Is this Ethical.. part II?

[Jubilee]

As a continuation, but slightly different theme about contact lenses, I have a question for you cl prescribers.

You have a new patient that currently wears contact lenses. At the initial exam, you notice a good amount (grade 2) neovascularization. Eyes are red, and the overall impression is that the contacts he is wearing are not a healthy match for his eye needs. Trial lens him in a higher oxygen permeability lens (silicone hydrogel) and the fit is perfect, acuties better than old kind, and patient "loves" the lens.

However, the new lens cost 2x as much as the old school biomedics 55. He is not planning on purchasing contacts through us. He is wanting to purchase through 1-800, so we don't have a strict financial interest in the actual purchase of CLs. He is demanding we keep him in the current Biomedics for a strictly financial reason. We don't feel comfortable with this since there is the signs of corneal damage and gross overwear.

Would you try to find a different lens that might be a bit healthier, but less expensive than the one brand? Would you give him a strong warning, have him sign a waiver stating you are not responsible for the damage and release the rx for the biomedics? Would you stand your ground and state they "have" to change brands if they want the doc to sign off on the rx?

When a patient comes utilizing insurance for the exam, would you charge a fee on top of the exam fee for "corneal evaluation" or "verfying the fit" even if they don't change anything about their previously prescribed (but not by you) lenses?

Cassandra

[fjpod]

Before I automatically refit into a higher O2 lens, I would try to detrmine if the patient is compliant with a healthy CL wear schedule, lens hygiene, and lens and case replacement schedule. If they are non-compliant, but happy in their existing lenses, I make them read and sign a CL instruction sheet that outlines all the above. They are re-taught everything as if they were a new patient. I make them swear that they will comply. I would take anterior seg photos to show the patient what I am talking about. I would limit the Rx in this case to six months, and inform the patient that he must be re-examined before refilling the Rx. I also emphasixe to the patient that they have a good pair of glasses for evening and/or weekend use, as patients without glasses, are the ones who overwear their CLs.

If the patient reports compliance (to the best of my ability to discern it), then I would fit with a high O2 lens as they obviously need it. I would not give the option to stay in the old lens even if they signed a form acknowledging that I said they should get the higher O2 lens...because then I am admitting that I gave the patient a sub-standard lens...

As far as charging extra...it depends on the plan. If the plan pays extra for a CL fit then no, I don't charge extra.

[chip anderson]

After advising the patient of his problems, tell the patient: If you are not going to follow my advise, and stay under my supervision you gonna git your Rx and your lenses somewhere else.
Higher O2 might or might not be the regimen I would choose for "treatment." And I surely would not base intended "treatment results" on a single trial lens observation. Would continue following patient with whatever treatment until condition cleared and at least ever six-months thereafter.
Now where does ethics come into this?
And fees sound like a routine exam fee to me. You can't tack on something extra for everything you see especially if the condition is something that should be checked for and found on every exam. Although this does seem to be a new trend with today's doctors.

[fjpod]

The extra fee is for evaluating the fit and teaching the patient proper CL care and handling. For demonstrating and explaining why CLs can be dangerous. For documenting CL complications. These services are not part of a routine eye exam, whether you are a doctor or not.

(I see you did it again, Chip. Congratulations, you managed to hijack the thread on the second post.) The ethics question was whether you allow a patient with corneal complications to have what he wants, even though it might be dangerous. It was not whether today's doctors can or should charge for services over and above a routine eye exam...and I assume you mean that today's doctors are not real doctors in your opinion.

Am I correct Jubilee about the ethics question?

[Jubilee]

fjpod is correct..

The ethics portion is in regards to whether to write the rx for what the patient wants, not what the doc would believe to be healthiest.

The guy plans on using his amterials benefit towards the purchase of a new pair of glasses. However, he feels that he will still wear cls 90% of the time due to his coaching schedule.

In our office, we typically charge a one time fit fee for either being new to cls, new type of fit (sv to mono), or new brand. We don't charge extra everytime just for having contacts...

For what it is worth Chip, my doc is old school. He is a contact lens specialist, and does take cls seriously. He has been practicing longer than I have been alive. However, it is rare that we can not convence the patient to go with what is heathier.


Cassandra

[ziggy]

After advising the patient of his problems, tell the patient: If you are not going to follow my advise, and stay under my supervision you gonna git your Rx and your lenses somewhere else.

I fully agree. this IS true ethics.

[Andrew Weiss]

Before I automatically refit into a higher O2 lens, I would try to detrmine if the patient is compliant with a healthy CL wear schedule, lens hygiene, and lens and case replacement schedule. If they are non-compliant, but happy in their existing lenses, I make them read and sign a CL instruction sheet that outlines all the above. They are re-taught everything as if they were a new patient. I make them swear that they will comply. I would take anterior seg photos to show the patient what I am talking about. I would limit the Rx in this case to six months, and inform the patient that he must be re-examined before refilling the Rx. I also emphasixe to the patient that they have a good pair of glasses for evening and/or weekend use, as patients without glasses, are the ones who overwear their CLs.

If the patient reports compliance (to the best of my ability to discern it), then I would fit with a high O2 lens as they obviously need it. I would not give the option to stay in the old lens even if they signed a form acknowledging that I said they should get the higher O2 lens...because then I am admitting that I gave the patient a sub-standard lens...

I agree.

Depending on the severity of neovascularization, I might also recommend or even require a brief period of no-CL-wear to let the eyes recover (anywhere from a few weeks to a couple of months).

[Jubilee]

Currently we are thinking of an alternative. There is a higher 02 lens that is less expensive for a year's supply than the original one we were recommending. Not as great as the original one, but a better candidate than the one he is wearing. His cost would still be $40 more than his current brand, but considerably less than the other.


I am just getting really aggravated with our cl patients. Called another this morning to let her know that we had in a set of trials for a new fit. She wanted to go from wearing a clear lens to a colored contact.

Last year we recommended her to go with a higher 02 lens due to neovascularization. (she was a new patient at this time) Instructed her on proper care again, she chose a pair of glasses for off contact times, and a year later, her eyes are looking much healthier. Now she is wanting to go back to colors. She has really flat K readings, and we took a week finding her a colored lens that comes in a variety of colors (since this is a priority for her) and has a flat BC (8.9 or 9.1)

She asked when I called to set a dispense and follow up if there will be a fee involved. I explained that since we were fitting her with a new type/brand of lens, yes there was. She said it wasn't her fault that we didn't have a colored pair for her to try on during her visit. I explained that the fee was for the fit, not the inventory issues. The fee is to cover the cost associated with the extra testing and time it takes to evaluate the contact lens. The time portion is based on chair time, not the time it takes to order trials, have them shipped etc. It is strictly on the amount of time spent with the doctor and the assesment for the lens.

She told me that there shouldn't be a charge, since she wanted colored lenses last year, and that it isn't her fault we pushed a lens on her that didn't come in colors. I explained that last year, on her initial visit that she had signs of gross overwear and admitted to wearing a 2 week lens for 2-3 months at a time. Due to the damage that was caused to her corneas for this abuse, we had to recommend a higher oxygen lens for health reasons. Had our Dr not done this, she may not be able to wear colored lenses now due to the additional damage her eyes would have received. Unfortunately they don't make colored lenses in her curvature in the higher oxygen materials.

Not her fault, completely ours.. she should not be having to pay for the additional time or materials. No one has ever bother with her "curvatures" worried about corneal damage, etc in the past. So we must be making this up!

I asked her which was better, wanting to take her money regardless of eye health, or wanting what would be best for long term health. She said she wanted someone who would give her the lenses she wants, without all the bull crap. I told her I would be more than happy to fax/send copies of her records to whomever she felt fit the bill.

Why do people not care.. maybe I oughta have them read some postings on the Prevent Blindness Acanthamoeba Keratitis forum or something to make them understand...


Cassandra

[Andrew Weiss]

Cassandra, sounds like your patient is "Queen of de Nile" ;)

You are definitely better off without her. I also feel really badly for the office which inherits her.

[ziggy]

You cant make them understand, you need two new words in your vocabulary, "GET OUT". My contact lens patients wear the lens the way I want or they go elsewhere. and while I'm at it, selling your patients anything less than a years supply is doing a disservice to those patients. For those who say "I cant afford a years supply " then they should be told that they cant afford to wear any contacts.

[Fezz]

selling your patients anything less than a years supply is doing a disservice to those patients. For those who say "I cant afford a years supply " then they should be told that they cant afford to wear any contacts.

Paul,
I agree 100% I try to get our staff and Docs to sell the yearly supply. They rarely do. It saves us and the patients money and time. Its way convienent for all involved.


:cheers::cheers::cheers:

[drk]

Fun thread, Cassandra!

Firstly, after years of experience, I have come to a few conclusions I'd be happy to share.

1.) CL patients are really a special breed . They have a true sense of "entitlement" to their CL wear. They are oftentimes ridiculously irresponsible. They generally have little appreciation of the risks inheirent with CL wear, nor the skill and care needed for them to remain successful wearers. They are generally the biggest bunch of PIA's we can deal with.

2.) While in reality intermediate, CLs are truly skewed more towards a drug than an optical device. Somehow, since "glasses and contacts" seem so analogous, and because historically, "originally non-medical" professionals (ODs and opticians) could prescribe them in the 60's and 70's, the FTC and the general population have seen contacts more like OTC readers than Rx drugs. The state prescription laws reflect this, unfortunately.

I truly advocate re-modeling our CL Rx laws to mirror pharmaceuticals more than spectacles. That will happen when hell freezes over or a state senator gets vision loss from ulcerative keratitis.

3.) As such, "true ethics" mandates that state-regulated, licensed professionals do WHAT'S RIGHT for the citizens they serve. That translates to being very receptive to patients' wants and needs, but being brutally frank about the fact that we exist to keep them safe, even from their own requests. Safety trumps financial consideration and patient desires, period. Just don't be a power-hungry control-freak about it, and always act in the true best interests of your patients for whom you work, and it will come across the way it is intended.

[opticalwoman]

Well, we have a couple of rules. We charge a fit/eval. for all contact lens wearers and that price is based on the type of contacts/script. The only time it is waived is if the patient falls under VSP's or Spectera's contact lens care program. Our doctor is usually pretty frugal when trying to keep the patient's cost down. (I however care more about the comfort and don't even consider price). If the patient choses to to go cheap, we do sign the contact lens verification form and stamp it "Our doctor has recommended a different contact lens for comfort and visual acuity for this patient. If the patient chooses to go with this brand, he does so at his own risk and with no responsibility falling on our office". We do the same for colored contact lenses and we post signs in our office saying such. We also do not give trial contact lenses to patients that do not purchase their contacts from us. Period. No exceptions.

[For-Life]

After advising the patient of his problems, tell the patient: If you are not going to follow my advise, and stay under my supervision you gonna git your Rx and your lenses somewhere else.

Agree. It would be unethical to keep him in biomedics.

[Jubilee]

Since this thread was brought back up..

We did convince this man to get the slightly better, slighty more expensive lens as a compromise. OF course he had no trouble paying $50 or more out of pocket for a designer frame...

Most of our contact lens patients are fantastic.. however it seems that 90% of our problem patients, are contact lens wearers.

Love the ones who never come back in to finalize fit. Sent letters, left a dozen phone messages, etc.. Then calls back 4-5 months down the line letting you know her 2 week lens trial has torn and she wants a new one...

*sigh*

[shanbaum]

Agree. It would be unethical to keep him in biomedics.

I don't think that it would be unethical to provide the patient with a prescription for what he wants rather than what a reasonable practitioner would conclude that he needs - unethical behavior usually involves a conflict of interest, which does not appear to be present here... unless, "keeping the patient" is seen as your interest in doing the wrong thing.

It would in any case, however, be malpractice.

[tigerlilly]

I had thought that a lot of our problems with CL wearers was due to them seeing us as a retail store there to keep them happy rather than as a doctor's office there to see to their healthcare. Now I see that they treat a "real" doctor's office the same way. I'm so disillusioned. :( Oh, the humanity.

My take is that a doctor prescribes what s/he feels is best for the patient's health, regardless of what the patient demands. Sometimes there's room for compromise, sometimes there's not. The patient can take the prescription as written by their doctor and either fill it or try to convince another doctor to give them what they want. They shouldn't be able to demand and get an RX for their chosen lens AMA.

[HarryChiling]

The idea of fitting lenses is to fit what gives good vision, and is the healthiest. If you already know that the lens he's currentyl wearing is either being overworn, or does not provide adequate vision then you can't continue to fit that lens especially if you've already tried another lensand seen improvements. Have them sign all the waivers they want it will not protect anyone from negligence.

Ultimately the patient had the choice of continuing to wear these lenses, when they wore them longer than prescribed and/or abused them they negated this lens as an option, it's not your responsibility to fit what he wants, if he don't get it, then he don't get it here is our policy.

[chip anderson]

Fjpod:
I ment that today's doctors feel that thier time and thier persona is far more valuable and important than the patient. This was not often the case a few decades ago.

Chip

[35oldguy]

Do as the Romans do! If you have taken your time to see the patient he has the responsibilty to pay you for your expertise regardless of the outcome.

Every time I go see my GP he sees me for about 5 minutes after I have waited for him for over thirty minutes, charges me $60 and does not bat an eye!

After advising the patient of his problems, tell the patient: If you are not going to follow my advise, and stay under my supervision you gonna git your Rx and your lenses somewhere else.
Higher O2 might or might not be the regimen I would choose for "treatment." And I surely would not base intended "treatment results" on a single trial lens observation. Would continue following patient with whatever treatment until condition cleared and at least ever six-months thereafter.
Now where does ethics come into this?
And fees sound like a routine exam fee to me. You can't tack on something extra for everything you see especially if the condition is something that should be checked for and found on every exam. Although this does seem to be a new trend with today's doctors.

[ikon44]

since we got our digital imaging system and can show people what they are doing to their corneas by overwear,we have had a much easier job persuading people to upgrade their lenses.

[HarryChiling]

since we got our digital imaging system and can show people what they are doing to their corneas by overwear,we have had a much easier job persuading people to upgrade their lenses.

Has it improved compliance?