionary]

People used to be able to bill separately for both eyes and would do nerve as well as retinal imaging.

Bottom line: there is a limited number of available health care dollars. We are having cuts in reimbursement because it has been decided that the dollars are better spent elsewhere and the cost of eye care (or any other health care) cannot keep increasing just because we have a better diagnostic tool available. Arithmetic.

So how low is too low? As others have said, it's becoming difficult to make the investment in SD-OCT, because of the drop in reimbursement. Fact is that it is a necessary tool. Even TD-OCT is substandard care now. Since we're talking about health care dollars, what do you think costs more? OCT reimbursements or the costs or the drugs we use to treat? The government doesn't seem to want to put cost controls in place on the drugs, do they? I wonder why that is? I also wonder why hospitals and HMOs seem to escape the same sorts of cuts that physicians keep having to take. Continuing to cut physician reimbursement is going to result in a major physician shortage--mark my words. The time, effort, and debt required to become a physician will simply not be justified by the compensation.

 

[orbitsurgMD]

Blank checks went out 25 years ago. We are now at the point of price controls that are below costs.

There have always been limited health care dollars. The trouble now is that people want to start drawing their benefits at the same age as in the past but are living twice as long, on average, as they did when Parts A and B were created and now want more and have available far more treatments than were available in 1965 and 1967. Add to that the far fewer contributing workers to be taxed (and the relatively stagnant to declining wage base among those workers) and you can appreciate the impossibility of the requirement.

Paying less while closing your eyes to costs that are increasing, not decreasing, is not the answer at all; that is a surefire way to non-participation. Trying to link licenses to participation is not a solution either. Forcing a practice to insolvency means that practices close. Period. Doctors are not going to drain out their personal savings to keep practices afloat that have no hope of solvency. They will either find a way to sell services at a viable market price or they will close up shop.

This should not be a mystery. Huge areas of this planet have relatively few medical services available to populations who could use them but lack them all the same for utter lack of ability to pay for them. Somehow that condition--which is a market condition too, that of no market--seems to be beyond many planners' and politicians' imaginations. It really shouldn't be. It really is possible to kill off markets with regulations and price controls. It really is possible to create economic deserts.

 

[Visionary]

^ Solid post is solid.