A new look on an Old topic

[eyeliddoc]

I am a lurker. I have been reading the ophthalmology and optometry threads for some time but have not commented or posted before. I created this username to post this comment because my old username had my full name in it. Anyways here it goes and I know that certain people will jump all over me with all sorts of accusations for this but I recognize that unbiased comments are difficult if not impossible from those people.

I moved to Atlanta to practice about a year ago. As a new plastics person, I have been meeting ophthalmologist (OMDs as you folks call them) and optometrists to introduce myself. I did this over the last year. Well...on Friday I got a call from an optometrist who I had met before. When I met him he was very nice. He sent me a couple patients over the year and so when he called I was happy to talk to him. He told me that "he has been doing a lot of thinking and wanted to meet me for lunch". I thought to myself ok maybe he just wants to get to know me better before sending more patients so I scheduled a lunch together.

When we met this doctor informed me that he really liked the work I did and thought I was a great doctor. However he felt he wanted to "create something that was mutually beneficial" for us. He kept repeating over and over mutually beneficial and I asked him what he meant exactly. He informed me that he would like to send me more patients but he wanted some sort of financial compensation for the referrals. I informed him it would be a clear violation of Stark law to have kickbacks and he proudly told me he thought of a "great way around it" which was to just have him comanage the patients. I asked him if he has removed stitches or ever seen a patient after orbital, eyelid, and lacrimal surgery. He told me that not really but that didn't even matter. The point was that I would remove the stitches at 1 week as I normally do but he would see the patients also that week. That way he could get 25% of the surgical fee and it would be ok. He also told me that he would send all his patients to me even those that are at his office 50 miles outside Atlanta to me in downtown Atl if I did this and it would be great because of all the money I would make and how he would get a cut also. He kept repeating terms like "win win" and "mutually beneficial". I told him that I don't "comanage" plastics patients with ophthalmologists and really was not comfortable with comanaging with optometrists either and it wasn't really in the spirit of the comanagement laws for us to do this. His response was "Seriously...what else did you think ODs in Atlanta would do with those laws. This is an easy income incentive for me. Come on don't be so Naive Dr G!" Needless to say I told him that at this point I wasn't interested in doing this and he seemed fine with it though disappointed. The whole experience made me feel like I was being strong armed by Boss Hogg or a mob boss.

On a recent post people were discussing this and talking about how comanagement takes so much time and is a waste of time for ODs. I think this recent experience for me and for most ophthalmologists sums up what comanagement is when it comes to cataract surgery. The whole experience made me very disappointed and frankly sad.
I know there are ODs here who don't view comanagement this way and actually CARE ABOUT THE PATIENTS. I beg you to talk to your colleagues who do things like this and frankly make the profession look very bad. I told this story at my hospital staff meeting with about 75 docs there and people were pretty disgusted. A couple ophthalmologists told me that they have had the same conversation with ODs in Atlanta concerning cataract surgery as well which I was shocked. I guess I was naive.

Comanagement may have been created to allow patients from rural areas to get care but it is obvious to me that it is a loophole that lets certain doctors try to make more money and direct their referrals. It is slimy as hell and as a physician it makes me sick. How would anyone here with an optical shop would feel if I came to their office and said I will send you referrals for glasses but I want 25% of the sale?

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[KHE]

Clearly, you've dealt with a bad apple. 99% of optometrists do not operate in that fashion. However, I would say that the best way to get referrals from optometrists is not to comanage with them but to send THEM a few patients. Got some contact lens patients? Weird multifocal fittings? Just because someone has -1.75 cyl doesn't mean they can't wear contact lenses so don't just tell them "their astigmatism is too high" like most ophthalmologists do. Send them to someone.

 

[Tippytoe]

I'll give you the optometrist perspective. Sounds like the guy just wanted to co-manage his patients with you. But he made it sound like he just wanted some money from you.

I see some ophthalmologist do not want to co-mange any patients with ODs. But from my persepective, the patients I send to you are MY patients. I have seen them for a long time and they need a particular procedure I can't do.

So I send the pt out for cataract surgery. HERE IS THE PROBLEM: Every ophthalmologist here will take the patient, do a full comprehensive exam even thought they have my EMR notes of the complete exam that was just performed (waste of Medicare money). Then they will sit the patient in their reception area which just happens to have a very large and elaborate optical shop 5 feet away so MY patient (and the family members) can browse the optical during their 90 minute wait to be seen (what else is there to do).

So the pt is seen and the ophthalmologist confirms the need for cataract surgery. But they don't stop there. They see one drusen near the macula so they have the patient back before surgery to do a full retinal work up (OCT, VF) and diagnose dry eyes and begin treatment.

All this despite my notes clearly saying I have noted all of those condition and have it all under control.

So for most of us, comangement is simply a way to keep OUR patient's time as brief as possible in the surgeon's office. The more time a patients hangs around your office, the more likely they will decide to just stay there for all of the routine care. Money is not really an issue. We get $118 for post op care for cataract surgery (for 2-3 post op visits-- about $40 per visit). Not really going to retire off that money.

If you are strictly in a surgery center without an optical, I applaud you. But I have no non-optical Ophthalmologists around here.

P.S. Many times the patients want to come back to us for comanagment because frankly, we have better chair-side manners,shorter waiting periods and more time to spend with the patient (due to the oversupply of ODs and shortage of patients). I''m not trying to be a smart-ass, just stating a general observation that I believe is true overall.

Some patients do insist on seeing the surgeon for post-op because they view you as a god. I have no problem with that.

 

[thiaeyemd]

Interesting post. I am an oculoplastic surgeon and no OD has approached me ever to try and comanage a plastics patient. I wouldnt comanage another oculoplastic patient because I don't know the procedure, stitches used etc.. Don't think those are cases where someone who didn't do the surgery can properly do the post op management..optometrist, ophthalmologist or oculoplastic surgeon.

In response to tippy toe I do see your points and i understand if that is how you feel. I don't have optical or even do refractions so isn't an issue for me. One thing however I do disagree with you in that you said that even though they have your complete note, the OMD does a full exam. You can ask any malpractice attorney for confirmation but if you operate on a patient and don't do a full exam on them and they have an untoward outcome you are done..you will be completely raped at trial. It is unforgivable and you will have a line of "expert witnesses" ready to rain hell on you. If there is a surgeon out there operating based on others notes...god bless him or her but they are essentially risking their whole license and career on someone else's note. Regardless of that person's competency they are taking a tremendous risk and I know no eye surgeon who would do that.

I don't think most plastic people who are not in a group have anything to do with optical. Oculoplastics surgeons in general dont enjoy and avoid routine eye care. Just how the subspecialty works. I am sure eyeliddoc is the same.

 

[Tippytoe]

In response to tippy toe I do see your points and i understand if that is how you feel. I don't have optical or even do refractions so isn't an issue for me. One thing however I do disagree with you in that you said that even though they have your complete note, the OMD does a full exam. You can ask any malpractice attorney for confirmation but if you operate on a patient and don't do a full exam on them and they have an untoward outcome you are done..you will be completely raped at trial.
.

Yes sir, you have a good point there. I can understand doing it for malpractice "insurance". I don't co-manage much in the way of oculoplastics---just not that much needed in my primary care place. I see the patients back after belphroplasty as soon as the sutures are out. But I do participate in alot of cataract, glaucoma and retina comanagement. The surgeons communicate with me via a note or phone call and I communicate back to them. There are no secrets or surprises. The ophthalmologists benefit by my frequent referrals and I benefit by a happy patient that tells friends and family that I know what I'm doing and who to send to for the best surgery. I also benefit by the small post op fees (20%) and, as I said, by keeping the patient in my office.

I agree I wouldn't trust just anybody to see the post op pts if I was a surgeon. There are some VERY stupid ODs out there and I've meet some OMDs that seem to be dumb as a rock. But I have followed the surgeons I work with closely and we trust each other. They have been in my office too and have seen that I have an updated clinic with all the necessary equipment (OCT, VF, B-scan, corneal topo, etc....). This area is where my foolish Walmart-ish colleagues drop the ball and don't see the big picture.

I have been in the OR with a few surgeons that I wouldn't send my dog to. They are really that bad.

In a proper relationship, comanagement IS a win-win scenerio. It allows the surgeon to concentrate on and do more surgeries (if that's what he likes) and allows the OD to do what he likes, follow the patient for post op (freeing the surgeon) and routine care. Absolutely nothing wrong with it in the proper enviroment.

But in the end, I can't blame you for not wanting to comanage with a bunch of idiot Walmart pseduo-doctors. I'm totally ashamed of my profession for what it has become. We have a bunch of sell-outs that just want the money that the Walton family will give them for the trade-off of giving up any professionalism the profession has tried to gain over the last 100 years. I could never, in good conscience, tell my surgical post-op patient to "go see your doctor at Walmart for the rest of your follow-up".

 

[stonegoat]

Several years ago, the group I was practicing with was approached my an ophthalmologist who wanted to pay us $50 for every cataract patient we sent to him. Of course we did not accept the offer, but I guess there are always those who want to function outside of the law for financial gain.

 

[east]

I am a lurker. I have been reading the ophthalmology and optometry threads for some time but have not commented or posted before. I created this username to post this comment because my old username had my full name in it. Anyways here it goes and I know that certain people will jump all over me with all sorts of accusations for this but I recognize that unbiased comments are difficult if not impossible from those people.

I moved to Atlanta to practice about a year ago. As a new plastics person, I have been meeting ophthalmologist (OMDs as you folks call them) and optometrists to introduce myself. I did this over the last year. Well...on Friday I got a call from an optometrist who I had met before. When I met him he was very nice. He sent me a couple patients over the year and so when he called I was happy to talk to him. He told me that "he has been doing a lot of thinking and wanted to meet me for lunch". I thought to myself ok maybe he just wants to get to know me better before sending more patients so I scheduled a lunch together.

When we met this doctor informed me that he really liked the work I did and thought I was a great doctor. However he felt he wanted to "create something that was mutually beneficial" for us. He kept repeating over and over mutually beneficial and I asked him what he meant exactly. He informed me that he would like to send me more patients but he wanted some sort of financial compensation for the referrals. I informed him it would be a clear violation of Stark law to have kickbacks and he proudly told me he thought of a "great way around it" which was to just have him comanage the patients. I asked him if he has removed stitches or ever seen a patient after orbital, eyelid, and lacrimal surgery. He told me that not really but that didn't even matter. The point was that I would remove the stitches at 1 week as I normally do but he would see the patients also that week. That way he could get 25% of the surgical fee and it would be ok. He also told me that he would send all his patients to me even those that are at his office 50 miles outside Atlanta to me in downtown Atl if I did this and it would be great because of all the money I would make and how he would get a cut also. He kept repeating terms like "win win" and "mutually beneficial". I told him that I don't "comanage" plastics patients with ophthalmologists and really was not comfortable with comanaging with optometrists either and it wasn't really in the spirit of the comanagement laws for us to do this. His response was "Seriously...what else did you think ODs in Atlanta would do with those laws. This is an easy income incentive for me. Come on don't be so Naive Dr G!" Needless to say I told him that at this point I wasn't interested in doing this and he seemed fine with it though disappointed. The whole experience made me feel like I was being strong armed by Boss Hogg or a mob boss.

On a recent post people were discussing this and talking about how comanagement takes so much time and is a waste of time for ODs. I think this recent experience for me and for most ophthalmologists sums up what comanagement is when it comes to cataract surgery. The whole experience made me very disappointed and frankly sad.
I know there are ODs here who don't view comanagement this way and actually CARE ABOUT THE PATIENTS. I beg you to talk to your colleagues who do things like this and frankly make the profession look very bad. I told this story at my hospital staff meeting with about 75 docs there and people were pretty disgusted. A couple ophthalmologists told me that they have had the same conversation with ODs in Atlanta concerning cataract surgery as well which I was shocked. I guess I was naive.

Comanagement may have been created to allow patients from rural areas to get care but it is obvious to me that it is a loophole that lets certain doctors try to make more money and direct their referrals. It is slimy as hell and as a physician it makes me sick. How would anyone here with an optical shop would feel if I came to their office and said I will send you referrals for glasses but I want 25% of the sale?

Why did you have an old username if you have never posted before? Just curious.

Anyway, I won't be "jumping all over you will all sorts of accusations." but I have to set the record straight a little.

Food for thought...do you really believe that you are the only one who has been approached for a nefarious reason. I have posted on this site certain things and many cried "n=1, n=1..." or anecdotal, anecdotal..." Go back and read my posts regarding co-management. Unethical things do go on, on BOTH SIDES. I have a whole arsenal of "n=1" and "anecdotal" cases of which I have personal knowledge where the ophthalmologist was the one approaching the OD. Who needs the referral more, the OD who has the patient base and can't do the procedure, or the ophthalmologist (note in all my posts I intentionally write Ophthalmologist not OMD so you won't be "offended").

Therefore I implore you please...please speak to your fellow ophthalmologists and ask them not to steal patients. Frankly it makes your profession look very bad. I think the many cases of patient theft sums up for me and most ODs our feeling toward co-management situations. These experiences have left me disappointed and frankly sad.

Next time I am in a room with 75 Medical professionals I will have no choice but to proclaim my dissatisfaction with ophthalmology as a profession, due to one bad experience with a single ophthalmologist and anecdotal evidence of a "couple optometrists who the same thing." I'm sure everyone will be pretty disgusted. Brilliant.

I have a large practice in a fairly rural area, have about 5000 or so patient ecounters a year and I can count on two hands my plastic referrals. There is no co-management with me, nor should there be, but I am just surprised this OD could actually make money from plastic co-management??

 

[PBEA]

I am a lurker. I have been reading the ophthalmology and optometry threads for some time but have not commented or posted before. I created this username to post this comment because my old username had my full name in it. Anyways here it goes and I know that certain people will jump all over me with all sorts of accusations for this but I recognize that unbiased comments are difficult if not impossible from those people.

I moved to Atlanta to practice about a year ago. As a new plastics person, I have been meeting ophthalmologist (OMDs as you folks call them) and optometrists to introduce myself. I did this over the last year. Well...on Friday I got a call from an optometrist who I had met before. When I met him he was very nice. He sent me a couple patients over the year and so when he called I was happy to talk to him. He told me that "he has been doing a lot of thinking and wanted to meet me for lunch". I thought to myself ok maybe he just wants to get to know me better before sending more patients so I scheduled a lunch together.

When we met this doctor informed me that he really liked the work I did and thought I was a great doctor. However he felt he wanted to "create something that was mutually beneficial" for us. He kept repeating over and over mutually beneficial and I asked him what he meant exactly. He informed me that he would like to send me more patients but he wanted some sort of financial compensation for the referrals. I informed him it would be a clear violation of Stark law to have kickbacks and he proudly told me he thought of a "great way around it" which was to just have him comanage the patients. I asked him if he has removed stitches or ever seen a patient after orbital, eyelid, and lacrimal surgery. He told me that not really but that didn't even matter. The point was that I would remove the stitches at 1 week as I normally do but he would see the patients also that week. That way he could get 25% of the surgical fee and it would be ok. He also told me that he would send all his patients to me even those that are at his office 50 miles outside Atlanta to me in downtown Atl if I did this and it would be great because of all the money I would make and how he would get a cut also. He kept repeating terms like "win win" and "mutually beneficial". I told him that I don't "comanage" plastics patients with ophthalmologists and really was not comfortable with comanaging with optometrists either and it wasn't really in the spirit of the comanagement laws for us to do this. His response was "Seriously...what else did you think ODs in Atlanta would do with those laws. This is an easy income incentive for me. Come on don't be so Naive Dr G!" Needless to say I told him that at this point I wasn't interested in doing this and he seemed fine with it though disappointed. The whole experience made me feel like I was being strong armed by Boss Hogg or a mob boss.

On a recent post people were discussing this and talking about how comanagement takes so much time and is a waste of time for ODs. I think this recent experience for me and for most ophthalmologists sums up what comanagement is when it comes to cataract surgery. The whole experience made me very disappointed and frankly sad.
I know there are ODs here who don't view comanagement this way and actually CARE ABOUT THE PATIENTS. I beg you to talk to your colleagues who do things like this and frankly make the profession look very bad. I told this story at my hospital staff meeting with about 75 docs there and people were pretty disgusted. A couple ophthalmologists told me that they have had the same conversation with ODs in Atlanta concerning cataract surgery as well which I was shocked. I guess I was naive.

Comanagement may have been created to allow patients from rural areas to get care but it is obvious to me that it is a loophole that lets certain doctors try to make more money and direct their referrals. It is slimy as hell and as a physician it makes me sick. How would anyone here with an optical shop would feel if I came to their office and said I will send you referrals for glasses but I want 25% of the sale?

Again with this ridiculous characterization of comanagment as having been corrupted by ODs...........what a bunch of happy horseshiit. While I sympathize with your experience with that OD, let me be perfectly blunt. The same EXACT thing happens with OMD approaching OD for "comanagement" arrangments, so if "our profession looks bad" then SO DOES YOURS. Let me repeat and clarify, that your profession, being ophthalmology, is riddled with the equivalent of ******. So much so that I want to vomit, and try and keep my distance from these misguided "main street" ophthalmologists, give me a f@#$ing break already. Take a look in your own house, before you open your mouth.

 

[east]

I think eyeliddoc is just demonstrating his/her naivety with regards to his/her own profession. Either that or blatant disingenuousness. Either way is shows a lack of maturity in my opinion to take the experience of one or two encounters and extrapolate that to everyone. I have had more than a few ophthalmologists come to me with various schemes using the exact words "win,win" and "mutually beneficial". Guess what I still like ophthalmology and there are many great ophthalmologists I work with. I would never go in front of 75 doctors to proclaim my bewilderment at the unethical displays I have witnessed. To give you the benefit of the doubt eyeliddoc, I will just assume you do not see many general opthal and OD interactions, and this shady experience you had was your first taste that there are greedy unethical people in the world.

 

[eyeliddoc]

I was not saying all of optometry was unethical. I am new out of training and maybe I haven't become a "*****" yet as was stated by another post but the medical referral system everywhere else in medicine has no financial component to it. I was pointing out a situation where someone was trying to take advantage of it. If there are ophthalmologists who do this sort of thing then I have as much disdain for them as this person who approached me. I wasn't as much disappointed with the whole comanagement thing in general as much as I was with the way this guy wanted to do it...where for all intensive purposes we are using comanagement to just give him $150 per referral etc.. This was not an attack on optometry as a whole. I will repeat it..this was not an attack on optometry as a whole.
I never said all of medicine is pristine..it isn't but I think when I was approached it turned me off and I wanted to post my experience. Sorry.

To answer tippytoe, I created a login to just read optometry and eye surgery posts. I didn't think of it at the time but JohnSmithMD is not a wise user name for a plastics person who is trying to buildup business especially when you have people like PBEA or east who respond as they do...

 

[east]

I'm just curious as to why the Stark law (you referred to in your conversation with the unethical OD) was implemented if there is as you state "no financial component to the medical referral system" i assume anywhere but the OD/MD relationship? You realize the Stark law and Stark II,III was passed because of the multitude of shady medical financial kickbacks and self referrals happening all the time. Have you read the Stark law or Stark II, and it's history?

"people like PBEA and east who respond as they do"....can you tell me where I said anything inflammatory? I speak from my experience and I qualify it as such. Just because I don't preface every statement with "I know there are MANY horrible ODs out there" doesn't mean I can't have a point and can't make sense, or should be dismissed as an inciter.

 

[Tippytoe]

To answer tippytoe, I created a login to just read optometry and eye surgery posts. I didn't think of it at the time but JohnSmithMD is not a wise user name for a plastics person who is trying to buildup business especially when you have people like PBEA or east who respond as they do...

Twasn't I that asked that question.

 

[Tippytoe]

EVERYTHING is about MONEY. Just a fact of life. In medicine we can pretend that we do it all for the patient. But MONEY is what pays the bills. Unless you work in a gov't run clinic in the ghetto or an native-american reservation (I still call them indians) there is a multitude of bills that have to be paid every month.

It's tougher and tougher running a small business/office/clinic. Insurance reimbursement is down. Competition is at an all-time high. Self pay patients are almost non-existent. And there are always patients that you will help out for free. I've taken air conditions to patients and set them up. I've jumped started their cars. I've given an unknowned about of free glasses.

Side note: A hair dresser asked me about getting an eye exam while I was in her shop with my wife. She charges $155 to do my wife's hair (which I learned was normal for women to pay routinely. My barber charges $12 ). I told the lady to call my office to schedule. I never understand when people approach me on the street and say they need an eye exam. What do they expect me to do? ? Call the office and schedule. I dont have my schedule openings in my head.

So the next time I see this lady in her hair salon, she tells me she called but we don't take her insurance. (It was crappy Spectera which pays about $35 for an exam). So i tell the lady she could pay cash and get an exam at my office. She laughed and laughed and laughed.

So it's perfectly normal for people to pay hundreds of dollars for a hair style but heaven-forbid they have to pay for an eye exam out of their pocket.
This is people's mindset. Insurance is supposed to pay EVERYTHING.

But I digress.....

What some docs do to get money to survive might sometimes be unethical. They probably aren't doing to buy a yacht. They are probably trying to find a way to keep their office open and their lights on and meet payroll. Running an office is Expensive and diffcult.

I'm not defending the unethical behavior. Just explaining it. Times are tough.!

 

[q1we3]

EVERYTHING is about MONEY. Just a fact of life. In medicine we can pretend that we do it all for the patient. But MONEY is what pays the bills. Unless you work in a gov't run clinic in the ghetto or an native-american reservation (I still call them indians) there is a multitude of bills that have to be paid every month.

It's tougher and tougher running a small business/office/clinic. Insurance reimbursement is down. Competition is at an all-time high. Self pay patients are almost non-existent. And there are always patients that you will help out for free. I've taken air conditions to patients and set them up. I've jumped started their cars. I've given an unknowned about of free glasses.

Side note: A hair dresser asked me about getting an eye exam while I was in her shop with my wife. She charges $155 to do my wife's hair (which I learned was normal for women to pay routinely. My barber charges $12 ). I told the lady to call my office to schedule. I never understand when people approach me on the street and say they need an eye exam. What do they expect me to do? ? Call the office and schedule. I dont have my schedule openings in my head.

So the next time I see this lady in her hair salon, she tells me she called but we don't take her insurance. (It was crappy Spectera which pays about $35 for an exam). So i tell the lady she could pay cash and get an exam at my office. She laughed and laughed and laughed.

So it's perfectly normal for people to pay hundreds of dollars for a hair style but heaven-forbid they have to pay for an eye exam out of their pocket.
This is people's mindset. Insurance is supposed to pay EVERYTHING.

But I digress.....

What some docs do to get money to survive might sometimes be unethical. They probably aren't doing to buy a yacht. They are probably trying to find a way to keep their office open and their lights on and meet payroll. Running an office is Expensive and difficult.

I'm not defending the unethical behavior. Just explaining it. Times are tough.!

This is sad but cold hard truth. Only $35 and she laughed at you when you asked if you would pay out of her pocket to get her eyes examined. There is virtually no respect for what ODs do anymore. Time to take my anti-depressant lol.

 

[east]

This was too good and timely so I just had to post this. I literally just walked into my office from seeing a patient and there is a huge basket with wines, etc. along with 4 tickets to an NFL game. This is no joke, it is sitting on my desk and I am staring at it right now. Guess who it is from??? Anyone..... Big points to anyone who guesses. Anyway I should probably return it right? This crap happens all the time!!

 

[KHE]

I was not saying all of optometry was unethical. I am new out of training and maybe I haven't become a "*****" yet as was stated by another post but the medical referral system everywhere else in medicine has no financial component to it. I was pointing out a situation where someone was trying to take advantage of it. If there are ophthalmologists who do this sort of thing then I have as much disdain for them as this person who approached me.

If you're at the end of your training/beginning of your career, you're probably going to get a rude awakening as to how the real world actually works because yea, it's all about money in the end.

I will also say that in my 12 year career I've been approached by about about 10 people wanting to comanage patients. 9 of them were ophthalmologists (mostly lasik guys, a few general guys sniffing for cataract patients) and one was an optometrist but he came because he worked for an ophthalmologist that does LASIK. lol

 

[VA Hopeful Dr]

I'm just curious as to why the Stark law (you referred to in your conversation with the unethical OD) was implemented if there is as you state "no financial component to the medical referral system" i assume anywhere but the OD/MD relationship? You realize the Stark law and Stark II,III was passed because of the multitude of shady medical financial kickbacks and self referrals happening all the time. Have you read the Stark law or Stark II, and it's history?

"people like PBEA and east who respond as they do"....can you tell me where I said anything inflammatory? I speak from my experience and I qualify it as such. Just because I don't preface every statement with "I know there are MANY horrible ODs out there" doesn't mean I can't have a point and can't make sense, or should be dismissed as an inciter.

All true, but recent grads wouldn't know about how things used to be because of the Stark law. Now us primary care folks use other metrics to decide where we refer. A few of my favorite - do I get adequate communication from the specialist, will they see the occasional medicaid/self pay patient, are they competent, how do they react if I call for a consult/to discuss a patient I already refered.

 

[PBEA]

I was not saying all of optometry was unethical. I am new out of training and maybe I haven't become a "*****" yet as was stated by another post but the medical referral system everywhere else in medicine has no financial component to it. I was pointing out a situation where someone was trying to take advantage of it. If there are ophthalmologists who do this sort of thing then I have as much disdain for them as this person who approached me. I wasn't as much disappointed with the whole comanagement thing in general as much as I was with the way this guy wanted to do it...where for all intensive purposes we are using comanagement to just give him $150 per referral etc.. This was not an attack on optometry as a whole. I will repeat it..this was not an attack on optometry as a whole.
I never said all of medicine is pristine..it isn't but I think when I was approached it turned me off and I wanted to post my experience. Sorry.

Well it sure sounded like an attack on optometry, and while the episode you had with that one OD sounds like a clear violation of the of the law, frankly its a drop in the bucket. All one has to do is google stark law and you will find that medicine is the culprit here and is the primary target of anti-kickback legislation. Does it apply to optometry? sure does and some do violate it. Does it apply to ophthalmology? sure does and some do violate it. I don't like it, but there is not much I can do except refuse to participate in any such arrangement. Kudos to you for making that decision as well.

My reaction to your post is due to the all too common attempt by ophthalmology to cast optometry as some kind of "boogie man". Sorry to shatter that mold. Welcome to the real world.

 

[Zorro12]

So I send the pt out for cataract surgery. HERE IS THE PROBLEM: Every ophthalmologist here will take the patient, do a full comprehensive exam even thought they have my EMR notes of the complete exam that was just performed (waste of Medicare money). Then they will sit the patient in their reception area which just happens to have a very large and elaborate optical shop 5 feet away so MY patient (and the family members) can browse the optical during their 90 minute wait to be seen (what else is there to do).

So the pt is seen and the ophthalmologist confirms the need for cataract surgery. But they don't stop there. They see one drusen near the macula so they have the patient back before surgery to do a full retinal work up (OCT, VF) and diagnose dry eyes and begin treatment.

So from the other side:
You think my complete exam pre-op is a waste of money? First, Medicare/Insurers require the surgeon perform a complete exam within 90 days of surgery, otherwise, tis fraud. Second, you may be surprised how many of your colleages miss pseudoexfoliation, diabetic retinopathy, advanced OAG with central field cut, drusen, ERM with fluid, RD, etc... It is also important to know how well the patient dilates. I am pretty sure YOUR patient would not like to go through cataract surgery, with all of the attendant risks, and end up seeing exactly what they did before surgery. Before anybody clicks the quote button, yes, I miss things, other OMDs miss things, everybody misses things, but the surgeon is the one on the hook for an outcome which is less than expected, hence I want to know if there are any co-morbitities. Lastly, if am looking at a patient with 20/100 vision and 1+ NS, yes, they get an OCT and / or an HVF if the poor vision cannot be explained by cataract alone.

 

[east]

So from the other side:
You think my complete exam pre-op is a waste of money? First, Medicare/Insurers require the surgeon perform a complete exam within 90 days of surgery, otherwise, tis fraud. Second, you may be surprised how many of your colleages miss pseudoexfoliation, diabetic retinopathy, advanced OAG with central field cut, drusen, ERM with fluid, RD, etc... It is also important to know how well the patient dilates. I am pretty sure YOUR patient would not like to go through cataract surgery, with all of the attendant risks, and end up seeing exactly what they did before surgery. Before anybody clicks the quote button, yes, I miss things, other OMDs miss things, everybody misses things, but the surgeon is the one on the hook for an outcome which is less than expected, hence I want to know if there are any co-morbitities. Lastly, if am looking at a patient with 20/100 vision and 1+ NS, yes, they get an OCT and / or an HVF if the poor vision cannot be explained by cataract alone.

Totally agree with all you said, just give the patient back when you're done

 

[Tippytoe]

So from the other side:
Before anybody clicks the quote button, yes, I miss things, other OMDs miss things, everybody misses things, but the surgeon is the one on the hook for an outcome which is less than expected, hence I want to know if there are any co-morbitities. Lastly, if am looking at a patient with 20/100 vision and 1+ NS, yes, they get an OCT and / or an HVF if the poor vision cannot be explained by cataract alone.

The proper and friendly way to handle this would be a nice little note to the referring optometrist saying something like this:

"Thanks for sending Mrs Jones. I agree that her cataracts are most likely causing her reduced acuity. She will be having surgery soon. Also I did noticed some mild drusen in/near the macula - could be developing ARMD (glaucoma, pseudo-exfoliation, etc...) So I think you might want to keep an check that. Thanks again for entrusting me with your patients."

Something like that.

This does 2 things: It lets the referring doc know what you saw without making him feel stupid and it allows you to send the patient back to the referring doc instead of keeping the patient and seeing them every 3 months for life.

If you feel the OD is an idiot, you probably should not accept referrals from him and tell him you are not comfortable co-managing with him. Or report him to the state board if he's that incompetent.

P.S. It's hard to believe any OD missed "advanced" glaucoma but I suppose it happens.

P.S.S. I was talking about an OD/ OMD relationship that is on-going and they know and trust each others abillties. In this case a 92002 is plenty sufficient if I did a 92004 and OCT/HRT/photos and/or VF and sent the results along with the full exam notes.

 

[VA Hopeful Dr]

The proper and friendly way to handle this would be a nice little note to the referring optometrist saying something like this:

"Thanks for sending Mrs Jones. I agree that her cataracts are most likely causing her reduced acuity. She will be having surgery soon. Also I did noticed some mild drusen in/near the macula - could be developing ARMD (glaucoma, pseudo-exfoliation, etc...) So I think you might want to keep an check that. Thanks again for entrusting me with your patients."

Something like that.

This does 2 things: It lets the referring doc know what you saw without making him feel stupid and it allows you to send the patient back to the referring doc instead of keeping the patient and seeing them every 3 months for life.

If you feel the OD is an idiot, you probably should not accept referrals from him and tell him you are not comfortable co-managing with him. Or report him to the state board if he's that incompetent.

P.S. It's hard to believe any OD missed "advanced" glaucoma but I suppose it happens.

P.S.S. I was talking about an OD/ OMD relationship that is on-going and they know and trust each others abillties. In this case a 92002 is plenty sufficient if I did a 92004 and OCT/HRT/photos and/or VF and sent the results along with the full exam notes.

Its only sufficient if there is no bad outcome. If the OD misses something and the MD doesn't do a thorough exam and so also misses whatever else is going on leading to a bad outcome, guess who's getting sued more?

 

[Tippytoe]

Its only sufficient if there is no bad outcome. If the OD misses something and the MD doesn't do a thorough exam and so also misses whatever else is going on leading to a bad outcome, guess who's getting sued more?

Answer: EVERYONE is going to get sued. The OD. The MD, The tech. The receptionist. Every drug company. The makers of the slit lamps. The UPS driver, etc.......

At two surgery centers here, they employ ODs to do all of the pre and post surgical work. The surgeon sees the patient on the day of surgery and never again. They do very well.

 

[VA Hopeful Dr]

Answer: EVERYONE is going to get sued. The OD. The MD, The tech. The receptionist. Every drug company. The makers of the slit lamps. The UPS driver, etc.......

At two surgery centers here, they employ ODs to do all of the pre and post surgical work. The surgeon sees the patient on the day of surgery and never again. They do very well.

I'm not saying it isn't done, just that I can understand surgeons who want to do their own pre-op assessment. Even with a positive CT scan, no surgeon I've ever met will take out an appendix without seeing the patient first; and, that's a semi-emergent issue. Cataract surgery isn't even close to being emergent, so I'd be cautious about the pre-op as well.

 

[eyeliddoc]

just because people do that..doesn't mean that it is a gross violation of surgical principles and training. Greed has a strong lure...

In terms of lawsuits, the person who gets sued is everyone but in reality it is the person operating on the patient and has the most resposibility (and deepest pockets) usually.

 

[Zorro12]

P.S. It's hard to believe any OD missed "advanced" glaucoma but I suppose it happens.

Trust me, ones that would be obvious to most people were followed into blindness. I guarantee you have missed a case yourself. It is not always a 50 yo AA with an IOP of 50 and a C of 0.99. A neuro-ophthamologist referred a patient to me with 1+ PSC cataracts. We both looked at the nerves, C 0.4, very shallow cup. Surgery went fine, IOP always low. On her one month PO from the CE I noticed a very small disc heme. Turned the mag way up with a super 66, talked myself into rim loss. Confirmed with OCT and a paracentral scotoma, in both eyes. If it were not for the subtle disc heme she would come in one day with unexplainable 20/60 central vision. I saw her last week and it is truly remarkable how unremarkable her exam is, but she is a text book case for NTG.

 

[KHE]

Trust me, ones that would be obvious to most people were followed into blindness. I guarantee you have missed a case yourself. It is not always a 50 yo AA with an IOP of 50 and a C of 0.99. A neuro-ophthamologist referred a patient to me with 1+ PSC cataracts. We both looked at the nerves, C 0.4, very shallow cup. Surgery went fine, IOP always low. On her one month PO from the CE I noticed a very small disc heme. Turned the mag way up with a super 66, talked myself into rim loss. Confirmed with OCT and a paracentral scotoma, in both eyes. If it were not for the subtle disc heme she would come in one day with unexplainable 20/60 central vision. I saw her last week and it is truly remarkable how unremarkable her exam is, but she is a text book case for NTG.

I don't see how that qualifies as "advanced glaucoma."

 

[east]

Trust me, ones that would be obvious to most people were followed into blindness. I guarantee you have missed a case yourself. It is not always a 50 yo AA with an IOP of 50 and a C of 0.99. A neuro-ophthamologist referred a patient to me with 1+ PSC cataracts. We both looked at the nerves, C 0.4, very shallow cup. Surgery went fine, IOP always low. On her one month PO from the CE I noticed a very small disc heme. Turned the mag way up with a super 66, talked myself into rim loss. Confirmed with OCT and a paracentral scotoma, in both eyes. If it were not for the subtle disc heme she would come in one day with unexplainable 20/60 central vision. I saw her last week and it is truly remarkable how unremarkable her exam is, but she is a text book case for NTG.

I agree everyone misses stuff, but per this thread you have to follow your argument a little better, and not change in the middle of the thread. Big difference between advanced glaucoma being "followed into blindness" and subtle NTG that could be difficult to pick up in the early stages as per your example. Don't really understand where you're going with this?

 

[Zorro12]

I don't see how that qualifies as "advanced glaucoma."

I stated paracentral scotoma OU.

from the American Glaucoma Society web site.

http://www.surveymonkey.com/s.aspx?sm=WZYn83JpWg6hpd56KauBpQ==

The following guidelines are to be used for grading the severity of glaucoma in ICD-9 coding. If both of the patient's eyes are glaucomatous, code for the more severe stage of the two eyes.

GLAUCOMA SEVERITY SCALE DEFINITIONS:

Mild Stage: optic nerve changes consistent with glaucoma but NO visual field abnormalities on any visual field test OR abnormalities present only on short-wavelength automated perimetry or frequency doubling perimetry.
Moderate Stage: optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation.
Severe Stage: optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield.

Examples of SEVERE visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees)

 

[east]

Patients with NTG tend to have more of a focal loss of rim tissue, especially inferiorly. There is a typically a greater incidence of optic-nerve hemorrhages (as you saw) and often paracentral scotomas are seen first due to the focal nature of rim tissue loss. A good look at the literature will back me up on this one.

Advanced glaucoma defined can be very subjective, and I have read and heard a multitude of glaucoma specialists explain their definition. The one I have heard and read the most is something like, advanced glaucoma would be defined as having enough loss of vision to produce significant symptoms and functional impairment.

I have seen many focal, steep, paracentral scotomas that have not caused significant symptoms and/or significant functional impairment.

just my .02

 

[Zorro12]

Patients with NTG tend to have more of a focal loss of rim tissue, especially inferiorly. There is a typically a greater incidence of optic-nerve hemorrhages (as you saw) and often paracentral scotomas are seen first due to the focal nature of rim tissue loss. A good look at the literature will back me up on this one.

Advanced glaucoma defined can be very subjective, and I have read and heard a multitude of glaucoma specialists explain their definition. The one I have heard and read the most is something like, advanced glaucoma would be defined as having enough loss of vision to produce significant symptoms and functional impairment.

I have seen many focal, steep, paracentral scotomas that have not caused significant symptoms and/or significant functional impairment.

just my .02

Thanks professor, sorry I didn't spoon feed it to you, but my point was that NTG usually starts with paracentral defects with usually unimpressive cupping and the first sign being a disc heme.

To recap, someone wrote it was a waste of money for a surgeon to perform a full workup on a pre-op cataract. I wrote that people miss things and the surgeon needs to be sure there is no other pathology, and gave examples. Then someone wrote it is hard to believe an OD would miss advanced glaucoma. I made the point that a neuroophthalomogist and a glaucoma specialist both missed advanced glaucoma (read severe according to the new standard CMS guidelines) in a patient to demonstrate it would not be out of the realm of possibilty an OD could miss advanced OAG.

Now you are saying some paracentral defects do not cause functional impairement. While this is may be true, would you rather have the same size defect as a nasal step or in your central vision with split fixation? I have patients that have difficulty reading, driving, following the golf ball off the tee, and one that I know of who can no longer play tennis due to these paracentral field cuts. While they can still ambulate and feed themselves I would opine the paracentral field loss is causing functional impairement. Almost univerally patients with paracentral cuts should be managed more aggressively than those with mild or moderated damage, hence the reason it is called severe. If followed long enough your paitents with "focal, steep, paracentral scotomas" are going to have a problem without (and possibly with) adequate treatment.

 

[east]

Thanks professor, sorry I didn't spoon feed it to you, but my point was that NTG usually starts with paracentral defects with usually unimpressive cupping and the first sign being a disc heme.

To recap, someone wrote it was a waste of money for a surgeon to perform a full workup on a pre-op cataract. I wrote that people miss things and the surgeon needs to be sure there is no other pathology, and gave examples. Then someone wrote it is hard to believe an OD would miss advanced glaucoma. I made the point that a neuroophthalomogist and a glaucoma specialist both missed advanced glaucoma (read severe according to the new standard CMS guidelines) in a patient to demonstrate it would not be out of the realm of possibilty an OD could miss advanced OAG.

Now you are saying some paracentral defects do not cause functional impairement. While this is may be true, would you rather have the same size defect as a nasal step or in your central vision with split fixation? I have patients that have difficulty reading, driving, following the golf ball off the tee, and one that I know of who can no longer play tennis due to these paracentral field cuts. While they can still ambulate and feed themselves I would opine the paracentral field loss is causing functional impairement. Almost univerally patients with paracentral cuts should be managed more aggressively than those with mild or moderated damage, hence the reason it is called severe. If followed long enough your paitents with "focal, steep, paracentral scotomas" are going to have a problem without (and possibly with) adequate treatment.

relax a little, .....if you read up the thread, i agree with you that all eye surgeons should do their own complete work-up prior to surgery. I also agree with what you just wrote here, my point was simply to respond to your response to KHE when he said how is that advanced glaucoma? You came back guns hot saying "I stated paracentral scotoma OU",

All I am saying is that one could argue that not everyone who has an early repeatable focal/steep paracentral scotoma due to focal loss in NTG would necessarily be considered to have advanced glaucoma. These patients could definitely progress to advanced glaucoma, especially if not managed properly (and sometimes even when every option is exhausted).

Anyway I am far from a professor, just a small time OD tryin' to enjoy my life. This was not an attack on you or your knowledge or skill. I respect Ophthalmology and value their expertise daily.