ABO kills Retina FPD

[eyeeye_captain]

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Thoughts?

 

[Ophthodoc2018]

Do you have the article ?

 

[eyeeye_captain]

Check your email, assuming you get your correspondence there.

I’ve got my opinions, but I’ll let there be some dialogue first.

 

[Slide]

Well, who really wants to go first?

A lot of my colleague and I have talked about this issue ad nauseum and it's all in the details. I like the idea of having retina seen almost as a separate entity compared to other ophthalmologists, but if it's gonna require more board certification and fees, then forget it. There needs to be a very tangible benefit for it.

 

[eyeeye_captain]

The fees are why I was a little surprised they scuttled it. The extra cert was probably going to be like the current MOC exam, so meh, whatever. There’s some requirement for an exam so we can’t just be grandfathered, but I’m sure it would just be for show.

The tangible benefit that I think most people were happy about is carving out from everyone else so we don’t look like major outliers to CMS. Lowering the chance of a painful audit is not a small thing.

The claim that there wasn’t enough support sounds fishy to me. While pretty much everyone I’ve spoken to similarly wanted some details taken care of, there was basically universal support. I suspect there was a big outcry from comp docs who do injections not wanting to look like they’re below the standard of care, and that put enough pressure on the board to completely shelve it instead of working on the things we would have liked tweaked.

 

[docdoc2012]

Im not surprised. Most retina specialists i spoke to just saw this as an additional money grab with no real meaning and extra exams
Does it limit non- retina trained scope of practice? No.
Does it create any tangible financial or practice benefit in terms of job search etc? No.
Im pretty sure a focused practice designation isnt going to stop CMS from interfering...if they want to audit, they will.
In my opinion the way to stop cms audits is to stop misusing modifier 25

 

[RetinaDude]

The fees are why I was a little surprised they scuttled it. The extra cert was probably going to be like the current MOC exam, so meh, whatever. There’s some requirement for an exam so we can’t just be grandfathered, but I’m sure it would just be for show.

The tangible benefit that I think most people were happy about is carving out from everyone else so we don’t look like major outliers to CMS. Lowering the chance of a painful audit is not a small thing.

The claim that there wasn’t enough support sounds fishy to me. While pretty much everyone I’ve spoken to similarly wanted some details taken care of, there was basically universal support. I suspect there was a big outcry from comp docs who do injections not wanting to look like they’re below the standard of care, and that put enough pressure on the board to completely shelve it instead of working on the things we would have liked tweaked.

When I read about there being opposition to it, the very first thing I thought about were general ophthalmologists who also do injections as likely being the ones opposed. Maybe I’m way off base here but it was suspicious.

 

[hello lady!]

When I read about there being opposition to it, the very first thing I thought about were general ophthalmologists who also do injections as likely being the ones opposed. Maybe I’m way off base here but it was suspicious.

As a general who does injections I didn't even know the FPD was a thing (I had to Google what FPD even was). I haven't seen anything mentioned online in other forums or in magazines or publications? I feel like if the opposition was stronger in the general community or if people were talking about it I would have heard of it sooner? After more searching it seems like it was mainly discussed in the ASRS setting?

 

[Gonio5]

I did not receive such an email saying it's over.

One of the arguments for Retina FPD is that there are ophthalmology practices with multiple sub-specialties, including retina. When a patient is referred from one of those ophthalmologists to the retina person in the group, the retina person cannot bill the patient as a new patient (CPT codes 92004, 99205, 99204, 99203, etc.). They must bill the patient as a return patient (92014, 99215, 99214, 99213, etc.). That pays less.

Such argument does not affect retina-only practices.

In terms of impressing patients, a Retina PFD will not do anything. In fact, a FASRS after M.D. might impress patients more.

 

[MstaKing10]

Im not surprised. Most retina specialists i spoke to just saw this as an additional money grab with no real meaning and extra exams
Does it limit non- retina trained scope of practice? No.
Does it create any tangible financial or practice benefit in terms of job search etc? No.
Im pretty sure a focused practice designation isnt going to stop CMS from interfering...if they want to audit, they will.
In my opinion the way to stop cms audits is to stop misusing modifier 25

This. Polling retina specialist in my area the support was definitely not unanimous. More burdensome testing and fees for what? I think there are more details to be sorted out before this gains widespread adoption.

 

[docdoc2012]

I did not receive such an email saying it's over.

One of the arguments for Retina FPD is that there are ophthalmology practices with multiple sub-specialties, including retina. When a patient is referred from one of those ophthalmologists to the retina person in the group, the retina person cannot bill the patient as a new patient (CPT codes 92004, 99205, 99204, 99203, etc.). They must bill the patient as a return patient (92014, 99215, 99214, 99213, etc.). That pays less.

Such argument does not affect retina-only practices.

In terms of impressing patients, a Retina PFD will not do anything. In fact, a FASRS after M.D. might impress patients more.

Yea ive heard the billing argument too...but FPD wouldnt have made a difference because it has to do with being under the same tax ID

 

[PhospholipaseA2]

I don't know too much about this, but it in part seems like a weird way to try and ensure only retina specialists do Intravitreal injections. Are drug companies behind it? In urban areas with many retina docs, having them do them all makes total sense. In rural areas, not so much. Does someone need to see a glaucoma specialist to get SLT? How about a cornea specialist to have punctal plugs? Does every lid lesion biopsy need to be done by an oculoplastic surgeon? I could go on and on. I get that some things are tricky to diagnose and we all know about dunning Kruger and you don’t know what you don’t know. When things are tricky, refer. It doesn’t require a cardiologist to diagnose afib and prescribe metoprolol, but if the afib isn’t behaving, the generalist refers. We can and do act this way within our own specialty too.

 

[TheLesPaul]

FPD is not meaningful apart from preserving turf as the other posters noted. In oculoplastics we are seeking a fully separate board certification as our specialty is truly distinct from ophthalmology and needs protection from other specialties, legitimacy for hospital credentialing, etc. I don't think you can make the argument that the time and expense needed for a second board cert/FPD is necessary for retina.

 

[eyeeye_captain]

FPD is not meaningful apart from preserving turf as the other posters noted. In oculoplastics we are seeking a fully separate board certification as our specialty is truly distinct from ophthalmology and needs protection from other specialties, legitimacy for hospital credentialing, etc. I don't think you can make the argument that the time and expense needed for a second board cert/FPD is necessary for retina.

So to make it more apples to apples, do you feel a comp doc is truly at a comparable level to an ASOPRS doc for things like lid lesions, chalazions, Botox/fillers? If you don’t, you see the point being made by a distinction for retina as well.

I don’t mean to be rude to our colleagues, but there’s an awful lot of nuance you don’t get without fellowship. Dunning Kruger does exist. I work semi-rural a good bit, and yeah, the injecting docs who help with “access” have significant knowledge gaps when I see their patients. I don’t blame them, but it’s not subtle.

That’s not even counting the potential billing differences outside of the CMS audit stuff, which could also lead to better rates on negotiating with insurance carriers.

Sure, time and expense were the quibbles. Those could also have been *negotiated/discussed* instead of shooting the idea down completely.

 

[RetinaDude]

So to make it more apples to apples, do you feel a comp doc is truly at a comparable level to an ASOPRS doc for things like lid lesions, chalazions, Botox/fillers? If you don’t, you see the point being made by a distinction for retina as well.

I don’t mean to be rude to our colleagues, but there’s an awful lot of nuance you don’t get without fellowship. Dunning Kruger does exist. I work semi-rural a good bit, and yeah, the injecting docs who help with “access” have significant knowledge gaps when I see their patients. I don’t blame them, but it’s not subtle.

That’s not even counting the potential billing differences outside of the CMS audit stuff, which could also lead to better rates on negotiating with insurance carriers.

Sure, time and expense were the quibbles. Those could also have been *negotiated/discussed* instead of shooting the idea down completely.

I’ve told plenty of people before that one of the big lessons you learn from fellowship is how much you thought you understood during your general residency but really didn’t learn until your fellowship. There’s a huge difference.

 

[docdoc2012]

Its quite simple really - we expect generalists who do their own injections to manage the endophthalmitis.
I think generalists need to be able to do shots especially in rural areas unless retina now wants to travel to satellites 3 hrs away

 

[RetinaDude]

Its quite simple really - we expect generalists who do their own injections to manage the endophthalmitis.
I think generalists need to be able to do shots especially in rural areas unless retina now wants to travel to satellites 3 hrs away

This argument sounds an awful lot like the one some ODs use to justify why they should have expanded scope of practice…….”well, the next closest ophthalmologist is three hours away so us local ODs should be allowed to do X surgery/laser”.

 

[docdoc2012]

This argument sounds an awful lot like the one some ODs use to justify why they should have expanded scope of practice…….”well, the next closest ophthalmologist is three hours away so us local ODs should be allowed to do X surgery/laser”.

I mean...if you want to compare an ophthalmologist MD training to OD training then sure.

 

[RetinaDude]

I mean...if you want to compare an ophthalmologist MD training to OD training then sure.

Our state legislators, and many patients, sure don’t seem to know the difference.

 

[docdoc2012]

Sure. But once again, a residency trained ophthalmologist doing injections in rural America where patients dont have the time or resources to travel distances monthly for the same procedure? Definitely different that optoms wanting to do lasers

 

[TheLesPaul]

So to make it more apples to apples, do you feel a comp doc is truly at a comparable level to an ASOPRS doc for things like lid lesions, chalazions, Botox/fillers? If you don’t, you see the point being made by a distinction for retina as well.

I don’t mean to be rude to our colleagues, but there’s an awful lot of nuance you don’t get without fellowship. Dunning Kruger does exist. I work semi-rural a good bit, and yeah, the injecting docs who help with “access” have significant knowledge gaps when I see their patients. I don’t blame them, but it’s not subtle.

That’s not even counting the potential billing differences outside of the CMS audit stuff, which could also lead to better rates on negotiating with insurance carriers.

Sure, time and expense were the quibbles. Those could also have been *negotiated/discussed* instead of shooting the idea down completely.

to be honest I think any ophthalmologist should and could be competent for lid lesions and chalazia. toxin and fillers are not difficult either; plenty of nonphysicians can do pretty good work here. I think the privileges reflect this. Lid lesions and chalazion removal are part of the 'general ophthalmology' privilege set, not oculoplastics-specific privilege sets. comp and peds ophtho commonly do these and even some ptosis/tear ducts.

the reason to develop an oculoplastics board is that there really is a huge distinction between true oculoplastics fellowship training and ophthalmology. face/neck lift, liposuction, laser resurfacing of the skin, and complex orbital surgery are in the realm of several ABMS-recognized specialties but not general ophthalmology. there is not a standard "oculoplastics privilege set" so we often have to get these additional privileges signed off on by someone in another department. obviously you can see the potential for turf wars and bias here. it's a lot better than it was before but still -- we have to formally define our specialty in the context of other specialties.

I don't really see that issue for retina. there is no ABMS-recognized specialty apart from ophthalmology who will touch the eyeball.

if I had a medical retina issue, i would want an ASRS member to treat me. but i'm not sure it is necessary to mandate that

 

[TheLesPaul]

Its quite simple really - we expect generalists who do their own injections to manage the endophthalmitis.
I think generalists need to be able to do shots especially in rural areas unless retina now wants to travel to satellites 3 hrs away

this line of thinking is faulty so I'm not sure why it keeps being thrown around. if a comp drops a lens they are not expected to do the vit. if a glaucoma or retina doc loses an eye due to ranging endopthalmitis I don't expect them to do the evisceration. if I get a CSF leak, neurosurgery doesn't expect me to patch it. and so on....

 

[Slide]

this line of thinking is faulty so I'm not sure why it keeps being thrown around. if a comp drops a lens they are not expected to do the vit. if a glaucoma or retina doc loses an eye due to ranging endopthalmitis I don't expect them to do the evisceration. if I get a CSF leak, neurosurgery doesn't expect me to patch it. and so on....

I don't think that's a good argument - what we're asking is to at least manage it initially and then consider referral. We don't expect comp to do a full vitrectomy after dropping a lens but we do expect them to at least do an anterior vitrectomy, place a sulcus lens if possible, and suture the main wound.

Likewise, if you're general and get a post-injection endophthalmitis, the general who did the injection needs to at least do the initial management before referring it - most post-injection endophthalmitis needs a tap and inject, not a vitrectomy immediately. Most in private practice aren't really culturing so it's really an antibiotic injection. It's not any different from doing a regular injection so the argument it needs a different skillset is not true. I also don't buy the cost argument because it's no different from retina, and you can buy them frozen and reconstitute them to maintain long shelf life. The most important thing you can do for any sort of endophthalmitis is getting in antibiotics as soon as possible anyway so I don't understand why you would send a patient and delay treatment for 12-24 hours to another person when you can just do it yourself.

to be honest I think any ophthalmologist should and could be competent for lid lesions and chalazia. toxin and fillers are not difficult either; plenty of nonphysicians can do pretty good work here. I think the privileges reflect this. Lid lesions and chalazion removal are part of the 'general ophthalmology' privilege set, not oculoplastics-specific privilege sets. comp and peds ophtho commonly do these and even some ptosis/tear ducts.

the reason to develop an oculoplastics board is that there really is a huge distinction between true oculoplastics fellowship training and ophthalmology. face/neck lift, liposuction, laser resurfacing of the skin, and complex orbital surgery are in the realm of several ABMS-recognized specialties but not general ophthalmology. there is not a standard "oculoplastics privilege set" so we often have to get these additional privileges signed off on by someone in another department. obviously you can see the potential for turf wars and bias here. it's a lot better than it was before but still -- we have to formally define our specialty in the context of other specialties.

I don't really see that issue for retina. there is no ABMS-recognized specialty apart from ophthalmology who will touch the eyeball.

if I had a medical retina issue, i would want an ASRS member to treat me. but i'm not sure it is necessary to mandate that

I'm pretty ambivalent about some of these arguments. If you're trained well enough in retina as a comprehensive and can handle straightforward stuff, I don't mind injecting in rural populations. My main concern would be comprehensive not referring appropriately and keeping patients that need a specialist referral. I would like to believe most comprehensive know when to send someone off but from experience many will not for fear of losing their patients, even if it's managed to the point of incompetence (e.g. getting monthly injections for a pseudovitelliform lesion for 3 years). The one thing I'll add is if comprehensive wants to do injections, they should be held to the standard of a subspecialist - I do expert witness work and my colleagues and I agree on this so beware.

 

[eyeeye_captain]

any ophthalmologist should and could be competent

In theory, but I don’t share your optimism when it comes to retina. The injections aren’t technically difficult, but the decision making is more complex than non-retina folks seem to realize.

My n=3 of programs I know well that all produce good comp docs, all middle tier or better. One had double the retina clinic time, probably 50% more volume per clinic, and at least 3 times the procedures of the other 2. One of them has a notoriously weak retina department that can’t keep faculty, and sadly that’s the one in my region where I’ve got some rural comp doc graduates doing less than bright things that occasionally trek over to me. I’d say most programs don’t really train you to be a truly competent even basic medical retina doc without fellowship.

Similar to Slide, I don’t think it’s unreasonable to ask a comp doc to do the basics. Keep antibiotics if you’re doing shots. Do an anterior vit/sulcus lens/suture when you break bag.

If you’re wiling to cede bread and butter stuff to non-physicians but also advocate for special status for plastics (which I’m fine with btw), that seems like a really odd stance.

 

[PhospholipaseA2]

Interesting discussion going here. Appreciate the contributions and always interesting to see the varying points of view on this forum. I’ll just add that covering another doctor’s complications is sometimes just part of what we do and doesn’t mean they shouldn’t be doing the procedure. This goes for retina too. Just had a PC rupture vs. Vitrector tap cataract referred post-vit from a retina doc. Patient developed rapidly progressive PSC after their mac hole repair. Did the cataract and it went well. There was a fibrotic scar and folds in the PC but still able to get the IOL in the bag. Usually it’s retina cleaning up after us anterior seg folks, but every once in a while it goes the other way.

 

[Slide]

Interesting discussion going here. Appreciate the contributions and always interesting to see the varying points of view on this forum. I’ll just add that covering another doctor’s complications is sometimes just part of what we do and doesn’t mean they shouldn’t be doing the procedure. This goes for retina too. Just had a PC rupture vs. Vitrector tap cataract referred post-vit from a retina doc. Patient developed rapidly progressive PSC after their mac hole repair. Did the cataract and it went well. There was a fibrotic scar and folds in the PC but still able to get the IOL in the bag. Usually it’s retina cleaning up after us anterior seg folks, but every once in a while it goes the other way.

I agree that part of the job is managing complications but one point we're making is that it's one thing to manage complications from another doctor (I agree for specialists it's part of the job), it's another to dump your complications on someone else and use the excuse that you don't have the skillset or training to at least try to stabilize the patient in some way. I've yet to hear a convincing argument why a comprehensive ophthalmologist has to draw the line between injecting a VEGF and an antibiotic - patient care is not the answer because the sooner you inject the better.

 

[Dusn]

The issue is not the endophthalmitis. It’s the OCT interpretation and injecting patients over and over again who never needed injections in the first place. If I were a patient who got a lifetime of monthly injections for Mac tel, pseudocysts, or for some collapsed vitelliform-like lesion that left a nonexudative hyporeflective space under my retina, I’d be pissed. But unfortunately this scenario happens all the time.

 

[TheLesPaul]

In theory, but I don’t share your optimism when it comes to retina. The injections aren’t technically difficult, but the decision making is more complex than non-retina folks seem to realize.

My n=3 of programs I know well that all produce good comp docs, all middle tier or better. One had double the retina clinic time, probably 50% more volume per clinic, and at least 3 times the procedures of the other 2. One of them has a notoriously weak retina department that can’t keep faculty, and sadly that’s the one in my region where I’ve got some rural comp doc graduates doing less than bright things that occasionally trek over to me. I’d say most programs don’t really train you to be a truly competent even basic medical retina doc without fellowship.

Similar to Slide, I don’t think it’s unreasonable to ask a comp doc to do the basics. Keep antibiotics if you’re doing shots. Do an anterior vit/sulcus lens/suture when you break bag.

If you’re wiling to cede bread and butter stuff to non-physicians but also advocate for special status for plastics (which I’m fine with btw), that seems like a really odd stance.

I absolutely agree that decision-making is complex, which is why I would want a fully fledged retina specialist for my eye. I definitely think I would do a much better job on a chalazion or toxin/filler then someone who isn’t ASOPRS or even a physician. But the standard of care is average work, not exceptional work and fortunately most patients can get by just fine with mediocrity. Especially in a rural setting, mediocrity is probably better than nothing at all.

I’m not really part of the intraocular world so on its face, it’s very surprising to me that someone would not start the initial antibiotic injection for early endophthalmitis before referring to a retina specialist. I agree that if you were going to do injections, you should at least diagnose and start the management for the best of the patient.

 

[TheLesPaul]

If you’re wiling to cede bread and butter stuff to non-physicians but also advocate for special status for plastics (which I’m fine with btw), that seems like a really odd stance.

The cat is already out of the bag with toxin and filler, and as with most procedural things practice makes perfect. I just don’t think it’s possible to fight a pharmaceutical industry whose goal is to sell as many vials or syringes to as many different injectors as possible.

 

[docdoc2012]

The issue is not the endophthalmitis. It’s the OCT interpretation and injecting patients over and over again who never needed injections in the first place. If I were a patient who got a lifetime of monthly injections for Mac tel, pseudocysts, or for some collapsed vitelliform-like lesion that left a nonexudative hyporeflective space under my retina, I’d be pissed. But unfortunately this scenario happens all the time.

There are definitely missed diagnoses, but a vast majority have the bread and butter pathology that need regular injections. I would rather them be treated for these instead of using there limited resources to travel a few hours once a month. They just simply wont come and will let themselves go blind. Ive seen this play out plenty of times.

The comparison of a dropped lens to endophthalmitis injections is preposterous. The only thing they have in common is that they are fear inducing to doctors that dont deal with them all the time. Most programs have residents doing intravitreal injections. Most do not have residencies graduating having done vitrectomies.

There will always be bad apples. And more people need shots than there are retina specialists available. Both statements are true

 

[eyeeye_captain]

There are definitely missed diagnoses, but a vast majority have the bread and butter pathology that need regular injections. I would rather them be treated for these instead of using there limited resources to travel a few hours once a month. They just simply wont come and will let themselves go blind. Ive seen this play out plenty of times.

The comparison of a dropped lens to endophthalmitis injections is preposterous. The only thing they have in common is that they are fear inducing to doctors that dont deal with them all the time. Most programs have residents doing intravitreal injections. Most do not have residencies graduating having done vitrectomies.

There will always be bad apples. And more people need shots than there are retina specialists available. Both statements are true

Even if we were to say that the vast majority of what is being treated is bread and butter and accurate (no way to quantify), I would posit that you’re far more likely to be overtreated by a non-retina doc. Retina is also more likely to be able to pivot if initial therapy is ineffective.

The ACGME minimum for injections as the surgeon is 10, and retina surgery is at least 10 as an assistant. Obviously you’re going to get more opportunities for injections, and every program is required to have you do them, but as I said above, there are wide differences in some programs’ exposure, even in good ones.

Where are you driving multiple hours to find a retina specialist? Alaska? The Dakotas? Rural Montana? I think even West Virginia and Mississippi have relatively good coverage. It’s not a big segment of the population. The comp people who inject in my region have retina colleagues either down the street or within 45 minutes in 2 or 3 directions, and I’m mostly semi-rural. My podunk undesirable hometown has 2 docs that go to the neighboring city. It probably takes those folks almost as long to drive to a Walmart or to see any other medical specialist, so while unfortunate, they know the ballgame.

 

[RetinaDude]

The issue is not the endophthalmitis. It’s the OCT interpretation and injecting patients over and over again who never needed injections in the first place. If I were a patient who got a lifetime of monthly injections for Mac tel, pseudocysts, or for some collapsed vitelliform-like lesion that left a nonexudative hyporeflective space under my retina, I’d be pissed. But unfortunately this scenario happens all the time.

Getting a late night call, from one of your general ophthalmology colleagues, saying they have a post injection endo and then realizing the patient was misdiagnosed and never needed the injection to start with.

 

[docdoc2012]

Even if we were to say that the vast majority of what is being treated is bread and butter and accurate (no way to quantify), I would posit that you’re far more likely to be overtreated by a non-retina doc. Retina is also more likely to be able to pivot if initial therapy is ineffective.

The ACGME minimum for injections as the surgeon is 10, and retina surgery is at least 10 as an assistant. Obviously you’re going to get more opportunities for injections, and every program is required to have you do them, but as I said above, there are wide differences in some programs’ exposure, even in good ones.

Where are you driving multiple hours to find a retina specialist? Alaska? The Dakotas? Rural Montana? I think even West Virginia and Mississippi have relatively good coverage. It’s not a big segment of the population. The comp people who inject in my region have retina colleagues either down the street or within 45 minutes in 2 or 3 directions, and I’m mostly semi-rural. My podunk undesirable hometown has 2 docs that go to the neighboring city. It probably takes those folks almost as long to drive to a Walmart or to see any other medical specialist, so while unfortunate, they know the ballgame.

India, ketucky, ohio, Illinois? Definitely the Dakota and Montana.
The only reason west Virginia as decent coverage is because the large group there satellites 2 -2.5 hrs away. How sustainable will that be?
I think you are truly underestimating how destitute many people are in small towns and rural areas. They arent going to Walmart once a month.
My practice has a 2 hr catchment area. People will literally go blind from not having rides to travel despite the satelliting that we do. Most amd patients cant actually drive. They dont go to Walmart on weekdays. Most of their families have to work. Its not as simple as telling people to drive 2 hrs so we can protect our turf.

 

[TheLesPaul]

most programs are getting multiple hundreds of injections now...I had 600+ and that was years ago...

Even if we were to say that the vast majority of what is being treated is bread and butter and accurate (no way to quantify), I would posit that you’re far more likely to be overtreated by a non-retina doc. Retina is also more likely to be able to pivot if initial therapy is ineffective.

The ACGME minimum for injections as the surgeon is 10, and retina surgery is at least 10 as an assistant. Obviously you’re going to get more opportunities for injections, and every program is required to have you do them, but as I said above, there are wide differences in some programs’ exposure, even in good ones.

Where are you driving multiple hours to find a retina specialist? Alaska? The Dakotas? Rural Montana? I think even West Virginia and Mississippi have relatively good coverage. It’s not a big segment of the population. The comp people who inject in my region have retina colleagues either down the street or within 45 minutes in 2 or 3 directions, and I’m mostly semi-rural. My podunk undesirable hometown has 2 docs that go to the neighboring city. It probably takes those folks almost as long to drive to a Walmart or to see any other medical specialist, so while unfortunate, they know the ballgame.

 

[PhospholipaseA2]

most programs are getting multiple hundreds of injections now...I had 600+ and that was years ago...

This is true. Same experience here. Every single injection was discussed with a retina doc too, so staffing 600+ injections, you develop some competence for routine disorders and a healthy respect for how nuanced many things can be. I agree the variability of residencies is probably drastic.

 

[eyeeye_captain]

India, ketucky, ohio, Illinois? Definitely the Dakota and Montana.
The only reason west Virginia as decent coverage is because the large group there satellites 2 -2.5 hrs away. How sustainable will that be?
I think you are truly underestimating how destitute many people are in small towns and rural areas. They arent going to Walmart once a month.
My practice has a 2 hr catchment area. People will literally go blind from not having rides to travel despite the satelliting that we do. Most amd patients cant actually drive. They dont go to Walmart on weekdays. Most of their families have to work. Its not as simple as telling people to drive 2 hrs so we can protect our turf.

I grew up in bumblef*ck and know all about the struggle of getting Meemaw to the doctor with my barely above dirt poor family. I work with that all the time now where Papaw also can’t afford even Avastin on his fixed income when he managed to get his niece off work to bring him. I’m not advocating for forgetting poor country folks. I’m just talking numbers.

Per Google, 86% of Americans live in a metro/micro of 50k+. In the states you listed, I doubt there’s many 50k population cities that don’t have a retina doc because we understand the need to travel. I know multiple docs who do/did fly somewhere. There aren’t many people that rural, and they choose to be, and there’s nothing wrong with it at all as long as they’re happy and know the trade offs.

 

[eyeeye_captain]

most programs are getting multiple hundreds of injections now...I had 600+ and that was years ago...

This is true. Same experience here. Every single injection was discussed with a retina doc too, so staffing 600+ injections, you develop some competence for routine disorders and a healthy respect for how nuanced many things can be. I agree the variability of residencies is probably drastic.

600 injections was maybe 2 months in my fellowship, with usually more difficult pathology. Plus I carried those patients through as opposed to county/VA where the resident never sees what’s happening on the back end.

When you don’t see the extended course, you don’t know as much. When you’re too green to understand what the retina attending is telling you, you don’t know or learn as much. Dunning Kruger is real. There’s significant variability in numbers and supervision in training. It’s not a rip on the comp folks other than saying “hey, you only know the basics”

 

[docdoc2012]

I grew up in bumblef*ck and know all about the struggle of getting Meemaw to the doctor with my barely above dirt poor family. I work with that all the time now where Papaw also can’t afford even Avastin on his fixed income when he managed to get his niece off work to bring him. I’m not advocating for forgetting poor country folks. I’m just talking numbers.

Per Google, 86% of Americans live in a metro/micro of 50k+. In the states you listed, I doubt there’s many 50k population cities that don’t have a retina doc because we understand the need to travel. I know multiple docs who do/did fly somewhere. There aren’t many people that rural, and they choose to be, and there’s nothing wrong with it at all as long as they’re happy and know the trade offs.

Yes...and this once again boils down to access. I guarantee you the new generation of retina doctors are not going to fly to a satellite for the decreasing reimbursements. No one was doing crazy satellite days out of the goodness of their hearts.
A few mactels and ShRms being overinjected or people going blind due to inability to travel? I would vote for the comp doc doing avastin.
.

 

[Ophthodoc2018]

I completely agree - the number of gunners and workaholics in the younger generation are dwindling. Millennial doctors are increasingly more and more lifestyle and location driven. I fear that rural americas access will plummet because the younger retina doctors will begin to stop flying/driving 2 hours to satellite clinics and also stop taking rural job offers.

I honestly still think if all the comp docs did injections, there will still be an access issue …

 

[eyeeye_captain]

I guarantee you the new generation of retina doctors are not going to fly to a satellite for the decreasing reimbursements. No one was doing crazy satellite days out of the goodness of their hearts.

Kind of an “Ok boomer” post. (For reference I think I’m a millennial and busted it as much as possible coming out). Maybe it’s because we’ve got a physician owned practice, but every hire in the last 20 years bar one (that was before my time) wanted to work hard, including the most recent ones.

Declining reimbursements are precisely the reason to go to satellites. This is a business, and the two ways to make money are volume and ancillaries. More volume drives the ancillaries as well.

If the kids want to sit in one office and have no patients, then go ahead I guess. But with federal loan caps, their higher debt load probably will motivate some of them. If PE is still a big player, they’ll send the suckers wherever they can to make numbers. Yay access! I’m well aware they will - I had an offer back in the day and they sent the doc they hired instead to the type of underserved offices you’re talking about instead of the ones in town they claimed I would work in.

A few years ago, we interviewed someone who felt there was too much driving. Ok, cool. Ran into them at a conference and they’d left some cozy but low paying hospital gig. They then went and joined a PE group where they’re flying them around the state, so I guess even the young ones can suck it up.

 

[eyeeye_captain]

And let’s be honest, at least around me, the new grad comp docs want absolutely nothing to do with anything behind the lens. Cataracts and MIGS, and then anything funny on the dilated exam/photo gets a referral. I’m actually pretty excited about it - their lack of comfort and/or laziness gives me easy business.

 

[Slide]

was

Yes...and this once again boils down to access. I guarantee you the new generation of retina doctors are not going to fly to a satellite for the decreasing reimbursements. No one was doing crazy satellite days out of the goodness of their hearts.
A few mactels and ShRms being overinjected or people going blind due to inability to travel? I would vote for the comp doc doing avastin.
.

Funny thing, with how reimbursement has changed this year it might be the opposite. 14% reduction for RD repair, 5% increase for injections - for high injection volume clinics (which satellites tend to be) you might see more retina willing to do satellites.

 

[Slide]

I completely agree - the number of gunners and workaholics in the younger generation are dwindling. Millennial doctors are increasingly more and more lifestyle and location driven. I fear that rural americas access will plummet because the younger retina doctors will begin to stop flying/driving 2 hours to satellite clinics and also stop taking rural job offers.

I honestly still think if all the comp docs did injections, there will still be an access issue …

I think the rural access issue is way overblown. The reality for rural areas is that many of these towns are dying off if not dead already and metros continue to consolidate. The only rural areas I see growing are those near certain attractions and destinations (like ski areas). Most patients across the country can get to a specialist within a 90 min drive, and probably much less than that. PE is literally flying specialists to these places too to see patients, and even with a focus towards lifestyle, when you start seeing your salary get whittled down and your family/spouse no longer want to live like they did in residency/felllowship, that attitude changes fast.

 

[RetinaDude]

Kind of an “Ok boomer” post. (For reference I think I’m a millennial and busted it as much as possible coming out). Maybe it’s because we’ve got a physician owned practice, but every hire in the last 20 years bar one (that was before my time) wanted to work hard, including the most recent ones.

I've gotta say, the "younger" retina docs we have added to our group, in recent years, are nothing like the media portrays Millenials. All of the ones we have added work their tails off and are more than willing to do whatever is needed to build their practice. We are very open with our numbers, so I believe they see how much partners make and think "if I work hard, and build my practice up, that'll be my numbers in a few years".

 

[Ophthodoc2018]

I think the rural access issue is way overblown. The reality for rural areas is that many of these towns are dying off if not dead already and metros continue to consolidate. The only rural areas I see growing are those near certain attractions and destinations (like ski areas). Most patients across the country can get to a specialist within a 90 min drive, and probably much less than that. PE is literally flying specialists to these places too to see patients, and even with a focus towards lifestyle, when you start seeing your salary get whittled down and your family/spouse no longer want to live like they did in residency/felllowship, that attitude changes fast.

I have a large proportion of patients who refuse to drive 20-25 minutes for an appointment, let alone 90 minutes...

Another issue with access in rural/satellite areas is that when the patient misses the appointment due to illness or transportation its very hard for them to get back onto the already fully packed schedule where docs rotate once or twice a month.

 

[dantt]

Kind of an “Ok boomer” post. (For reference I think I’m a millennial and busted it as much as possible coming out). Maybe it’s because we’ve got a physician owned practice, but every hire in the last 20 years bar one (that was before my time) wanted to work hard, including the most recent ones.

Declining reimbursements are precisely the reason to go to satellites. This is a business, and the two ways to make money are volume and ancillaries. More volume drives the ancillaries as well.

If the kids want to sit in one office and have no patients, then go ahead I guess. But with federal loan caps, their higher debt load probably will motivate some of them. If PE is still a big player, they’ll send the suckers wherever they can to make numbers. Yay access! I’m well aware they will - I had an offer back in the day and they sent the doc they hired instead to the type of underserved offices you’re talking about instead of the ones in town they claimed I would work in.

A few years ago, we interviewed someone who felt there was too much driving. Ok, cool. Ran into them at a conference and they’d left some cozy but low paying hospital gig. They then went and joined a PE group where they’re flying them around the state, so I guess even the young ones can suck it up.

Plenty of patients in the cities.

 

[Slide]

I have a large proportion of patients who refuse to drive 20-25 minutes for an appointment, let alone 90 minutes...

Another issue with access in rural/satellite areas is that when the patient misses the appointment due to illness or transportation its very hard for them to get back onto the already fully packed schedule where docs rotate once or twice a month.

I do as well. I live in one of the most rural states in the country, and also one of the poorest (if not the most). The patients who want to get care find a way to make it work. I do get the transportation/illness part because I have a lot of sick diabetics and vasculopaths but at the same time this often means they're likely to not be seen even if you're in the same town since they'll likely be in the hospital or in a similar setting and are usually out for a while. 20-25 minutes is not a long time to drive if you're rural, and if that's too much of a bother for them, then you could set up shop in their neighborhood and they still probably won't come. You can bring down the travel time all you want but the patients have to make it their responsibility to see you.

But to the original point, like the VA, the rural access issue will likely sort itself in the next upcoming decades. The only rural places that are growing are the richer, well do to areas (like New England and Nashville surrounding areas).

 

[docdoc2012]

I think consideration for patients needs to re-enter this conversation. No other speciality really requires as many visits as retina does, nor are the visits as crucial. Especially for the sick pts, we arent the only doctors they have to see and get rides for.
I practice in a Midwest state in a small city with a 2 hr catchment radius. Its not as simple as 'you'll find a way if u really want to'.
No. People cant. And they dont. They just go blind. And if they miss a satellite appointment, it throws everything off.
People's lives dont revolve around their injection schedules.
A lifetime of avastin (due to ****ty insurance and no gooddays) every 1-2 months is crazy if you think about it.

No. The access issue is not overblown at all in my experience. And if, as some of you are arguing, that these patients basically should be left behind cuz they don't care enough to make it to their appointments somehow, then why do you care if the comp guy in town injects them instead

 

[Slide]

I think consideration for patients needs to re-enter this conversation. No other speciality really requires as many visits as retina does, not are the visits as crucial. Especially for the sick pts, we arent the only doctors they have to see and get rides for.
I practice in a Midwest state in a small city with a 2 hr catchment radius. Its not as simple as 'you'll find a way if u really want to'.
No. People cant. And they dont. They just go blind. And if they miss a satellite appointment, it throws everything off.
People's lives dont revolve around their injection schedules.
A lifetime of avastin (due to ****ty insurance and no gooddays) every 1-2 months is crazy if you think about it.

No. The access issue is not overblown at all in my experience. And if, as some of you are arguing, that these patients basically should be left behind cuz they don't care enough to make it to their appointments somehow, then why do you care if the comp guy in town injects them instead

To your point, I'm not opposed to the comp guy doing injections monthly (have never been if you've seen my posting history) in these situations, but more so that they refuse to refer patients when they are getting monthly Avastin for 2 years without any attempt to extend or send post-injection endophthalmitis to me without trying to at least stabilize the patient. Monthly injections are going to be difficult for anyone after several months whether you're 15 min away or 90 minutes away.

But you also bring up a point my colleagues have bought up repeatedly - I guarantee you most patients don't need to be on monthly Avastin and can either be extended with good outcomes or switched to a later generation anti-VEGF and be successfully extended even with crappy insurance. There is plenty of literature supporting extending with stable subretinal fluid without an adverse change in outcome long term but these patients don't even get discussions about this with their injector. Genentech and Eylea have programs for these patients to receive heavily discounted medications or have them replaced for free- Genentech is pretty good about this. In fact, I have a considerable amount of people on the replacement program. There's even Susvimo for these situations - insurance oddly will cover this sometimes instead of branded medications. Can't use branded? These crappy insurances will still often let you try a biosimilar like Cimerli/Byooviz or even Pavblu, which is still better than just slamming monthly Avastin. I have maybe less than 10 patients in a mature practice that need monthly Avastin. And the thing is, when I see some of these patients, these conversations are never brought up by their ophthalmologist. It's just inject and move on.

I understand not all states do this but Medicaid here provides transportation if you give 3 days notice; I looked at the logistics and in a desolate state like mine, a patient is almost no more than 90 minutes from a satellite clinic or main clinic. And to be frank, I try to accommodate our patients as much as possible, but if someone isn't willing to take 20-25 minutes to come for a visit that takes an hour or less but has no problems driving an hour to their deer camp for days at a time or their local bar/casino, I don't have that much sympathy for them.

 

[Dusn]

I've seen plenty of patients who would not go blind if they stopped getting injections -- because they never needed the injections in the first place. Unnecessary monthly injections for life is also a big burden on the patient and a waste of everyone's healthcare dollars. I'm not saying that comprehensive docs can't do injections, but if they do do it, they need to keep paying attention. If the fluid does not improve, it could mean that the patient doesn't really need injections, rather than the patient needs more frequent injections. And if the fluid seems to improve, and then gets worse again, and fluctuates randomly despite a stead injection interval, and the patient has a thick choroid... chronic CSR can be very hard to differentiate from NVAMD.