Ophthalmic Assistants

[Core Dome Ahhh]

How about creating 1-2year ophthalmic assistant programs administered by ophthalmology departments in which we teach people to refract and do basic slit lamp surveys/indirect and legislate to allow them to practice under the supervision of an ophthalmologist dispensing glasses and contacts . Of course, it will all be about improving patient access and making healthcare more affordable--- except it may actually do both in this case. We could control their licensing and no longer worry about someone doing our post-op cataract checks believing they should be doing the yags.

We could lobby with commercial optical providers, oversee large volume commercial centers with auto-refracting kiosks, have internal referrals from our centers, and watch optometry disappear

I'm actually kind of serious. If we made some large power moves to take over vision care and/or totally disconnect ourselves from the bad joke that is current US optometry, maybe our legislative battles would be over a different topic.

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[90 diopter]

Like a COMT?

 

[Core Dome Ahhh]

Like a COMT?

I didn't realize COMT's had as much training as some obviously do , although I have known some very smart techs who are amazing at what they do-- especially refraction. What role do you think they may have in expanding the scope of primary MEDICAL eye care? Do you know of anyone who uses PA's? I read about an ophtho advocacy meeting in which using physician extenders more was a major topic.

I would also like to imagine a system where we in ophthalmology try to empower more PCP's (who IMHO are actually the primary care docs of the eyes and all organs). Some ideas I've had, in addition to pushing for PCP competency in dilating and taking a look with a direct-- a competency the AAO thinks they should have, would be using physician extenders to go out to PCP clinics on a regular (monthly or q6mo, whatever) basis to help with primary eye surveys based on the ages and risk factors that the AAO has outlined. If they could provide simple refractions and glasses/contact Rxs, that would be superb. It seems to me that even a moderately sized ophtho practice with a large catchment of rural areas should be able to provide basic eye screening covering a large area in this manner, overseen by an actual physician.

I know an ophthalmologist who, as part of outreach to the uninsured/underinsured/poorly compliant, has placed retinal cameras at PCP offices as a bit of a pilot program. I haven't actually talked to him about all of the objectives but it seems like quite an interesting idea to me. Anyway, I think using extenders to have an actual presence in the "medical home" model would be great for both professions. Generally I think ophthalmologists, especially in the private world, interacting more with their colleagues is essential.

I could imagine such a system with extenders being easily being expanded to provide coverage for basic ophthalmic eye surveys at commercial clinics under agreements with ophtho practices--- it seems they don't want to hire full time optometrists anyway-- maybe even involving retinal imaging that can be reviewed by an ophthalmologist. It seems to me this would really expand access for quality expert care for patients, allow a broad self referral base for ophthalmologists, and generally empower both primary care and ophthalmology.

 

[ophthope]

Outpatient Family and Internal med docs are so swamped with patient visits right now and exceedingly limited in the amount they are reimbursed per visit that I doubt they'd want to do any more than the minimal eye screening they already do. That is unless there is some sort of paradigm shift that allows them to actually spend an appropriate amount of time with each patient and be appropriately reimbursed for their work, but with the PPACA/"Obamacare" impending I do not foresee that happening.

Hoping for expanded PCP training in eye pathology is great, but we also have to remember that every other specialty has the same hope for primary care. Ortho would like them to be able to deal with more bone stuff, cards would like them to always know LBBB from a pathologically widened QRS, pulm would prefer that they manage COPD patients for a little longer before referral, etc. But medical knowledge is constantly and rapidly expanding and it is likely that 'primary care' in the coming days will need to set its own firm boundaries just like we specialists have done. No man is an island and the PCPs can't know everything. I think the solution for the aging population and increased eye care needs will likely be more routine referrals to Ophtho for evaluation and expanded use of extenders like COMTs and specialized techs like you've mentioned. Maybe in the future we'll see more use of those tiny fundus cameras by PCPs with teleretinal screening of known diabetics by Ophtho, but I doubt they'll ever have slit lamps in their offices just because you can't reasonably know how to do everything well.

 

[Core Dome Ahhh]

Outpatient Family and Internal med docs are so swamped with patient visits right now and exceedingly limited in the amount they are reimbursed per visit that I doubt they'd want to do any more than the minimal eye screening they already do. That is unless there is some sort of paradigm shift that allows them to actually spend an appropriate amount of time with each patient and be appropriately reimbursed for their work, but with the PPACA/"Obamacare" impending I do not foresee that happening.

Hoping for expanded PCP training in eye pathology is great, but we also have to remember that every other specialty has the same hope for primary care. Ortho would like them to be able to deal with more bone stuff, cards would like them to always know LBBB from a pathologically widened QRS, pulm would prefer that they manage COPD patients for a little longer before referral, etc. But medical knowledge is constantly and rapidly expanding and it is likely that 'primary care' in the coming days will need to set its own firm boundaries just like we specialists have done. No man is an island and the PCPs can't know everything. I think the solution for the aging population and increased eye care needs will likely be more routine referrals to Ophtho for evaluation and expanded use of extenders like COMTs and specialized techs like you've mentioned. Maybe in the future we'll see more use of those tiny fundus cameras by PCPs with teleretinal screening of known diabetics by Ophtho, but I doubt they'll ever have slit lamps in their offices just because you can't reasonably know how to do everything well.

That PCP's are swamped and hardly have the time for many things is a great point, although getting them to dilate on every x years after y age and look at the back of the eye with a direct scope, to screen for glaucoma and basic dm/htn changes, especially if they can bill for it and it's made as part of their quality measurements and integrated into their EMR alerts seems like it could be a reasonable goal. Maybe a lofty goal though, you're right.

Also, maybe I wasn't totally clear with what I meant as far as allying with PCP offices and using physician extenders-- which I think could be even bigger than trying to get PCPs to do things. I imagine an optimal scenario in which an ophthalmology practice can pair up with many PCP offices and send out a physician extender (hell, maybe even an ophthalmologist if large enough pt base at a particular practice) with basic ophtho tools to set up for basic vision and eyecare exams at set intervals for their patients. It could be performed by the extender completely but at the pcp's office. This idea is mostly for rural areas.


Sending techs long distances is a reality in some fields like clinical neurophysiology--- done remotely withy techs traveling to rural places.

Seems like it would promote ophtho referrals like you mentioned, if nothing else--- even if such a PCP allying campaign was done sparsely. Providing basic eye meds could also be done for patients. At my med school we have a very well developed mobile ophtho clinic-- run by med students, residents, and COMTs, we provide glasses Rxs, basic eye Rxs, and do basic screening exams. This is done by a less organized and experienced group of people than would exist with a private practice. I think it could be a good model and would be very beneficial for ophthalmology and public health.

 

[guttata]

First of all, PCPs are busy enough. There is no way they are going to dilate a patient and perform a screening fundus exam. There are already quality measures for diabetics. Referrals to the eye specialists work to fulfill the quality measures for some PCPs. Reimbursement for vision screening exams done at the same time as a physical exam would be difficult.

Secondly, have you rotated through medical school? There is very little ophthalmology exposure. The view is already quite limited on a direct monocular ophthalmoscope, especially in a nonmydriatic patient. Couple that with limited exposure to ophthalmology, and the screening exam becomes useless.

Thirdly, many ophthalmology practices already utilize extenders. Technicians can perform a lot of pre-dilation workup, including refractions. Some practices also hire ODs to manage medical eye care, including post-operative care. If it makes economic sense, the specialists will partner with other ODs offices to provide surgical care. But, unless you are generating tons of volume or RVUs, it does not make economic sense to drive hours away to provide care.

The argument of rural care access (or lack thereof) was used to push through the Kentucky ODs surgical privileges. But, in reality, many rural areas have access to care within 30-45 minutes.

Nonmydriatic cameras will most likely provide the rural care you desire. They could be placed in PCPs offices - the photos would be interpreted by an eye specialist. If needed, the patient would then be sent to the eye specialist. Right now, it does not make economic sense for most PCPs offices (photo screening reimbursement is difficult).

Also, I bet there is a high proportion of uninsured patients cared for by your mobile eye care. Unfortunately, uninsured patients will always have an access to care problem, especially if they are not close to an academic center. Most physicians, while generally altruistic, will not (or cannot) provide free care in a seemingly hostile (financial, legal) environment.

 

[Core Dome Ahhh]

First of all, PCPs are busy enough. There is no way they are going to dilate a patient and perform a screening fundus exam. There are already quality measures for diabetics. Referrals to the eye specialists work to fulfill the quality measures for some PCPs. Reimbursement for vision screening exams done at the same time as a physical exam would be difficult.

Secondly, have you rotated through medical school? There is very little ophthalmology exposure. The view is already quite limited on a direct monocular ophthalmoscope, especially in a nonmydriatic patient. Couple that with limited exposure to ophthalmology, and the screening exam becomes useless.

Thirdly, many ophthalmology practices already utilize extenders. Technicians can perform a lot of pre-dilation workup, including refractions. Some practices also hire ODs to manage medical eye care, including post-operative care. If it makes economic sense, the specialists will partner with other ODs offices to provide surgical care. But, unless you are generating tons of volume or RVUs, it does not make economic sense to drive hours away to provide care.

The argument of rural care access (or lack thereof) was used to push through the Kentucky ODs surgical privileges. But, in reality, many rural areas have access to care within 30-45 minutes.

Nonmydriatic cameras will most likely provide the rural care you desire. They could be placed in PCPs offices - the photos would be interpreted by an eye specialist. If needed, the patient would then be sent to the eye specialist. Right now, it does not make economic sense for most PCPs offices (photo screening reimbursement is difficult).

Also, I bet there is a high proportion of uninsured patients cared for by your mobile eye care. Unfortunately, uninsured patients will always have an access to care problem, especially if they are not close to an academic center. Most physicians, while generally altruistic, will not (or cannot) provide free care in a seemingly hostile (financial, legal) environment.

Haha, yes, I did all of my medical school rotations. I think my school had unusually good ophtho exposure too actually-- although I was interested in ophtho, worked in free ophtho clinics, and did sub-i's ect so I'm probably biased. Anyway, I think I already agreed with the busy PCP, not having enough time, needing more training for many of them (my point initially, advocating for some increased training). Also agree that direct exams on undilated patients aren't very helpful, which is why I said dilated exams-- yes, I know it takes time to dilate that pcp's don't have. Anyway, I largely agree with you, it's probably a lofty and difficult idea but one that the AAO has and should be promoted as it could one day be possible in our evolving system-- the AAO actually makes a book for med student and pcp education including techniques they should know and very clear points for when they should refer.

My bigger point-- not really a point, more of a question and thought-- is how we may as a profession use extenders more liberally to cover primary medical eye care and create systems without initial pseudo medical optom coverage, but initial primary medical coverage with an Ophtho practice. I know that ODs are used in pp for post op checks--- i think this is a huge problem and led to them thinking they should do yags and other surgical procedures in KE and other states. I think surgery by surgeons should involve postop checks by a surgeon (i know this is a $ issue, why not use an extender like a PA you operate with though--- seems to me better than an OD from a professional standpoint). Maybe great legislation would involve requiring this and preventing Medicare dollars from going to optoms to check on our surgical post ops... ( I know, it's how the private system is, it's economically advantageous, ect but maybe it's our fault if they all start doing yags and other laser surgery the ???)

Actually seems like it should be "medicine and surgery by physicians and surgeons".

I'm aware of what COMTs do in offices, including refraction, merely thinking of extending their training and use to work with PCP practices, especially in rural areas where free standing optoms who practice pseudo ophtho actually exist, may be a good way to build good relationships with pcp's, get referrals from them, and also ensure that patients who need dilated medical eye exams aren't being sent to some optical shop to have an optom who believes he is fellowship trained in glaucoma do a dilated eye exam. I did a family medicine rotation in a more rural area not very far from the city-- and definitely within reach of ophthalmology within the town-- and the fm attending I worked with didn't really seem to get the importance of ensuring her patients who needed dilated exams-- including diabetics-- see an ophthalmologist, not just "have an eye exam" which on my further questioning was often an optom exam at Walmart. I actually wouldn't be surprised if she had some rural optom who got her to send her patients... Which left a lasting impression on me that working with pcp's is important, It seems to me this would be the biggest step we could take to eliminate pseudo medical optom care-- regardless of what legislation they passed. And yes, I know the lack of access was a contrived crisis in OK and KE ( as well as the other 25 states they were unsuccessful in) used to legally expand opto practice, however, it doesn't necessarily matter what they make their legal scope as creating a system that increases access of patients to ophthalmology practices without optoms in the loop (at least not outside of an ophtho practice where they function as an expert in vision/refraction/contact specialist) seems like a great way to address the entire issue of scope of practice, no? If they were granted full scope of practice in every state, we could easily shut their profession down if we created such a medical system-- ie we asserted our presence, were there and giving primary medical and surgical access as actual physicians and surgeons.

I'm aware that such a system does not exist and that reimbursement may not support such a system. I could, however, imagine finding a way of developing a system of sending a trusted extender with a slit lamp, indirect, equipment for refraction, and a retinal camera you own to a rural PCP office (for a scheduled day done well in advance with the pcp's patients signed up) and being able to bill for a slew of primary eye exam extender visits may be financially sound-- at least when taking into account the referrals it would provide after determining who needs to see the ophthalmologist. Even if it didn't provide a huge boost in revenue it seems to me that sending them to strategic areas with optoms only or an optom practice trying to do glaucoma management would be advantageous to the profession and to patients-- but I guess it may be hard to convince pp guys to personally invest in the prevention of optoms stealing medical patients when they're trying to get enough phacos ... Which is what probably led to ophtho's problems with optoms in the first place.

Anyway, I once rotated with plastic surgery and a visiting chair came to grand rounds and talked about surgical oncology creating breast recon training--- he said that its the fault of prs for not being there for the general surgeons that there was such a need and OPPORTUNITY in the first place. Optoms and ophtho is very different of course (these are people without any surgical training and only what they think is medical training) but I think that ophtho creating a system for "being there" more and advocating among the larger medical profession, especially for non-cataract medical ophtho care, seems like it should be a major topic and activity in ophtho advocacy.

 

[90 diopter]

If this subject is that important to you, you should run with it and see if you can alter the system to your liking.

As far as the general comments about optometrists, I think it really depends on the optometrist. In my experience, most of them have no interest in "stealing" our procedures. There is one guy in town who routinely sends patients to me, and I place more trust in his clinical judgment than I do in a few of the board certified ophthalmologists in the area.

 

[Core Dome Ahhh]

If this subject is that important to you, you should run with it and see if you can alter the system to your liking.

As far as the general comments about optometrists, I think it really depends on the optometrist. In my experience, most of them have no interest in "stealing" our procedures. There is one guy in town who routinely sends patients to me, and I place more trust in his clinical judgment than I do in a few of the board certified ophthalmologists in the area.

You're right, and I don't think that most optoms are interested in trying to be surgeons or even play glaucoma doc. However, I don't think legislation attempts in 27 states should be ignored and not make us sit back and think about the system we've developed overall-- we've blurred the lines between medicine surgery and vision/refraction/contacts, especially in the pp world, which is most of ophtho. Allowing the whole"primary care eye doc" thing is also troublesome to me. The optoms I've personally worked with have been great. I would prefer they stick with contacts, glasses, and developing other niches that aren't readily covered by med/surg fields of ophtho. When I read about optom schools teaching students to do laser surgery on rabbits and their faculty talk about how this is "surgical training" and their near future scope of practice, I'm a bit pissed.

I also am undertaking a project to look into piloting such a system locally.

 

[barkatthemoon]

I was at a talk by nsurg chair at our school talking about getting new codes approved how values get assigned ect and it seems like everything takes a long time and you have to be very proactive to get anything done. I think the idea of screening w/cameras and using more tech will make it possible for a big shift in primary care for eyes in the next little while. I'm still in school but i hope people are starting to work on this from the financial side. I know that screening programs based out of PCP offices are being piloted and will grow if it makes financial sense. It also fits into the idea of primary care making a 'patient centered medical home' and not having to see different people all over the place for every differnt problem/body part.

 

[PBEA]

I also am undertaking a project to look into piloting such a system locally.

It sounds like what you are suggesting is a system mainly designed to somehow "outmaneuver" optometry, and less about pt care. Your motivation is obviously political and as well is likely driven by anti-competitive interests. Your going to actually claim that your little fragmented telephoto care is even close in comparison to the full range of exam/service that optometry provides to the community. Get real, you don't give a damn about "pt care", you just care about the fing money or maybe its your precious ego that matters most. Frankly I dont care what your *******ss reasons are, I can see you coming from a mile away (hint: and so do most others) the only way to shut guys like you up is with the legislature. You don't like it? so what? who cares what you dont like

 

[Core Dome Ahhh]

It sounds like what you are suggesting is a system mainly designed to somehow "outmaneuver" optometry, and less about pt care. Your motivation is obviously political and as well is likely driven by anti-competitive interests. Your going to actually claim that your little fragmented telephoto care is even close in comparison to the full range of exam/service that optometry provides to the community. Get real, you don't give a damn about "pt care", you just care about the fing money or maybe its your precious ego that matters most. Frankly I dont care what your *******ss reasons are, I can see you coming from a mile away (hint: and so do most others) the only way to shut guys like you up is with the legislature. You don't like it? so what? who cares what you dont like

everyone knows you like legislating

 

[Dusn]

There is no shortage of ophthalmologists. There is a shortage of primary care doctors. Many ophthalmologists, their first year out of residency or fellowship spend half their day sitting around doing nothing because they don't have enough patients. The ophthalmologists who are talking about putting retinal cameras in PMD offices are doing it because they're trying to find more patients, not because they already have too many and need PMDs to help out.

Ophthalmologists who have optoms take care of their post-ops have no integrity. They're doing it so that the optoms continue to send them patients and for no other reason. Any surgeon with ethics would see his or her own post-ops.

 

[ophthope]

Ophthalmologists who have optoms take care of their post-ops have no integrity. They're doing it so that the optoms continue to send them patients and for no other reason. Any surgeon with ethics would see his or her own post-ops.

Strangely enough co-management is legal per Medicare reimbursements even though it would be considered a kickback in any other field. Optometry never should have lobbied for that and more relevant to the argument at hand - Ophthalmology was never a political field until it had to be as a reactionary measure so I can see how there may be some overzealous response among our ranks at this point. The problem is ultimately one that is purely created by Optometry's education system over-producing ODs which has led to continued attempts to expand scope and there is likely going to be anger about that from both sides. Trust me, most ODs would like to see their organizations stop pushing for scope increases and to stop over-training ODs. I agree that it is the ethics of allowing someone to see your post-op is questionable - eye surgery is nothing like a POD #1 s/p Appendectomy. However I think that there are some places where Optometry has used co-management to gain market control and the unfortunate truth is that the only way many patients are going to get surgery in those areas is to have an Optom see them post-op. It's hopefully not like that in many places yet though and remains available for Ophthalmologists to stand their ground on this issue since it is obviously better for the surgeon who did the surgery to follow up.

Ultimately it is far better for our patients if we all work together within our own scopes of practice. Comprehensive Ophthalmologists don't do PPVs with scleral buckles and A/F Exchange, Optometrists don't do surgery, and we all do what's best for the patient. 99% of the Ophthalmologists AND Optometrists that I speak with would agree but I'm a sample of N=1.

 

[PBEA]

everyone knows you like legislating

said the kettle to the pot

 

[Core Dome Ahhh]

Strangely enough co-management is legal per Medicare reimbursements even though it would be considered a kickback in any other field. Optometry never should have lobbied for that and more relevant to the argument at hand - Ophthalmology was never a political field until it had to be as a reactionary measure so I can see how there may be some overzealous response among our ranks at this point. The problem is ultimately one that is purely created by Optometry's education system over-producing ODs which has led to continued attempts to expand scope and there is likely going to be anger about that from both sides. Trust me, most ODs would like to see their organizations stop pushing for scope increases and to stop over-training ODs. I agree that it is the ethics of allowing someone to see your post-op is questionable - eye surgery is nothing like a POD #1 s/p Appendectomy. However I think that there are some places where Optometry has used co-management to gain market control and the unfortunate truth is that the only way many patients are going to get surgery in those areas is to have an Optom see them post-op. It's hopefully not like that in many places yet though and remains available for Ophthalmologists to stand their ground on this issue since it is obviously better for the surgeon who did the surgery to follow up.

Ultimately it is far better for our patients if we all work together within our own scopes of practice. Comprehensive Ophthalmologists don't do PPVs with scleral buckles and A/F Exchange, Optometrists don't do surgery, and we all do what's best for the patient. 99% of the Ophthalmologists AND Optometrists that I speak with would agree but I'm a sample of N=1.

All great points. Now let me point out a few things now that mister optom lobby is done (maybe)

1. Perhaps the tone of my initial few posts seemed a bit strong with respect to optometrists but actually my personal experiences and impressions of the optoms working in OPTOMETRY that I have worked with is that they have been great, and work in a niche that they fill very well. My extremely negative opinion is directed toward state optom boards that seem to have a general, non-collegial attitude and lack of respect not only for ophthalmology but medicine and surgery in general as they seem to think they can lobby themselves into being physicians and surgeons so they can institute training on rabbits to train to work in a very well filled subspecialty niche medical field -- it would be a funny joke if not reality.

2. If all I cared about was money or ego, I would start a LASIK only practice and buy a Porsche, not be interested in primary eye care and academics. I think the use of ophthalmic imaging is overstated, my major point is the use of non-OD physician extenders and taking advantage of our already more integrated, continuing to become more integrated medical system should be fully taken advantage of as i think the system we've developed is a bad apple as evidenced by the legal comanagement kick backs. The physician I know who put the ophthalmic cameras at PCP offices is not trying to make money or really get pts-- he commonly treats pts for free, is an academic, and is waaaay more worried about diabetics going blind because, unknown to their pcp, they're getting their ophthalmic care from an optom at Wal Mart--- they provide a great level of care there that just can't be replaced

3. The fascination with what I refer to as pseudo-ophtho by optoms seems to me to start with many optoms initially wanting to be MD/DO's, is encouraged by the system of private optom schools who want their money and pitch them what they want, and is just as disadvantageous if not more to optometry as it is to ophtho. These delusions that OD's are going to become ophthalmologists more and more are spread all over sdn and similar sites, largely by optom students at the aforementioned schools from what I can tell, like a terminal case of herpes. What would do optoms a great bit of help ( well, their state boards and schools, this applies to the ones I know) would be to drop these delusional political ambitions and devote their energy to developing more optom niches that aren't filled by more educated and experience practitioners--- specialized contacts, vision therapy/behavioral optom, carving out a niche as a required team member for quality refraction at LASIK centers (instead of as a surgeon or post op kick back gig)' ect. Optoms originally became super valued in the US for having a niche for treating eye strain with glasses when physicians thought it was quackery. Pseudo ophtho's have already become extinct for lacking a niche in the US before. Better yet, keep your jobs from being taken over by kiosks.

4. Ophtho's should worry more about providing great primary ophtho medical care and post op care. Co-management is a bad joke and should be done away with. Our physician colleagues should be better educated. I think if we stepped this up we could all still have time for phacos

 

[PBEA]

the exceedingly naïve comments here are representative of why there are continuous scope of practice arguments. Attempting to pigeon-hole optometry as refraction only care is absurd. To suggest that ODs only provide "refractions" is akin to saying OMD's only provide "surgery". Where neither is in fact the case. The reality is that there is plenty of overlap in the day to day practice of many OD and MD, (and OD/MD) offices. We both see a lot of glaucoma, diabetes, macular degeneration, corneal disease, red eyes, foreign bodies, and a whole host of rare but in your chair type presentations. Generally speaking we both deliver this care in a manner consistent with best practices and or guidelines, and we both sometimes refer cases outside of our comfort zone or scope of practice. Fact is OD's can and do manage the vast majority of the nation's eyecare. period. The constant innuendo from ophthalmology not withstanding, optometry's role in healthcare is mainstream, evidenced -based, efficient, and cemented. We have been licensed in the US for as long as medicine has and we aren't going anywhere. So before you climb on your horse again and try and pretend we don't compete for the same exact patient's, remember that high volume ophtho offices that pump out 3 minute visits don't exactly inspire patients about the care they are receiving...and they might be right. At that speed you could run over any number of subtle presentations and not even notice. If you can afford to swallow your ego and a bit of your half a mill salary you might realize that the fing DOCTOR is probably best at examining pts and not some godam tech.

 

[Core Dome Ahhh]

the exceedingly naïve comments here are representative of why there are continuous scope of practice arguments. Attempting to pigeon-hole optometry as refraction only care is absurd. To suggest that ODs only provide "refractions" is akin to saying OMD's only provide "surgery". Where neither is in fact the case. The reality is that there is plenty of overlap in the day to day practice of many OD and MD, (and OD/MD) offices. We both see a lot of glaucoma, diabetes, macular degeneration, corneal disease, red eyes, foreign bodies, and a whole host of rare but in your chair type presentations. Generally speaking we both deliver this care in a manner consistent with best practices and or guidelines, and we both sometimes refer cases outside of our comfort zone or scope of practice. Fact is OD's can and do manage the vast majority of the nation's eyecare. period. The constant innuendo from ophthalmology not withstanding, optometry's role in healthcare is mainstream, evidenced -based, efficient, and cemented. We have been licensed in the US for as long as medicine has and we aren't going anywhere. So before you climb on your horse again and try and pretend we don't compete for the same exact patient's, remember that high volume ophtho offices that pump out 3 minute visits don't exactly inspire patients about the care they are receiving...and they might be right. At that speed you could run over any number of subtle presentations and not even notice. If you can afford to swallow your ego and a bit of your half a mill salary you might realize that the fing DOCTOR is probably best at examining pts and not some godam tech.

wow, you're really great. Thanks for chiming in on the thread again.

I don't think I marginalized optometry to refraction only. I do think optoms niche is vision/glasses/contacts as this is their vast majority of practice from every stat I've ever seen. That this is the vast majority of "eye care" is clear. Obviously doing an exam to see if there is a non refractive cause for visual problems is important, as well as other basic eye care. I don't think anyone cares if optoms remove foreign bodies and I certainly don't-- I also would never call it surgery.

That a medical DOCTOR should be examining and treating a patient with a medical problem is my point exactly. Especially cases of DM, glaucoma, and serious infections. That a well trained PA could do primary screening exams and help with postoperative care within the practice of and under the close supervision of a physician is an assertion I'll stand by. I also think this would be much better than an optom kick back exam.

Keep accusing me of wanting tons of money, it's a great way to make a valid, well received point!

Anyway, I was having a discussion on an ophtho forum about ophthalmology, so I think I'm done with wasting my time otherwise. Best of luck on Capitol Hill and feel free to troll this thread in whatever direction you wish! Maybe I'll stop by and troll some optom threads!

 

[PBEA]

In case you had not noticed, it's an open forum. If you want a dark little room where you could plot devious machinations, under the guise of pt care, that serve no other purpose but your own, then you came to the wrong place. Sunlight being the best disinfectant, as it were. In an open forum, ideas have to stand on their own based on their actual merit, and not some petty, protectionist concern about market share. Why not just chat up some colleagues in private about how unskilled or dumb ODs are that we cant even examine pts "especially DM, glaucoma, and serious infections". I'm sure you'd find plenty of "brotherhood" in that.

 

[east]

Anyway, I was having a discussion on an ophtho forum about ophthalmology, so I think I'm done with wasting my time otherwise. Best of luck on Capitol Hill and feel free to troll this thread in whatever direction you wish! Maybe I'll stop by and troll some optom threads!

Getting another point of view from the side you are marginalizing is not trolling. By the tone of your posts, you had to expect to be confronted by the other side. C'mon man don't bow out after a little disagreement. It might be good for you be exposed a little more to what optometry does in the 21st century in the good 'ole USA. I know, I know, you already know everything about optometry but.....just maybe you don't??

 

[310]

delete

 

[Core Dome Ahhh]

If you want a dark little room where you could plot devious machinations, under the guise of pt care, that serve no other purpose but your own, then you came to the wrong place. Sunlight being the best disinfectant, as it were. In an open forum, ideas have to stand on their own based on their actual merit, and not some petty, protectionist concern about market share.

wow, you fancy yourself a heroic character in a movie you have designed in your head? I know, ophtho being more heavily involved with pts medically and working with colleagues is EVIL and without merit!!! Good thing you were here to stop me Ed Snowden!

 

[PBEA]

wow, you fancy yourself a heroic character in a movie you have designed in your head? I know, ophtho being more heavily involved with pts medically and working with colleagues is EVIL and without merit!!! Good thing you were here to stop me Ed Snowden!

you still here? Gee I thought you took your ball and went home. Guess not.....anyway I don't mind that your posts are sarcastic, as it creates some levity, at least we can assume you don't take yourself (or your ideas) THAT seriously.

 

[Core Dome Ahhh]

you still here? Gee I thought you took your ball and went home. Guess not.....anyway I don't mind that your posts are sarcastic, as it creates some levity, at least we can assume you don't take yourself (or your ideas) THAT seriously.

Well, in all honesty I think my humorous jabs at optoms distracted from the actual points I was trying to make and inevitably led to a slew of unhappy optoms, which wasn't the point of my thread or how I'd like to spend (waste) my time (arguing). . I think there is much to be disliked about the optom-ophtho professional relationship, especially in the pp world which, coming from a medical and medical administration perspective and with that view of kick back systems, I think is very sleazy and not conducive to good patient care. Both optoms and ophtho are to blame.

As far as I can tell from any data I've ever seen (soemthing like 95% optoms getting 95% of income from non-med glasses/contact/refraction-- feel free to correct me), optoms being totally shut out of medical care would have a very little effect on optom practice or job market-- not that this is, in reality, what I think or want to happen. I don't think ophtho's should rest on optoms referrals, I don't agree with kick backs, and I think working with Primary care and our general medical community is something we don't do enough. That we really "compete" for the same patients is debatable overall-- of course, I live in a large NE city where there is close to zero independent pp optoms-- a few dilapidated old Indy optical shops aside-- they function more as a referral base from commercial optical centers or are employed in pp ophtho practices. That I've seen patients who have been mismanaged in rural areas by optoms with each condition I've named is a reality and I would prefer patients are hooked in with a more comprehensive ophtho system early, starting with PCPs. That ophtho's and other physicians sometimes mismanage patients is also a reality. Optoms could clearly have a role in a more integrated system--I think they already do where I am and so many work in large multi-discipline ophtho practices-- but I think it needs to be a more integrated comprehensive one---not an optical shop or Walmart medicine. I also think PA's could have a role in that system.

That I think optoms niche is refraction/glasses/contacts and that focusing energy on pseudo surgical rights instead of further developing a niche to thrive in is counterproductive for optometry, and that this impulse comes largely from private optom schools and their young grads is an opinion of mine heavily influenced by (wait for it): a very close family member of mine who is an optometrist. Lest you think I hate people for having an OD, I respect him and his practice very much. I also once came across an interesting history of optom lecture from an academic optom making just that point--that there's a niche that should be pursued and not doing so and/or trying to fill a less skilled duplicative role is bad for the field as seen in a historical perspective. I think he was from IUO, google it if you wish. Anyway, all of that was not really the discussion I wanted to have, I actually wanted to talk about ideas for improving and integrating ophtho practice.

And as far as legislating is concerned, I think people get more worked up about it than is really necessary. I can tell you first hand that training to be a surgeon is very hard and that a government official telling you that you can cut people in no way makes one a surgeon. I can also tell you that becoming a physician and surgeon doesn't happen with reading a book or being gabbed at in a classroom. It starts mainly after you leave the classroom with medical school rotations , continues with internship, and is carried on to residency and fellowship. It consists of observing pathology over and over, discussing diagnosis and management with experts, finding you gaps in knowledge and being viscerally humiliated at times for them, and having practical knowledge and skills --surgical included-- transmitted to you in that setting by these experts who in turn were taught by the generation of experts before them. That optom and ophtho both have special expertise handed down to one another is certain, as well as the fact that the experts passing the expertise down and the expertise they pass is different albeit with some overlap.

 

[east]

As far as I can tell from any data I've ever seen (soemthing like 95% optoms getting 95% of income from non-med glasses/contact/refraction-- feel free to correct me), optoms being totally shut out of medical care would have a very little effect on optom practice or job market-- not that this is, in reality, what I think or want to happen.

I derive 55% of my revenue from professional services and 45% from optical sales. Of the 55% professional service revenue, 35% is generated from non-routine medical eye care ( you know DM, glaucoma,and serious infections). I bill medical insurance much more than vision insurance.

I must be an extreme outlier? or maybe your data is wrong? I would be out of business if medical eye care was taken away from me.

 

[VA Hopeful Dr]

I derive 55% of my revenue from professional services and 45% from optical sales. Of the 55% professional service revenue, 35% is generated from non-routine medical eye care ( you know DM, glaucoma,and serious infections). I bill medical insurance much more than vision insurance.

I must be an extreme outlier? or maybe your data is wrong? I would be out of business if medical eye care was taken away from me.

I had always been told that the average across the country was about a 50/50 split professional fees/materials.

 

[JMK2005]

Well, in all honesty I think my humorous jabs at optoms distracted from the actual points I was trying to make and inevitably led to a slew of unhappy optoms, which wasn't the point of my thread or how I'd like to spend (waste) my time (arguing). . I think there is much to be disliked about the optom-ophtho professional relationship, especially in the pp world which, coming from a medical and medical administration perspective and with that view of kick back systems, I think is very sleazy and not conducive to good patient care. Both optoms and ophtho are to blame.

As far as I can tell from any data I've ever seen (soemthing like 95% optoms getting 95% of income from non-med glasses/contact/refraction-- feel free to correct me), optoms being totally shut out of medical care would have a very little effect on optom practice or job market-- not that this is, in reality, what I think or want to happen. I don't think ophtho's should rest on optoms referrals, I don't agree with kick backs, and I think working with Primary care and our general medical community is something we don't do enough. That we really "compete" for the same patients is debatable overall-- of course, I live in a large NE city where there is close to zero independent pp optoms-- a few dilapidated old Indy optical shops aside-- they function more as a referral base from commercial optical centers or are employed in pp ophtho practices. That I've seen patients who have been mismanaged in rural areas by optoms with each condition I've named is a reality and I would prefer patients are hooked in with a more comprehensive ophtho system early, starting with PCPs. That ophtho's and other physicians sometimes mismanage patients is also a reality. Optoms could clearly have a role in a more integrated system--I think they already do where I am and so many work in large multi-discipline ophtho practices-- but I think it needs to be a more integrated comprehensive one---not an optical shop or Walmart medicine. I also think PA's could have a role in that system.

That I think optoms niche is refraction/glasses/contacts and that focusing energy on pseudo surgical rights instead of further developing a niche to thrive in is counterproductive for optometry, and that this impulse comes largely from private optom schools and their young grads is an opinion of mine heavily influenced by (wait for it): a very close family member of mine who is an optometrist. Lest you think I hate people for having an OD, I respect him and his practice very much. I also once came across an interesting history of optom lecture from an academic optom making just that point--that there's a niche that should be pursued and not doing so and/or trying to fill a less skilled duplicative role is bad for the field as seen in a historical perspective. I think he was from IUO, google it if you wish. Anyway, all of that was not really the discussion I wanted to have, I actually wanted to talk about ideas for improving and integrating ophtho practice.

And as far as legislating is concerned, I think people get more worked up about it than is really necessary. I can tell you first hand that training to be a surgeon is very hard and that a government official telling you that you can cut people in no way makes one a surgeon. I can also tell you that becoming a physician and surgeon doesn't happen with reading a book or being gabbed at in a classroom. It starts mainly after you leave the classroom with medical school rotations , continues with internship, and is carried on to residency and fellowship. It consists of observing pathology over and over, discussing diagnosis and management with experts, finding you gaps in knowledge and being viscerally humiliated at times for them, and having practical knowledge and skills --surgical included-- transmitted to you in that setting by these experts who in turn were taught by the generation of experts before them. That optom and ophtho both have special expertise handed down to one another is certain, as well as the fact that the experts passing the expertise down and the expertise they pass is different albeit with some overlap.

quit trolling.

 

[east]

I had always been told that the average across the country was about a 50/50 split professional fees/materials.

I believe you're correct. I was just further differentiating professional fees into "routine" annual checks, and problem focused medical eye care. Some optometrists' professional services consist of mainly healthy eyes, and they usually utilize a vision insurance plan. This is changing a lot, and medical eye care using medical insurance is becoming much more common. Either way I was just questioning the "data" from the OP.

It just bugs me when someone who is not an optometrist comes on and says optometry is "this and that" when they really have no clue. I would never come on here and say ophthalmology is "this and that". I know many ophthalmologists well, but would never presume to speak authoritatively on their business.

 

[310]

I have a team of assistants beneath me, one of whom is lights-out at refractions and direct-opthalmoscopy. Without them, I would have an immeasurably harder time practicing psuedo-medicine on my diabetic and glaucoma patients.

 

[PBEA]

I have a team of assistants beneath me, one of whom is lights-out at refractions and direct-opthalmoscopy. Without them, I would have an immeasurably harder time practicing psuedo-medicine on my diabetic and glaucoma patients.

you are just a scam artist who is mismanaging diabetic and glaucoma pts, and you are a sleazy OD who refers people for cataract surgery or refers to retina for that injection thingy. Don't EVEN get me started on all that "lasik" shiit you keep sending to the cornea guys. Focus your energies on your refraction niche because that's all you are trained to do, anything else is just pseudo-medicine (I had to look that one up because I'm an OD......it means "not proven to be effective"). Have you no sense of decency...or responsibility?

you bastard

 

[linevasel]

Responding to Core Dome Ahhs original suggestion.
It is one idea.... but I wonder about its ultimate efficacy. Anesthesiologists tried Anasthesia Assistants. CRNAs are doing better than ever (incidentally, the AA field is not a bad gig at all&#8230. The Nurse Practitioner profession is becoming increasingly prominent despite its redundancy with the PA profession (don't even start with the NPs aren't trying to be physicians, we approach patients from a nursing model that looks at the patient as a whole…. I'm married to an NP. Its basically an alternate path to practicing medicine. The way they have increased their public image and academic standing with their non-inferiority studies is a thing of beauty.). There are some really smart optometrists who have means, and what I like to call "generational" political capital (2nd, 3rd generation ODs with political ties...) and the time to work on expanding practice scope. It's a reality that is not going away. Additionally, we work in an environment where OMDs routinely employ optoms (which is fine) but then they go to the next level and advertise their optoms' expertise in Glaucoma, Uveitis, etc , etc (I couldn't imagine doing this myself as an attending, but…. I'm only a lowly resident so what do I know?). Nonetheless I'm afraid the cat is already out the bag. It is true that few optoms are looking to expand scope. But once the activation energy for expansion is lowered and individuals see that money is on table (and lets be frank, patient safety or not, money is definitely ON the table) it will be a different story. NPs used to say they had no interest in replacing physicians. But soon the rallying cry will be equal pay for equal work/outcomes. I'm not saying optom and OMD have the same relationship dynamics as NPs and PCPs. But there are enough similarities to think that maybe we can borrow a page from our Primary Care colleages on what NOT to do when faced with a profession that increasingly seeks to blur the lines.

 

[KHE]

I am not going to get involved in this thread heavily because there have been dozens like it over the years and rarely are there any hearts or minds changed.

I have said for years that the problem with ophthalmology training with respect to this issue is that most ophthalmologists (any med students really) do not interact with optometry as part of their training.

They will interact with dentists, podiatrists, physical therapy, pharmacy etc. etc. But almost never with optometry. And if they DO, it is almost universally under the umbrella of the ophthalmology department where the optometrist is usually limited to low vision or contact lens fittings on bizarre corneas or other "low level" problems. As such,, ophthalmologists or other physicians rotating through get it in their head that that is all optometry is capable of.

If you are a resident at Johns Hopkins say, and you have a few fellowship trained glaucoma specialists on staff and an optometrist, how likely is it that that optometrist will see any glaucoma patients? Low.

And as such, you never get to see what an optometrist is capable of beyond the walls of your academic environments. Couple that with the indoctrination that goes on at most, not all but most programs that basically say that optometrists are nothing more than eyeglass monkeys....well I sort of get where your misguided notions of optometry come from.

But the fact remains that modern optometry is not your father's optometry. The notion that most optometrists in most situations are not equipped to handle glaucoma patients or evaluate diabetics for retinopathy or see a post operative cataract patient is absurd.

 

[ophthope]

But the fact remains that modern optometry is not your father's optometry. The notion that most optometrists in most situations are not equipped to handle glaucoma patients or evaluate diabetics for retinopathy or see a post operative cataract patient is absurd.

I can see the first arguments, but would like to see an experienced attending to comment on the idea of optometric post-op follow up. Most ophthalmologists that I have worked with have very much the opposite opinion and feel that it is not proper patient care to perform eye surgery on a patient and not follow up with them yourself.

 

[LightBox]

I can see the first arguments, but would like to see an experienced attending to comment on the idea of optometric post-op follow up. Most ophthalmologists that I have worked with have very much the opposite opinion and feel that it is not proper patient care to perform eye surgery on a patient and not follow up with them yourself.

I may take some grief about this on this message board, but I feel completely comfortable having **my** optometrists (i.e. the ones I employ) see my cataract and refractive surgery post-ops...starting one week out.

I always see my post-op day #1's, even if there are 20-40 of them. We have acclimated our optometrists very well on what constitutes a look by one of us ophthalmologists in the post-operative period. And if there is ANY question whatsoever (i.e. patient post-op course does not "seem" right), then our optometrists will have us see the pt immediately (they are just down the hall). But practically speaking, it is not feasible to see every pt for their post-op visits/refractions/etc if your center is doing a high volume # of cases. It also isn't cost-efficient for an anterior segment surgeon to do so, since your highest value is keeping yourself in the O.R.

Obviously, if any cataract surgery patient has any type of intra-operative complication then we follow them ourselves for all post-op visits. But fortunately, our cataract surgery is pretty steamlined and has a low complication rate.

For glaucoma surgeries and transplants, we see the pts for all of their post-op visits since these operations have many more (subtle) complications to deal with.

Btw, I typically like to see all of my glaucoma patients myself, because I know for a fact that I know how to manage glaucoma patients (especially surgical ones) better than 95% of all eye care providers out there! (optometrists and ophthalmologists combined!). I really do not think that optometrists (or even general ophthalmologists who do not know how to do anything beyond SLT) should be seeing moderately-advanced (and beyond) glaucoma patients.

 

[KHE]

I may take some grief about this on this message board, but I feel completely comfortable having **my** optometrists (i.e. the ones I employ) see my cataract and refractive surgery post-ops...starting one week out.

I always see my post-op day #1's, even if there are 20-40 of them. We have acclimated our optometrists very well on what constitutes a look by one of us ophthalmologists in the post-operative period. And if there is ANY question whatsoever (i.e. patient post-op course does not "seem" right), then our optometrists will have us see the pt immediately (they are just down the hall). But practically speaking, it is not feasible to see every pt for their post-op visits/refractions/etc if your center is doing a high volume # of cases. It also isn't cost-efficient for an anterior segment surgeon to do so, since your highest value is keeping yourself in the O.R.

Obviously, if any cataract surgery patient has any type of intra-operative complication then we follow them ourselves for all post-op visits. But fortunately, our cataract surgery is pretty steamlined and has a low complication rate.

For glaucoma surgeries and transplants, we see the pts for all of their post-op visits since these operations have many more (subtle) complications to deal with.

Btw, I typically like to see all of my glaucoma patients myself, because I know for a fact that I know how to manage glaucoma patients (especially surgical ones) better than 95% of all eye care providers out there! (optometrists and ophthalmologists combined!). I really do not think that optometrists (or even general ophthalmologists who do not know how to do anything beyond SLT) should be seeing moderately-advanced (and beyond) glaucoma patients.

I think another point that people on this forum miss is that when I do post op cataract and refractive surgery visits, I do it because the SURGEON wants me to to do it.

I actually LOSE MONEY on it doing those visits.

What does medicare pay for a cataract extraction these days? $600? $650?

Standard copayment fee is 20%. That's $120-$130 to do a one day, one week, one month post op visit. Sometimes more if there's some complication or the patient is high strung and wants to come back in sooner.

So THREE office visits for $130? Why would I want to do that? My average revenue per appointment slot is over 3 times that.

So what's better for me.....filling an appointment slot at average revenue of $400 or filling three appointment slots for $130? duh. Obvious choice.

Refractive post ops are obviously a bit more lucrative but to do three post op visits for 20% of $4000 or $5000 is still less than I could make otherwise.

And that's if everything goes smoothly. God forbid the patient needs an enhancement or is one of those high strung engineer types to calls every three days complaining about their pl -0.50 X 175 vision.

You guys want to do your own post-ops.....please.....by all means. Go right ahead.

Regarding optometrists being able to handle these visits.......optometrists as a group are notoriously conservative. Some would even say fearful. Many punt very simple cases. The number of optometrists who are desirous of handling a post surgical glaucoma patient with intra-operative complications is vanishingly small.

 

[especialleye]

I am not going to get involved in this thread heavily because there have been dozens like it over the years and rarely are there any hearts or minds changed.

I have said for years that the problem with ophthalmology training with respect to this issue is that most ophthalmologists (any med students really) do not interact with optometry as part of their training.

They will interact with dentists, podiatrists, physical therapy, pharmacy etc. etc. But almost never with optometry. And if they DO, it is almost universally under the umbrella of the ophthalmology department where the optometrist is usually limited to low vision or contact lens fittings on bizarre corneas or other "low level" problems. As such,, ophthalmologists or other physicians rotating through get it in their head that that is all optometry is capable of.

If you are a resident at Johns Hopkins say, and you have a few fellowship trained glaucoma specialists on staff and an optometrist, how likely is it that that optometrist will see any glaucoma patients? Low.

And as such, you never get to see what an optometrist is capable of beyond the walls of your academic environments. Couple that with the indoctrination that goes on at most, not all but most programs that basically say that optometrists are nothing more than eyeglass monkeys....well I sort of get where your misguided notions of optometry come from.

But the fact remains that modern optometry is not your father's optometry. The notion that most optometrists in most situations are not equipped to handle glaucoma patients or evaluate diabetics for retinopathy or see a post operative cataract patient is absurd.

Just so none of the Ophthalmology-hopefuls heading into interviews get the wrong impression of Ophtho: everything you are saying here can be said from our side too. I know of patients who got regular eye care at an optometry school that have been told to seek ophthalmology sub-specialist care an hour and a half away when there are multiple glaucoma, cornea, and vitreoretinal surgeons at an Ophthalmology residency literally down the road a few minutes away. So please stop telling us it's all us mean old Ophthos with the bad opinions of other professionals. In my minimal experience with OD students, Optometry indocrination is at least as significant as any 'indoctrination' we get in training and arguably worse especially for patients in the aforementioned situation. I'm curious as to how much direct interaction you feel like Optometrists have with Ophthalmologists as part of their training that makes their perspective on us better than ours is on them. I'm also curious as to how you feel informed to make the statement that this indoctrination happens at "most" Ophthalmology training programs. If you went through our training you'd see that the 'indoctrination' usually happens by seeing enough patients where an OD sat on an infection or some other problem for a week until Friday afternoon when they told the patient to go to the ER instead of handling the patient appropriately. Maybe this is a story of a few bad apples ruining our perspective on the whole bunch since the ODs I've ever been in close proximity to were great, but they've also been working in the same clinics as OMDs so I'm sure there is some selection bias there as well. And before somebody feels the need to bring it up: Yes there are bad Ophthalmologists too, I get that. Ultimately though the OMD-trainee's opinion on ODs is formed by seeing patients coming from ODs, not by some imagined back room conversations where we plan your demise and all agree to hate you.

You blame Ophtho for considering Optometry "eyeglass monkeys" but we're just your "surgery monkeys" anyway right? Our vastly more comprehensive and extensive medical training offers literally nothing to patients except that Optometrists can send their patients to us for a quick old surgerizin', because that is the only difference between the two professions, right? I'm not aware of what the most widely held perspective of ODs is, and per KHE's latest comment it would seem that most are very conservative with their patient management. However, it seems that the opinion of a lot of OD-students on SDN is that our 8 years of training is literally the equivalent of your 4 years of training with the added caveat that our 4 additional years lets us put in Ex-Press shunts and fix strabismus... but really ODs could do cataract surgery no problem plus ODs are already 'surgeons' because they buffed out a rust ring a couple of times. Just search youtube for "Ophthalmology vs Optometry" and the first video that pops up in the results relays that opinion.

 

[guttata]

I think another point that people on this forum miss is that when I do post op cataract and refractive surgery visits, I do it because the SURGEON wants me to to do it.

I actually LOSE MONEY on it doing those visits.

What does medicare pay for a cataract extraction these days? $600? $650?

Standard copayment fee is 20%. That's $120-$130 to do a one day, one week, one month post op visit. Sometimes more if there's some complication or the patient is high strung and wants to come back in sooner.

So THREE office visits for $130? Why would I want to do that? My average revenue per appointment slot is over 3 times that.

So what's better for me.....filling an appointment slot at average revenue of $400 or filling three appointment slots for $130? duh. Obvious choice.

Refractive post ops are obviously a bit more lucrative but to do three post op visits for 20% of $4000 or $5000 is still less than I could make otherwise.

And that's if everything goes smoothly. God forbid the patient needs an enhancement or is one of those high strung engineer types to calls every three days complaining about their pl -0.50 X 175 vision.

You guys want to do your own post-ops.....please.....by all means. Go right ahead.

Regarding optometrists being able to handle these visits.......optometrists as a group are notoriously conservative. Some would even say fearful. Many punt very simple cases. The number of optometrists who are desirous of handling a post surgical glaucoma patient with intra-operative complications is vanishingly small.

Honestly, I think most surgeons prefer to follow their post-ops. We are interested in seeing the results of our work. Surgeons co-manage for many reasons.

Seriously, how do you obtain an average revenue of $400 per patient? Glasses? What are your costs?

The post-op day one and week visits are usually very short (5 mins) so you should not have opportunity cost lost. The same applies for the great majority of refractive surgery post-ops. And, don't forget the 20% on toric/multifocals plus possible glasses sales for monofocals.

 

[LightBox]

I think another point that people on this forum miss is that when I do post op cataract and refractive surgery visits, I do it because the SURGEON wants me to to do it.

So what's better for me.....filling an appointment slot at average revenue of $400 or filling three appointment slots for $130? duh. Obvious choice.

Refractive post ops are obviously a bit more lucrative but to do three post op visits for 20% of $4000 or $5000 is still less than I could make otherwise.

And that's if everything goes smoothly. God forbid the patient needs an enhancement or is one of those high strung engineer types to calls every three days complaining about their pl -0.50 X 175 vision.

You guys want to do your own post-ops.....please.....by all means. Go right ahead.

Ummm, $400 net collections per patient for an Optometrist? Yeah, I'm calling that bluff. Unless you are selling glasses to every patient that has an appointment with you, there is no way you are collecting $400 without doing any procedures and/or running every diagnostic test under the sun on your patients.

I agree with guttata -- seeing a cataract sx post-op typically takes a few minutes at most and you basically don't have to document anything that takes any time (e.g. history, ROS, etc). And the post-op refraction is to your benefit since you probably will be selling them your frames if you have an optical. I actually love refracting my post-op 1 month patients. Owning the optical changes your perspective on refracting these patients from dread to delight. Plus my techs are awesome and can refract better than most providers out there. So it doesn't take that much time at all to refine.

To be honest, the optometrists that co-manage surgery patients are not doing it for the co-management fee. They are doing it to ensure that their patients come back to them for all of their regular care (i.e. to make sure the Ophthalmologist doesn't steal their patients). As someone who "co-manages" cataract Pts, I do think that "co-management" is kind of a farce, especially since most of the optometrists I do it with practice a few miles away. It's also too much paperwork and billing it out is a pain. But I understand why they do it with us, especially since we own an optical and have our own optometrists. Many of the surgery patients directly ask us, "can't I just follow up with you guys? It's so much nicer here". It's definitely uncomfortable answering their questions, because you don't want to piss anyone in the area off. I'm completely respectful of the optometrists, so I always refer them back, but it is a funny game that we play. I'd rather not have my staff deal with any of the co-management paperwork, and just have the optometrist trust me that I'm going to send the patient back.

Actually, several of our local optometrists have straight-up told us that they will not refer to us for cataract surgery because of our optical. But since we like having "everything under one roof", we are not going to close the optical anytime soon!

 

[especialleye]

Actually, several of our local optometrists have straight-up told us that they will not refer to us for cataract surgery because of our optical. But since we like having "everything under one roof", we are not going to close the optical anytime soon!

What? No way! How could this happen when the Optometrists promised us that getting Medicare to recognize them as 'physicians' and allowing co-management without considering it to be fee-splitting was all about better access to care for patients? Who could possibly have foreseen that this would be used to control which providers patients seek for surgical eye care by limiting referrals to say, OMDs who agree to always co-manage or don't have competing optical shops?

I am sure that you are absolutely the only Ophthalmologist with a story like this, though. All of the Optometrists on these forums will back me up here and say that this basically never ever happens and this is an issue being completely blown out of the water by the AAO and Ophthalmologists in general. Back me up here ODs and remind everyone that this is practically a non-issue.

 

[KHE]

Ummm, $400 net collections per patient for an Optometrist? Yeah, I'm calling that bluff. Unless you are selling glasses to every patient that has an appointment with you, there is no way you are collecting $400 without doing any procedures and/or running every diagnostic test under the sun on your patients.

You can think I'm bluffing but why would I do that? I've been on this forum for years and years and there is no benefit to me to lie about this. $400 net collections is not a difficult goal to obtain if you can create an environment and an experience that makes people want to spend money with you. Believe you me, when I bought my practice 6 years ago, we were not near that mark. I do practice in the northeast where fees are a bit higher so that may account for some of it but we certainly do not "sell glasses to every patient who has an appointment with us" nor do we run "every diagnostic test under the sun." That is a losing proposition in the long run. We have spent a lot of time and resources towards creating that environment and experience.

I agree with guttata -- seeing a cataract sx post-op typically takes a few minutes at most and you basically don't have to document anything that takes any time (e.g. history, ROS, etc). And the post-op refraction is to your benefit since you probably will be selling them your frames if you have an optical. I actually love refracting my post-op 1 month patients. Owning the optical changes your perspective on refracting these patients from dread to delight. Plus my techs are awesome and can refract better than most providers out there. So it doesn't take that much time at all to refine.

We do not schedule different blocks of time for post ups vs comprehensive exams. We've found that this works well for us because the followups do not take as much as time, as you say and it creates a release valve in the schedule. However, it is not financially viable to stuff our schedule with cataract post op visits.

To be honest, the optometrists that co-manage surgery patients are not doing it for the co-management fee. They are doing it to ensure that their patients come back to them for all of their regular care (i.e. to make sure the Ophthalmologist doesn't steal their patients). As someone who "co-manages" cataract Pts, I do think that "co-management" is kind of a farce, especially since most of the optometrists I do it with practice a few miles away. It's also too much paperwork and billing it out is a pain. But I understand why they do it with us, especially since we own an optical and have our own optometrists. Many of the surgery patients directly ask us, "can't I just follow up with you guys? It's so much nicer here". It's definitely uncomfortable answering their questions, because you don't want to piss anyone in the area off. I'm completely respectful of the optometrists, so I always refer them back, but it is a funny game that we play. I'd rather not have my staff deal with any of the co-management paperwork, and just have the optometrist trust me that I'm going to send the patient back.

Actually, several of our local optometrists have straight-up told us that they will not refer to us for cataract surgery because of our optical. But since we like having "everything under one roof", we are not going to close the optical anytime soon!

Whether an ophthalmologist has an optical or not has little bearing on whether I'll refer to them. I use three different cataract groups and 2 out of the 3 of them have opticals.

This is what I expect from people that I refer to:

1) That they are good surgeons. Obviously, that goes without saying but let's be honest here....when it comes to cataracts, virtually all surgeons are good. There are very few cataract surgeons in my area who aren't good.

2) That they will refer the patients back. Obviously, that also goes without saying. Yes, yes....I get that once in a great while there will be a patient who wants to stay with a surgeon for whatever reason and if that's the case, fine. Keep the patient. But I expect a good faith effort in returning the patient. I don't want any ridiculous stories about how the patient was told they have some "unusual astigmatism" or a 0.4 C/D ratio and that they need to stay with the surgeon and oh yea, the surgeon should see the person's entire family too.

Believe me, we know which practices do this and oddly enough, they all seem to have opticals. That's the issue with that. It's not that the practice has an optical, it's that the practices with the opticals are much more likely to pull the "unusual astigmatism" crap-o-la. The ones I refer to that have opticals.....they DON'T pull it so I don't mind sending people there.

3) I expect them to refer patients to me. Referrals are not a one way street. You have some problematic contact lens patient? Please send them my way. If you have a bunch of ODs working for you, it's highly likely you'll steer those patients towards your own ODs so again....why am I referring to you if you're not referring to me?

4) That your office is nice, your staff is pleasant and that you run on time. I can't tell you how many times I hear from patients that a particular doctor was very nice but his receptionist was a monster (usually that means it's the doctors wife or girlfriend) or that they were kept waiting for 90 minutes. I can't have that. Again, I've spent a lot of time and money creating an upscale practice. I'm not going to refer to someone who's practice looks like a Motel 6.


I have no idea where you practice but.......let's play a game here......let's say I buy out an optometric practice in your city/town. Tell me why I should refer to you? Make your pitch.

 

[LightBox]

You can think I'm bluffing but why would I do that? I've been on this forum for years and years and there is no benefit to me to lie about this. $400 net collections is not a difficult goal to obtain if you can create an environment and an experience that makes people want to spend money with you. Believe you me, when I bought my practice 6 years ago, we were not near that mark. I do practice in the northeast where fees are a bit higher so that may account for some of it but we certainly do not "sell glasses to every patient who has an appointment with us" nor do we run "every diagnostic test under the sun." That is a losing proposition in the long run. We have spent a lot of time and resources towards creating that environment and experience.

$400 collections per patient encounter is very good I guess my point was is that you can't be doing $400 on the exam fees alone, so there must be product/retail revenue factored into there. I think the average collections (excluding optical/retail products) for general Ophthalmologists are ~$125-175 per encounter; retina is at least double that due to all of their diagnostic testing. How many encounters per hour are you doing? If all optometrists are making $400 collections per encounter, I'm not sure why they should be complaining at all! This is why owning an optical is a no-brainer for any practice -- whether it be O.D. or M.D.

In my experience, optometrists prefer to send to ophthalmologists without an optical, all other things being equal. Again, several of our local optometrists have told us bluntly to "get rid of your optical and we'll send you patients." But perhaps this is just an exception (doubt it).

Let's face it: the majority of people's motivations in the private practice world boil down to money. This is true for ophthalmologists, optometrists, and just about any other provider out there. If an optometrist considers all cataract surgeons to be "about the same", they are going to send to the practice that makes their bottom line fatter (e.g. one which doesn't steal optical sales from them).

 

[guttata]

I co-manage a little bit. Even with co-management, I see every post-op up until week one. I just feel more comfortable that way. But, I agree with Lightbox that it is a farce. The patient has the choice of seeing the surgeon or the referring provider in the post-operative period. However, everyone in the system creates the impression that the referring provider takes over care after the surgery. The surgeon bears the ultimate responsibility and malpractice, making it more difficult to release post-operative patients to other providers.

Honestly, the referring provider has it easy - collect 20% for minimal work (plus hundreds of more dollars for premium lens), while not bearing any malpractice risks, and having the ability to refer back to the surgeon when 'problems' arise. If it were up to me, I'd eliminate all co-management fees and have the patient sign an agreement that they will return to the referring provider (since 'losing patients' seems to be the major concern).

KHE, obviously you are very successful. However, it is impossible to generate $400 per encounter solely from medical fees. As Lightbox mentioned, most ophthalmologists generate $125-150 per patient, that includes ancillary testing. I guess if you were doing tons of contact lens exams, you could get up to $200/encounter. Besides materials, do you care to share what else you are doing to generate that number? Please don't tell me it partially involves the optos.

 

[PBEA]

I co-manage a little bit. Even with co-management, I see every post-op up until week one. I just feel more comfortable that way. But, I agree with Lightbox that it is a farce. The patient has the choice of seeing the surgeon or the referring provider in the post-operative period. However, everyone in the system creates the impression that the referring provider takes over care after the surgery. The surgeon bears the ultimate responsibility and malpractice, making it more difficult to release post-operative patients to other providers.

Honestly, the referring provider has it easy - collect 20% for minimal work (plus hundreds of more dollars for premium lens), while not bearing any malpractice risks, and having the ability to refer back to the surgeon when 'problems' arise. If it were up to me, I'd eliminate all co-management fees and have the patient sign an agreement that they will return to the referring provider (since 'losing patients' seems to be the major concern).

KHE, obviously you are very successful. However, it is impossible to generate $400 per encounter solely from medical fees. As Lightbox mentioned, most ophthalmologists generate $125-150 per patient, that includes ancillary testing. I guess if you were doing tons of contact lens exams, you could get up to $200/encounter. Besides materials, do you care to share what else you are doing to generate that number? Please don't tell me it partially involves the optos.

ODs do have malpractice risk with comanagement, not sure why you say otherwise. Comanagement has got to be the biggest red herring I've ever heard of. On one hand MDs make these claims of blackmailing and poor clinical work by ODs, and on the other hand ODs sees multiple post op visits for relatively little reimbursement, probably does so because the SURGEON solicited such an arrangement in the first place, and the OD can probably count on one hand how many medical cases (glc, diabetes, serious infections) that have gone wrong due to their presumed "mismanagement" in the last 20 yrs. As well, I experience similar things as KHE, the MD now arranges for f/u on pt's ad infinitum for dry amd, borderline glc, diabetes, dry eye, etc. Add in an MD optical (something I don't personally deal with) and MD's want to make claims about "OD's diverting pts"...come on already ....surely the emperor has no clothes on.

Ideally the agreement you mention should work but with the above reality it's easy to see why it wouldn't....or doesn't. As mentioned these issues are driven not out of some concern for "pt welfare" so often the rallying cry for MD's, but instead because of one of the usual suspects (money...pride....power). Fortunately many pts that experience the MD full court press resist the innuendo and return to me. Thank heaven for the little things.

 

[KHE]

$400 collections per patient encounter is very good I guess my point was is that you can't be doing $400 on the exam fees alone, so there must be product/retail revenue factored into there. I think the average collections (excluding optical/retail products) for general Ophthalmologists are ~$125-175 per encounter; retina is at least double that due to all of their diagnostic testing. How many encounters per hour are you doing? If all optometrists are making $400 collections per encounter, I'm not sure why they should be complaining at all! This is why owning an optical is a no-brainer for any practice -- whether it be O.D. or M.D.

Well of course it is everything included. I am not getting paid $400 for an exam by medicare or any of the other insurance plans. I see 4 patients per hour.

In my experience, optometrists prefer to send to ophthalmologists without an optical, all other things being equal. Again, several of our local optometrists have told us bluntly to "get rid of your optical and we'll send you patients." But perhaps this is just an exception (doubt it).

All other things being equal, it's probably true. But rarely are all other things equal.

As I asked before.....as an optometrist, why do I want to refer patients to you and/or your practice?

Let's face it: the majority of people's motivations in the private practice world boil down to money. This is true for ophthalmologists, optometrists, and just about any other provider out there. If an optometrist considers all cataract surgeons to be "about the same", they are going to send to the practice that makes their bottom line fatter (e.g. one which doesn't steal optical sales from them).

As I said before, it's far more than optical sales. It's not as if post op cataract patients spend hundreds and hundreds of dollars on stylish frames and lenses. Most of them anyways. Most are content with the "Walmart special."

 

[KHE]

KHE, obviously you are very successful. However, it is impossible to generate $400 per encounter solely from medical fees. As Lightbox mentioned, most ophthalmologists generate $125-150 per patient, that includes ancillary testing. I guess if you were doing tons of contact lens exams, you could get up to $200/encounter. Besides materials, do you care to share what else you are doing to generate that number? Please don't tell me it partially involves the optos.

I never once claimed that it was from medical fees alone. It's the totality of everything.

BTW, contact lens fees account for a much higher increase in revenue than an average of $50. If you are doing contact lenses and those patients only give you an average increase of $50, you've got a problem.

We do not have an optos in the office.

If you're truly interested in what we do, send me a PM with a specific question.

 

[LightBox]

Well of course it is everything included. I am not getting paid $400 for an exam by medicare or any of the other insurance plans. I see 4 patients per hour.

That's pretty amazing. Let's say $400/patient * 4 patients/hour * 7 hours/day * 5 days/week * 49 weeks/year = ~2.7 M / year in collections.

Let's say overhead is 70%, then you are taking home ~800k/year! That's the most I've heard an optometrist make in a long time. All the doom-and-gloom I hear among Optometrists seems kind of overblown when I hear your practice situation. You should be pumping the Optometry students up on their forum with these numbers.

 

[east]

That's pretty amazing. Let's say $400/patient * 4 patients/hour * 7 hours/day * 5 days/week * 49 weeks/year = ~2.7 M / year in collections.

Let's say overhead is 70%, then you are taking home ~800k/year! That's the most I've heard an optometrist make in a long time. All the doom-and-gloom I hear among Optometrists seems kind of overblown when I hear your practice situation. You should be pumping the Optometry students up on their forum with these numbers.

It is pretty amazing, good for you KHE. I thought I was doing well. I see 25 pts/day and average $6000ish a day in gross charges minus insurance and other adjustments. It works out to somewhere around $250 per pt. gross charges minus insurance adjustments from usual and customary (this includes materials as well).

This is the exception not the rule, so we're surely not gonna go out and get a bunch of ODs to be excited about outliers. I'm only responding to this cause I detect disbelief, but what KHE says is possible, albeit way outside the "norms".

It's funny how when the money is good none of this seems to matter much. Problem is, there are too many of us on both sides, and the money just isn't there. As always follow the money on both sides. "Co-management" included.

 

[KHE]

That's pretty amazing. Let's say $400/patient * 4 patients/hour * 7 hours/day * 5 days/week * 49 weeks/year = ~2.7 M / year in collections.

Let's say overhead is 70%, then you are taking home ~800k/year! That's the most I've heard an optometrist make in a long time. All the doom-and-gloom I hear among Optometrists seems kind of overblown when I hear your practice situation. You should be pumping the Optometry students up on their forum with these numbers.

Not every appointment slot is a comprehensive exam. I do not see 4 comprehensive exams an hour.

I also do not work 7 hours a day nor do I work 5 days a week.

What I make is between my accountant and me. And I guess my wife. But when I see some of the numbers being thrown around on this forum for what the average compensation is for a comprehensive ophthalmologist....well.....I'm glad I'm an optometrist.

 

[LightBox]

Not every appointment slot is a comprehensive exam. I do not see 4 comprehensive exams an hour.

I also do not work 7 hours a day nor do I work 5 days a week.

What I make is between my accountant and me. And I guess my wife. But when I see some of the numbers being thrown around on this forum for what the average compensation is for a comprehensive ophthalmologist....well.....I'm glad I'm an optometrist.

Most of those crappy salaries you see are starting associate salaries and definitely do NOT reflect what many partners make. I personally know practices where all of the partners make in the 7 digits or close to it These partners are probably the OMD version of KHE (I.e. >90th percentile). They don't talk about it too much because nothing breeds resentment more than financial success.

So if money is what you are after, then know that the opportunity still exists. To be honest, these forums are mainly filled with residents and fellows and maybe a few young attendings. There aren't many mid-career OMDs on here.

 

[KHE]

Most of those crappy salaries you see are starting associate salaries and definitely do NOT reflect what many partners make. I personally know practices where all of the partners make in the 7 digits or close to it These partners are probably the OMD version of KHE (I.e. >90th percentile). They don't talk about it too much because nothing breeds resentment more than financial success.

So if money is what you are after, then know that the opportunity still exists. To be honest, these forums are mainly filled with residents and fellows and maybe a few young attendings. There aren't many mid-career OMDs on here.

I was not referring to starting salaries. I was referring to average salaries for all comprehensive ophthalmologists.

But I didn't want to make this thread about me. The tacit implication of the original posting and some of the followups was that optometrists try to force surgeons into comanagement relationships because the optometrist just wants the money.

My point was that whatever money is involved certainly does not come from providing the comanagement service and in fact, comanagement is frequently a money LOSING proposition for the optometrist.