Retinal Photos

[sharpstick777]

We dont charge anyone for retinal photos, its part of our comprehensive exam. In those cases where there is a billable pathology (diabetic retinopothy, macular pucker, etc) we do bill the photos to the medical insurance.

[HarryChiling]

Harry:
In addittion to allowing a good view of the retina, dillation keeps them from over minusing the patient.

Very true, latent hyperopes and what not, but todays optometrists sees accurate refractions as a hindrance to their medical based practices. I find it funny especially since I turn down a free refraction and drive to a doctor 50+ miles away (oh and so does my wife), because he is a skilled refractionist. I think most ODs do better when they practice as over skilled opticians than under skilled ophthalmologists, it's a cup half full or half empty thing.

[fjpod]

I could see where your going with that and it might be vaild to a degree, but keep in mind like many of your peers have said before we are in retail and you are psuedo medical, so you have a responsibility to do, "what's right for the patient", but with that said the equipment wouldn't have been purchased if it wasn't a good tool to offer your patients so it a case of which came first the chiken or the egg. I think it's a luxury to have a retinal camera in the office since data gained from a retinal camera could be obtained from actually looking with the naked eye, although it does offer a way to see subtle changes over time that could be missed without. Is it absolutely necessary, NO does it make money and offer a good revenue stream, YES otherwise we wouldn't have one in the office.

I agree wholeheartedly with the first half of what you said, and partially agree with the last half. I too thought a fundus camera was a luxury before I got one. And you're right, we don't often buy things that we know are going to lose money (whether they be frames or diagnostic instruments), but...this new camera is pretty amazing, even to a jaded old-timer like me. It does pick up subleteies (sp?...but I know u won't mind) that you cannot see any other way. For example, one can see the reflex of the flash off the papilo-macular bundle of retinal nerve fibers. If it is missing in one arc, or missing in one eye, it is an early warning indicator of glaucoma. I could give you several other examples. It's not just for documenting change over time.

[chip anderson]

Harry:

Keep this up and you are going to have as many OD's PO'd as I do.

Chip

[orangezero]

The vascular lab near my office gives away a free carotid screening, then charges thousands for the full workup when needed. Same machine, very similar results. The full workup provides some additional information and an interpretation by the doctor. I do not see many in the medical community complaining about this strategy, and I see very few insurance companies who are up in arms about it (but then again I'm not sure I'd be exposed to it). Would the insurance company be "upset" and cause a stink if they charged $15 for the screening? Not sure.

Another important fact worth mentioning is that even with non-myd cameras you are often able to get much better fundus photos after the patient is dilated. It also takes less time in many instances.

Most doctors provide a photo form for the patient to read (and perhaps sign) at check-in. The problem with this is that we could literally have the patient read a 15 page pamphlet on everything we feel is important before the exam, so you have to prioritize or patients just gloss over after three or four sentences (written or verbal). You could pay a lot for the videos which showcase retinal photography in the waiting room.

I often point out when showing the photographs to patients the black circle surrounding the photo is the area we often cannot see until their eyes are dilated, which is an interesting way of using photos to highlight the necessity of ongoing dilation. Saying photos are a partial replacement for dilation is somewhat like having a mechanic check one car tires and saying, "well, its better we checked one tire than none of them." They want to know if their car can drive, not that one part of their car is good, especially if they are coming in for routine maintenance. You'd be doing a disservice to your patients to leave them with the idea that photos are (even a partial) replacement for dilation, and be silly to put it in writing for all of them to see.

I'm of the opinion that it should not be given away for free or thrown in with the exam, but can understand the reasoning behind why some do.

[fjpod]

Harry:
In addittion to allowing a good view of the retina, dillation keeps them from over minusing the patient.

Not really. There are many ways to prevent over-minusing without using dilating drugs.

[fjpod]

Harry:

Keep this up and you are going to have as many OD's PO'd as I do.

Chip

POd...is that a new degree...can I get one...will it make me more like an OMd? What does it stand for? "perfect doctor of optometry"?

[fjpod]

I think most ODs do better when they practice as over skilled opticians than under skilled ophthalmologists, it's a cup half full or half empty thing.

A little too much of a generalization, I think. If opticians got refracting, they wouldn't be optometrists, would they?...by today's standards. They would be refracting opticians. So opticians are really not trying to become optometrists. And so, optometrists are not trying to become ophthalmologists...as they are defined today.

Anything more that I say now will seem self-serving. Maybe I am being too idealogical.

[chip anderson]

Fjpod:

I'd tell you what PO'd is if you accepted private messages or E. Mails. I am always willing to contribute to the elemetal education of O.D's when I can. But as it is my hands are tied and you will have to learn this from one of your fellow's who paid attention in life.

Chip

[HarryChiling]

A little too much of a generalization, I think. If opticians got refracting, they wouldn't be optometrists, would they?...by today's standards. They would be refracting opticians. So opticians are really not trying to become optometrists. And so, optometrists are not trying to become ophthalmologists...as they are defined today.

Anything more that I say now will seem self-serving. Maybe I am being too idealogical.

I get what your saying, the idea I was trying to portray is most patients at least in my neck of the woods prefer their OD's with better refracting and optics based skills. If that weren't true OD's wouldn't need refractions or have dispensaries in their offices. It's not something to be ashamed of as I think a lot of the newer graduates seem to be, it's a noble past that most seem to be trying to escape. Sure there are many that break the mold with VT or LV practices, but they are not the norm and don't represent the general populace.

[fjpod]

I get what your saying, the idea I was trying to portray is most patients at least in my neck of the woods prefer their OD's with better refracting and optics based skills. If that weren't true OD's wouldn't need refractions or have dispensaries in their offices. It's not something to be ashamed of as I think a lot of the newer graduates seem to be, it's a noble past that most seem to be trying to escape. Sure there are many that break the mold with VT or LV practices, but they are not the norm and don't represent the general populace.

Agreed.

[fjpod]

Fjpod:

I'd tell you what PO'd is if you accepted private messages or E. Mails. I am always willing to contribute to the elemetal education of O.D's when I can. But as it is my hands are tied and you will have to learn this from one of your fellow's who paid attention in life.

Chip

Chip, I know what it stands for, for cryin' out loud. (and I know that you know that I know). I'm just joshin' ya. But thanks for the offer for a free educamication.

[Hev]

We have always done retinal imaging as part of the examination at no charge.

Where I used to work, retinal imaging was relatively new at the time. The receptionist used to plant the seed. While confirming their details, she would ask the patient if they were interested in a new piece of equipment that we had. She explained that it would take an image of the back of the eye and allow us to get a better look at the general health of the eye. We would then store it and it would give us a reference for future images. By the time the patient went through to the test room, the seed had been firmly planted. We got around 70% uptake on the imaging.....at the time, we charge £15 (around $21).

As of the 1st April, our NHS (only in Scotland!) pays for retinal imaging to be done as part of the test for over 60's.....we already got grants from the NHS in order to make sure that each practice had the appropriate equipment in preparation for the new legislation.

Hev x

[OHPNTZ]

Very true, latent hyperopes and what not, but todays optometrists sees accurate refractions as a hindrance to their medical based practices. I find it funny especially since I turn down a free refraction and drive to a doctor 50+ miles away (oh and so does my wife), because he is a skilled refractionist. I think most ODs do better when they practice as over skilled opticians than under skilled ophthalmologists, it's a cup half full or half empty thing.

Are the refractions that far off in a 50 mile radius??? I would say that most of the poor refractions are done in a retail (ie crafters, best of america, etc...).

[chip anderson]

Fjp:

You spoiled it all, you were supposed to come back with an offended and offensive defense so I could come back and say: "I got you PO'd now do you understand?"
O' well nothing gained.

Chip

[Uncle Double]

Are the refractions that far off in a 50 mile radius??? I would say that most of the poor refractions are done in a retail (ie crafters, best of america, etc...).

Wow, really? Is that where you work? :hammer::finger: I would say poor refractions can be had anywhere and by anyone (any of the three O's, or any technician that is allowed to perform them). While I would love to think all commercial OD's suck and private OD's never make mistakes, we all know there are other reasons to go into a commercial practice than the doctors ability to refract or Dx pathology. Can't we all just get along?:D

[HarryChiling]

Are the refractions that far off in a 50 mile radius??? I would say that most of the poor refractions are done in a retail (ie crafters, best of america, etc...).

I work in a Pearle Vision, what do you think of the refractions and eye wear made out of a Pearle Vision?

I bet you have a dispensary, if I said retailers make better glasses than independents if we were comparing the glasses made out of our shops then I would be correct.

That kind of generalization only hurts your business when your trying to make decisions based on your competition. So with that said, "YOUR RIGHT, KEEP THINKING LIKE THAT AND THEN COME BACK AND COMPLAIN HERE WHEN YOU THINK GOVERNMENT CHEESE IS EXPENSIVE".

Lets do better in 2009 and shed the generalization and figure out how to exploit our competitions true weaknesses.

[HarryChiling]

Wow, really? Is that where you work? :hammer::finger: I would say poor refractions can be had anywhere and by anyone (any of the three O's, or any technician that is allowed to perform them). While I would love to think all commercial OD's suck and private OD's never make mistakes, we all know there are other reasons to go into a commercial practice than the doctors ability to refract or Dx pathology. Can't we all just get along?:D

Great posts, I think that the attitude of us vs them is getting to a feverish pitch and you can see how many companies are even exploiting it.

For instance Varliux won't sell retailers their blanks so the large retailers have to buy hem finished and mark them up exorbitantly to make the same profits as they can on other brands of progressives so for years independents have sold their lenses at a premium since the competition can't compete. At the same time the company selling them offers a 1980's design at 3 times what I can pay for a 2000 design and still many people think it's better.

A contact lens company C*Vue was built on the tag line supporting independents, their model revolved around selling old technology lenses to independent practices since many of the online retailers couldn't acquire the lenses until a few years ago.

The examples can go on and on and on and on, throw these guys a loop in 2009 and change your way of thinking. So in 2009 without changing a thing just the mentality you can prosper for instance when a patient refuses DFE then insist they get photo's and charge an additional fee for them. Instead of looking at it as the photo's being an alternative to DFE think of it as a way of coaxing your patients into a DFE or paying for additional services. The patient wants the convenience of a non dilated exam then they pay for more services. If you think about it your liability goes up since the possibility of missing something is higher yet your paid the same for the exam without dilation, the photo's can be a way of reducing your liability, especially if they come back in the next year and theirs something horrifically wrong with their eye's then you have documentation that the eye was quiet when they skipped dilation.

[chip anderson]

Back to the origional subject, doesn't almost everyone agree that a great deal of the excessive cost of medical care stem from costo of un-necessary tests and records. While much of this stems from doctors attempting to protect themselves from lawyers, here we are talking about doing same just to increase the bottom line. Many of the posters opinions here seem to be that nothing can be seen that they cannot find with a thourough exam.
Of course if abnormality is observed and records should be kept for future reference and conferences with collegues, the rest are just to pay for the damn machine. I really doubt if most of these films are ever viewed on patients found to be without pathology.
Now where does this put us?
Also reminds me when patients with retinal troubles were sent to Alice McPherson, left seening 20/80 came back 20/30 which they continued to do until they died of old age. Then they started being sent to Memphis and New Orleans (after all they had excellent reputations for thier heart repair there) and came back seeing 20/80. Of course those that went to Memphis and New Orleans came back bragging about the wonderful facilities and the hundreds of pictures of the retina they took. And yet, they still saw 20/80.

Chip

[fjpod]

Fjp:

You spoiled it all, you were supposed to come back with an offended and offensive defense so I could come back and say: "I got you PO'd now do you understand?"
O' well nothing gained.

Chip

I don't mean to be defensive here, but could you explain what you mean by an offended offensive defense? Is that a football thing? C'mon man. Help me out.

[OHPNTZ]

I work in a Pearle Vision, what do you think of the refractions and eye wear made out of a Pearle Vision?

I bet you have a dispensary, if I said retailers make better glasses than independents if we were comparing the glasses made out of our shops then I would be correct.

That kind of generalization only hurts your business when your trying to make decisions based on your competition. So with that said, "YOUR RIGHT, KEEP THINKING LIKE THAT AND THEN COME BACK AND COMPLAIN HERE WHEN YOU THINK GOVERNMENT CHEESE IS EXPENSIVE".

Lets do better in 2009 and shed the generalization and figure out how to exploit our competitions true weaknesses.

Harry,

What generalization are you referring to? I'm not sure I'm following your logic...

I think that "retail" refractions are sometimes not the best, usually because exams are based on volume. I have friends who work for "the best in america" and 5 minute EXAMS (not just refractions) are the norm I have filled in at Walmart and Lenscrafters...I see the charts AND the schedules. Now you agree with me right??? (That's why you refuse to have your exams at your Pearle?)

Now for the patients who are chronic refusers of dilation, and require photos...I think these retail areas attract these types of patients. I have had quite a few where you tell them they need such and such treatment or they will lose vision, and all they want are glasses or contacts...

Where I am now, I have few patients who refuse dilation...

[HarryChiling]

Back to the origional subject, doesn't almost everyone agree that a great deal of the excessive cost of medical care stem from costo of un-necessary tests and records. While much of this stems from doctors attempting to protect themselves from lawyers, here we are talking about doing same just to increase the bottom line. Many of the posters opinions here seem to be that nothing can be seen that they cannot find with a thourough exam.
Of course if abnormality is observed and records should be kept for future reference and conferences with collegues, the rest are just to pay for the damn machine. I really doubt if most of these films are ever viewed on patients found to be without pathology.
Now where does this put us?
Also reminds me when patients with retinal troubles were sent to Alice McPherson, left seening 20/80 came back 20/30 which they continued to do until they died of old age. Then they started being sent to Memphis and New Orleans (after all they had excellent reputations for thier heart repair there) and came back seeing 20/80. Of course those that went to Memphis and New Orleans came back bragging about the wonderful facilities and the hundreds of pictures of the retina they took. And yet, they still saw 20/80.

Chip

Yup, health care in this country sucks. The doctors and care providers need to make money to make a living. The insurance companies need to take money from the patient and give a percentage to the doctors and care givers to make money. The insurance companies need raises so they raise premiums until the premium can't really go any higher, then they lower reimbursements until they can't go any lower. So the doctors perform more procedures to get a fair compensation, but then everyone complains that the tests are unnecessary, but theirs no other choice than to maximize the profits per patient. I hate to say it, but patient care and health care as a business don't mesh so as long as patients keep purchasing insurance plan then the system will continue to move more to wards a business. Can't have your cake and eat it too. That creates a niche for premium patient care and that's already be exploited by doctors that are starting practices that see patients only if they pay a sort of subscription, so they take their money upfront.

[HarryChiling]

Harry,

What generalization are you referring to? I'm not sure I'm following your logic...

I think that "retail" refractions are sometimes not the best, usually because exams are based on volume. I have friends who work for "the best in america" and 5 minute EXAMS (not just refractions) are the norm I have filled in at Walmart and Lenscrafters...I see the charts AND the schedules. Now you agree with me right??? (That's why you refuse to have your exams at your Pearle?)

Now for the patients who are chronic refusers of dilation, and require photos...I think these retail areas attract these types of patients. I have had quite a few where you tell them they need such and such treatment or they will lose vision, and all they want are glasses or contacts...

Where I am now, I have few patients who refuse dilation...

OK that's like me naming the worst independent practice in America and judging you all by that barometer. America's Best is the LCD in retail, so they are not the norm they are the bottom of the barrel, we should all be so lucky to have them as our only competition.

I refuse to have my exams Deon at a Pearle, yes; but I go to a Four Eyes, because that doctor is the best I have encountered. He's considered retail, but he's also the owner of the doctors side and decides how his practice is run. They're not all like you describe, just the bad ones. Plus whens the last time anyone has told you of their good experiences in a retail optometry practice? Most independents don't even want to acknowledge that there is a such thing and many of the retail OD's that I know think that independent OD's have a stick up their buts and don't want to hear it, so you only get the bad because they know you'll listen and probably smile smugly inside when they talk about how bad it is.

All I'm saying is that their are two sides of every story and your generalization hurts you not me.

[fjpod]

I don't think you can generalize anything negative about refractions in a retail or big box setting. I'll bet most of them are better than those received from an OMD that does not have a dispensary.(not trying to disparage OMDs here. I can always do that later...:bbg:). The big box dispensary makes a living out of refracting and selling glasses that don't come back. Too many remakes and the OD gets the boot. Now their comprehensive eye exams...there you may find a hole.

[MarcE]

doesn't almost everyone agree that a great deal of the excessive cost of medical care stem from costo of un-necessary tests and records. Chip

I think that the excessive cost of kitchen remodeling stems from the cost of un-necessary granite countertops.

Some people are willing to pay for what they precieve is better. People drive Mercedes and have granite countertops. I don't agree that they are superior than other equally functional cars and countertops. But it's not for me to judge the consumer or the Mercedes dealer.

Offering retinal photos has been a boon for our business. We offer this as an added service. Our patients are impressed and often tell friends and relatives. Do we get rich? No. But the retinal camera would be losing money if we were just using it for "billable" conditions. About 50% of the comprehensive exams opt for this added service.

BTW, offering retinal photos as a screening is perfectable acceptable. There is a technical component (the photo) and a professional component (the Drs impression and written report) for most ancillary testing, including 92250. The screening is only for technical component.