Why Medical Management?

[Jubilee]

Lets keep this civil people...

In the now closed "Good Doctor" thread, some interesting points had been brought up about why todays ODs may need to be into medical management and the possible over-specialization of our OMD's. I wanted to go back to that conversation (not the blast "insert your opposing O here") and really think/move through this here...So I will repost the parts in that thread that I think were moving in this direction...

Originally posted by Jubilee

Maybe the reason more Optometrists are going towards Medical Management is because so many of the Ophthamologists are specializing and refuse to see patients without a referral and certain tests done prior.

On more than one occasion I have had patients showing signs of real ocular emergencies, and when trying to cut the chase and go for a straight referral (my doctor is one who doesn't get into treating more than allergies and simple infections) I was comfronted with people telling me that without a proper work up Mr/Mrs Smith will not be getting an appointment. Only after I did a full work up, including fields, photography, tomography etc would they see the patient. "We don't do work ups, we treat the patients with the actual problem"

Have a man being seen this AM with a history of Acute Glaucoma that basically destroyed his vision in the right eye a few years ago. (pressure 44!) Called with blood filling the eye yesterday... previous OMD refused to see him till we made sure it wasn't just a simple trauma and then if he was needing to be evaluated it would be a couple of days.. afterall we aren't talking of saving someone's sight since he is already blind in that eye...

So as far as I am concerned, I am happy that some ODs out there do embrace medical management and are willing to help, do the work ups and aid these people....

Harry followed up with his rational that part of this is due to the 3rd party insurances and the fact that ODs bill less that MDs...

Originally posted by HarryChilling

I have seen this trend here as well, the OMDs are trying to milk every patient for every possible diagnostic test whether needed or not. I have found that you can always justify a test and billing the most tests is how they get paid. It is actually becoming more and more difficult to get patients in to see OMDs, so then it has become a necessity for ODs to move towards medical management. Do you think that OMDs might one day specialize themselves into a corner?

I also think that HMOs have a great deal of meddling that has muddyed the waters. Lets face it ODs bill alot less than what an OMD is capable of billing for that same patient, so they are more likely to want to defer the primary care to an OD to cut costs, they can also defer the exam as routine and then it's the vision plan that covers it, not the health plan. I think this model is a cause for great strife in all facets of health care, not just eyecare. I have actually swithced gears from bashing ODs (sorry guys and gals, I know you'll miss me :D) to actually putting more bashing towards the insurance companies. It is getting to the point where enogh is enough. Me and my wife pay some pretty hefty premiums and I am sure most pay more than us, but for you pay into a system and what you get out their is some pretty big inconsistency. Maybe we should change insurance companies names to something that starts with an "O" so that we can start to see them who they really are, our worst competition. They take the eyecare dollars out of our patients pockets before they step into our stores and then further expect our stores to discount to their clients.

How do others out there feel? Is it the evil insurance empires following the premise of Michael Moore's Sicko, the natural evolution of the business (which means opticians will move into refracting) or something else?

Please once again.. keep this conversation civil and on track...

Cassandra

[Audiyoda]

My personal take is that ODs have seen the cash cow known as Medical Insurance. Medical pays more than Optical and you can do more (ie...more tests means more money).

The problem there is that ODs often are horrendous at Medical Management. Now don't tell them that - they think they're sheer genius's and can hang and bang with the best OMD out there. Problem is, they can't - Bottom line. I've been doing this gig of optical for almost 17 years - it's been within the last 4 or 5 that I've seen more mismanagement of patient wellbeing than I care to ever see. ODs went to school to learn to correct vision - that's it (to kep it simple). OMDs went to school (at least 4 years longer than the OD) to deal with medical conditions of the eye.

Now, has the poor mismanagement of patient's needs by ODs been caused by OMDs and their desire to co-manage? ODs maybe don't want to share in the wealth generated by this medical insurance cash cow. Or...are OMDs treading on the waters of the OD and the OD is fighting back by trying to manage the medical needs of their patients? Honestly, I think it's a bit of both.

Oh for the days when the 3 O's got along.

[chip anderson]

Audi: When was that (that the three O's got along)? Two of them did until one of them got greedy. I'll leave it to you which ones.

[drk]

Bullet-points of truth:

*Three O's never got along. OMDs just kept everyone in their place.

*The reason Optometry got into medicine is that there was a public health need.

*Most ODs cannot "bang" with the seasoned OMDs for the serious stuff, but most ODs now can provide very good medical care for basic conditions (which comprise 80% of most medical issues).

*How much eye care is being dispensed by family practitioners and ER docs? A WHOLE LOT. And, God bless them, they have the whole human body to deal with, so they only know the most basic stuff. Plus, they have not the instrumentation that ODs have.

*ODs are extremely accessible, even moreso than the family practitioner (unless you count the customary five minutes of phone examination, diagnosis, and treatment with a nurse).

*ODs providing medical care is good for OMDs: it keeps OMD offices unclogged so they can concentrate on their core competence.

*One OD = 70% of an OMD in medical usefulness

*One OD = 200% of a GP/Peds/ER doc in medical usefulness (ocular)

[shellrob]

My personal take is that ODs have seen the cash cow known as Medical Insurance. Medical pays more than Optical and you can do more (ie...more tests means more money).

The problem there is that ODs often are horrendous at Medical Management. Now don't tell them that - they think they're sheer genius's and can hang and bang with the best OMD out there. Problem is, they can't - Bottom line. I've been doing this gig of optical for almost 17 years - it's been within the last 4 or 5 that I've seen more mismanagement of patient wellbeing than I care to ever see. ODs went to school to learn to correct vision - that's it (to kep it simple). OMDs went to school (at least 4 years longer than the OD) to deal with medical conditions of the eye.

Now, has the poor mismanagement of patient's needs by ODs been caused by OMDs and their desire to co-manage? ODs maybe don't want to share in the wealth generated by this medical insurance cash cow. Or...are OMDs treading on the waters of the OD and the OD is fighting back by trying to manage the medical needs of their patients? Honestly, I think it's a bit of both.

Oh for the days when the 3 O's got along.

So much for keeping it nice huh. Going right to bashing the Optometrists. Gee wiz. I have worked for an Optometrist for almost 8 years now in private practice and 2 before that with a few others. I belive that Optometrists are underpaid to be honest. I know what they get paid for for an exams vs md's and it's ridiculous. I don't know about you guys, but my Optometrist does just as good as job as the surgeon next door if not better on eye exams. Now, he's not a surgeon but most people don't need a surgeon for routine exams. They just think because the doctor has md after his name, he must be better. The patients aren't educated properly to begin with. Most surgeons don't want to do the "routine" exams anymore anyhow, so it's up to educate the patients that they're Optometrist does just as good and thorough exam as they're Opthalmologist and that they can come here for they're "routine" exams.

[drk]

ODs went to school to learn to correct vision - that's it (to kep it simple). OMDs went to school (at least 4 years longer than the OD) to deal with medical conditions of the eye.

Get it right.

ODs went to OD school for four years to deal with the eye: visual science and medicine. About 50-50% when I went to school 20 yrs ago. Probably only 25% visual science, now!

OMDs went to med school for four years to qualify them to do absolutely nothing...MD degree is a very broad medical education but only a stepping stone! (Although I'd love to have such a broad knowledge base...)

Their residencies (the specialty of which they are assigned to and cannot choose freely: ophthalmology to proctology) is where they really learn their trade. In the case of ophthalmology, they spend three years as a resident learning eye stuff, including surgery. And they get thrown into the fire immediately! And it's a great education, no doubt...hospital-based, etc.

[Their ultimate level is fellowship training (which few do), where they hang out with a super-doc who teaches them all the stuff that's too advanced to be common, orthodox, didactic knowledge...cutting edge stuff. It's like mentoring.]

So, what's the modern day difference?

ODs: basic medical competence, specialty vision competence
OMDs: basic vision competence, specialty medical competence

You see, there's a large amount of overlap...OMDs can do most of the vision stuff, and we can do most of the medical stuff.

But I want to be clear: optometry is not equal to ophthalmology in medical knowledge and ability, for the really serious stuff, nor does optometry present itself that way.

Optometry is trying to be a basic eye care provider for all eye needs. The concept is a "family doctor for the eye".

[Audiyoda]

So much for keeping it nice huh. Going right to bashing the Optometrists. Gee wiz. I have worked for an Optometrist for almost 8 years now in private practice and 2 before that with a few others. I belive that Optometrists are underpaid to be honest. I know what they get paid for for an exams vs md's and it's ridiculous. I don't know about you guys, but my Optometrist does just as good as job as the surgeon next door if not better on eye exams. Now, he's not a surgeon but most people don't need a surgeon for routine exams. They just think because the doctor has md after his name, he must be better. The patients aren't educated properly to begin with. Most surgeons don't want to do the "routine" exams anymore anyhow, so it's up to educate the patients that they're Optometrist does just as good and thorough exam as they're Opthalmologist and that they can come here for they're "routine" exams.

I would expect the OD to do the better routine exam - that's their training.

[shellrob]

You must have had a bad experience with an Od. But to brand them all because of your experience is ignorrant.

[Audiyoda]

Get it right.

ODs went to OD school for four years to deal with the eye: visual science and medicine. About 50-50% when I went to school 20 yrs ago. Probably only 25% visual science, now!

OMDs went to med school for four years to qualify them to do absolutely nothing...MD degree is a very broad medical education but only a stepping stone! (Although I'd love to have such a broad knowledge base...)

Their residencies (the specialty of which they are assigned to and cannot choose freely: ophthalmology to proctology) is where they really learn their trade. In the case of ophthalmology, they spend three years as a resident learning eye stuff, including surgery. And they get thrown into the fire immediately! And it's a great education, no doubt...hospital-based, etc.

[Their ultimate level is fellowship training (which few do), where they hang out with a super-doc who teaches them all the stuff that's too advanced to be common, orthodox, didactic knowledge...cutting edge stuff. It's like mentoring.]

So, what's the modern day difference?

ODs: basic medical competence, specialty vision competence
OMDs: basic vision competence, specialty medical competence

You see, there's a large amount of overlap...OMDs can do most of the vision stuff, and we can do most of the medical stuff.

But I want to be clear: optometry is not equal to ophthalmology in medical knowledge and ability, for the really serious stuff, nor does optometry present itself that way.

Optometry is trying to be a basic eye care provider for all eye needs. The concept is a "family doctor for the eye".

As I said - "to keep it simple". Everyone here knows the training the ODs and OMDs go through - my entire point is that ODs and OMDs are treading on each others waters. And the problem is, some ODs and some OMDs don't know when to give up.

I'm not saying every OD is incompetent or incapable of medical diagnosis and treatment - my problem is when they know full well that they cannot treat a problem and they try to anyway. I know the limits of my skills - I know when to say I cannot make a repair or cannot make a modification without help from my lab. But when I see a patient continue for five weeks of treatment for herpes zoster without a IOP check only to be diagnosed with glaucoma a week later is scandalous. Goldman tono should have been mandatory - but the doc didn't want to make the patient uncomfortable. Now she's lost sight in that eye. To use your example - the family doctor would have referred the patient out immediately. But most of the family eyecare doctors that I have seen in this area have this feeling that they can handle just about anything this side of IOL replacement - and I'm not saying some can't - but I am saying that some simply cannot.

On the same note, I'm tired of seeing OMDs doing routine exams - they should have the cahones to refer patients to a OD for the simple fact that the exam will be better in most every way.

[Audiyoda]

You must have had a bad experience with an Od. But to brand them all because of your experience is ignorrant.

Not one, not two, but many. And only within the last 4 or 5 years - when medical management started to fall to ODs. I've heard far too many stories from colleagues about mismanagement to consider it a fluke. Of course I'm not saying that every OD is incapable - there are a number in this area that are stellar. But many are not - and as drk pointed out - ODs that were in school 25 years ago simply didn't get the training required. They've gotten by with CECs and think they're good to go. Unfortunately, those ODs that went to school 25 years ago are the ones with the well established practices and now their patients are coming to them expecting - as drk pointed out - a family doctor for the eye. But...some of those ODs cannot handle that need, but they certainly think they can especially when they see how lucrative billing medical can be.

So I think it's pretty darn ignorant of any doctor to go beyond their skillset. But since I'm an optician and I see the optical side of the medical arena, my focal bias it towards ODs/OMDs that go beyond their skillset and/or training.

[Audiyoda]

Audi: When was that (that the three O's got along)? Two of them did until one of them got greedy. I'll leave it to you which ones.

Personally Chip, I think all three have gotten greedy. LDOs refracting, ODs going beyond the scope of their medical training, OMDs butting in on routine exams...

[drk]

Really, the whole concept of "routine examination" is insurance-ese. What is really meant is "vision examination with health screening". OMDs can screen for eye health problems with the best of them. And your average vision care patient might do OK with ophthalmology, but when you factor in contact lens care, most vision care should be done with an optometrist, ergo most eye health screening.

As to herpes zoster ophthalmicus, sure, that's some serious stuff. Unless the OD had some serious training, I wouldn't touch it. I don't know that you'll find that most ODs, however, are cowboys. It is well-known that most are too conservative, which is fine.

[rep]

I would expect the OD to do the better routine exam - that's their training.

As an old school optician I once had some of the same attitudes set forth here regarding OD abilities to handle patient care. I was brought up in the world of ophthalmology and that was their mantra.

Then I had the opportunity for two week trips for ten years as part of a Tri O team working for the Foundation for International Eye Care in Micronesia. Needless to say I learned a lot and one of the things I learned was how well the OD we had with us handled major medical issues including infection management and control, glaucoma, and eye diseases that you only saw in books in the states. I set up a business with that OD later and we were very successful and that business is still flourishing, although I am no longer a principal.

His diagnostic and treatment skills were and are equal to any MD I had ever worked with. His refractive skills were superior to 75% of the MD's who's prescriptions I filled for 20 years.

Would I let this OD do cataract or lasik on me or mine - not a chance. But routine eye care absolutely.

OD's are just like Opticians and Ophthalmologist - there are good one's and not so good ones. I think a lot of it depends on the school they attend - This guy went to Berkley.

Until you have worked next to them for 10 years treating raging infections, rampant diseases and major health issues unrelated to the eyes but diagnosed during eye examinations - you need to withhold judgment on the professions as a whole because you really are not qualified to comment until you have.

Rep (and optician)

[Fezz]

I wonder if Dentists, Dental Hygeinist, and Orthodontists have a place to cry and complain about one another like we have here?

I can just see it:

Hygeinist: I clean teeth the best.

Dentist: No, I clean teeth the best. I have the most training doing it.

Orthodontist: No, I clean teeth the best, I'm a Doctor Dammmit.

Insurance Company: We don't care who cleans them the best, we aren't paying for it anyway!



:D:cheers::D:cheers::D

[drk]

Personally Chip, I think all three have gotten greedy. LDOs refracting, ODs going beyond the scope of their medical training, OMDs butting in on routine exams...

This thinking is useless, as well.

Listen, there was never a "harmonious balance" between these three separate professions that has been "upset" by scope expansion, greed, etc.

It should be all about public health need.

Is there a dearth of refracting professionals? Are opticians willing and able? Make a case to the controlling powers!

Is there a dearth of access to medical or surgical eye care? Are optometrists (heck, or opticians or chiropractors or nurse practitioners!) willing and able? Make a case to the controlling powers!

Ophthalmology is well within it's rights to provide routine eye care, as well.

Unfortunately, OD, optician, and OMD systems are not integrated and are parallel, and as such, will be largely redundant and necessarily competitive.

[drk]

But when I see a patient continue for five weeks of treatment for herpes zoster without a IOP check only to be diagnosed with glaucoma a week later is scandalous. Goldman tono should have been mandatory - but the doc didn't want to make the patient uncomfortable. Now she's lost sight in that eye.

Are you saying this patient got secondary glaucoma from the HZO? Because she's a steroid responder?
Because of secondary iridocyclitis?
How much "sight" was lost? Is it from corneal scarring?
How far is this patient post-treatment?

[1968]

Are you saying this patient got secondary glaucoma from the HZO? Because she's a steroid responder?
Because of secondary iridocyclitis?
How much "sight" was lost? Is it from corneal scarring?
How far is this patient post-treatment?

I'm afraid that this thread is going in the same direction as the previous one. It appears again that we are expected to make a third-hand assessment of information that someone else acquired second-hand in order to judge someone's competence.

[HarryChiling]

So much for keeping it nice huh. Going right to bashing the Optometrists. Gee wiz. I have worked for an Optometrist for almost 8 years now in private practice and 2 before that with a few others. I belive that Optometrists are underpaid to be honest. I know what they get paid for for an exams vs md's and it's ridiculous. I don't know about you guys, but my Optometrist does just as good as job as the surgeon next door if not better on eye exams. Now, he's not a surgeon but most people don't need a surgeon for routine exams. They just think because the doctor has md after his name, he must be better. The patients aren't educated properly to begin with. Most surgeons don't want to do the "routine" exams anymore anyhow, so it's up to educate the patients that they're Optometrist does just as good and thorough exam as they're Opthalmologist and that they can come here for they're "routine" exams.

Optometrists are underpaid, that I can agree with, but the other points I highlighted I think would come into play.

Optometrists do a heck of a lot better at routine eye exams than OMDs, this as well is true. If I had a patient walk in with a Rx in one hand from and OD and an Rx in hand from an OMD, I would always lean more towards the ODs Rx and usually explain to patients that they do this everyday all day, where a surgeon or OMD only does this a portion of there day if that and many times will delegate it to other office personnel.

Now going back to the first point underpaid, I think that OMDs are getting away from doing the exam because the insurance companies are paying next to nothing for refractions. Simple supply and demand, if ODs get more into medical management does anyone think that the trend of the reimbursemnts that has lead to the next to nothing being paid on routine exams will soon become an issue for the areas that ODs are getting into? And if it does wouldn't it be better for all the O's if optometry stops expanding it's scope of practice?

[chip anderson]

Last thread was mostly do to with practioner's integrity, not so much his competence. I do hope those of you that had so much to say in defence of his profession understand about integrity.

[drk]

I'm afraid that this thread is going in the same direction as the previous one. It appears again that we are expected to make a third-hand assessment of information that someone else acquired second-hand in order to judge someone's competence.

That's a very good point.

Listen, Optiboarders: This forum is read by many consumers, although they cannot post. Is it prudent to post hatchet-jobs on Optometry?

I find myself doing "damage control" in a lot of these posts.

I don't do hatchet-pieces on Opticianry for all to read.

Why not slam Optometry on the private forum?

Don't forget you may be responsible for damaging "Dr."-patient relationships by your irresponsible posts.

[optical24/7]

The group I work for now is about as close to harmony that I've seen between the 3 O's. We have 3 OMD's, 1 OD and our 2 locations opticals. The OD does routine exams, cl fits, ect. One OMD specializes in blepharoplasty, one lasik and one cataract/glaucoma/general conditions. All three OMD's and even the OD overlap to an extent, but are referred to the other if it is their specialty. All of the opticians are held in high regard and asked of our opinion on certain patient's complaints/needs.
We all ply our trade to the best of our ability and leave ego's at the door for the patients benifit.

Now, having said this, I find our setup very rare. But it was one of the main reasons I wanted to work here.

[drk]

Now going back to the first point underpaid, I think that OMDs are getting away from doing the exam because the insurance companies are paying next to nothing for refractions. Simple supply and demand, if ODs get more into medical management does anyone think that the trend of the reimbursemnts that has lead to the next to nothing being paid on routine exams will soon become an issue for the areas that ODs are getting into? And if it does wouldn't it be better for all the O's if optometry stops expanding it's scope of practice?

No, you misunderstand.

Lower reimbursement is procedure code-specific, not specialty-specific.

"Routine eye exams" (ugh) are lesser-reimbursed because it's a different animal.

[drk]

Here's a nice hatchet-piece for you...

http://www.hbutz.com/wwwboard/messages/201.html

[k12311997]

Here's a nice hatchet-piece for you...

http://www.hbutz.com/wwwboard/messages/201.html

page never loaded maybe you could just copy the text please.

No, you misunderstand.

Lower reimbursement is procedure code-specific, not specialty-specific.

"Routine eye exams" (ugh) are lesser-reimbursed because it's a different animal.

some (vision) insurances do pay MD's more for even routine exam same code as OD, NVA that I'm sure of.

Some medical insurances won't pay some procedure codes if not preformed by MD.

[drk]

The link works for me...too long to cut and paste...it's a blog...

You're right about those instances you cite...there is discrimination going on with some insurers. Parity exists for Medicare and many/most payers. Sure, some surgical codes are not payable for non-surgeons...no problem with that!

But our biggest challenge is fighting exclusion from providing medical services on some panels. We're licensed to do so, but some payers want to keep their networks small and under control, plus many insurance companies are beholden to MD interests, have MDs in charge as directors, etc.

It's frank discrimination, and thats what "AWP" or "Any Willing Provider" legislation is about. Kentucky has a good law that way.

Optometry has to unify it's scope of care, nation-wide, and then take AWP nation-wide.