Routine Cataract Reimbursement to fall below $300

[idoc]

What would we all do if this was the headline we woke up to from the AAO tomorrow. Just stop and think about it. Some say that this will never happen, but look at how compensation has fallen over the last 10 years alone. One attending has told me that we he started about 10 yrs ago cataract reimbursement was $1,800, and no one could ever foresee it falling below $1000. Now, medicare is currently paying around $650 per case, and if you are co-managing, this puts your personal collection at about $500. To add insult to injury, the SGR is slated to cut the compensation rate each year, with the goal being to pay the same dollar amount to ophthalmologists for the total cost of cataract surgery, despite a dramatic rise in number of cases from the baby boomer generation. As a current third year resident, it is scary. The government is putting the squeeze on ophthalmology along with other specialties and despite our (WEAK) political action group, we are getting the proverbial shaft. I however propose a solution.

I may get flamed for this post per my normal routine, but I propose that the only way to get real action from congress is to form a water-tight labor union for ophthalmology. It would likely be in everyone's best interest if optometry were included in this union so as to form a collective front on reimbursement issues. As DrGreggory pointed out in a past post, decreased cataract compensation is stressing optometry to supply more and more cataracts to the cutters, with less margin for comanagement. Also, by having a united front with optometry we could solve scope of practice issues internally. We must remember that although we are professional healthcare providers held in high esteem in our community, we are really just highly trained laborers who are being taken advantage of by our employers (i.e. medicare and other third party payers). We have been taking this abuse for too long, and I believe we need to band together and leverage what power we have for the future of our profession. Any and all comments are welcome regarding this issue from all eye care professionals.

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[VA Hopeful Dr]

Unions are illegal for doctors.

That being said, I think a political alliance with ODs about reimbursement is a fantastic idea. The AOA needs something useful to do for a change.

 

[PBEA]

What would we all do if this was the headline we woke up to from the AAO tomorrow. Just stop and think about it. Some say that this will never happen, but look at how compensation has fallen over the last 10 years alone. One attending has told me that we he started about 10 yrs ago cataract reimbursement was $1,800, and no one could ever foresee it falling below $1000. Now, medicare is currently paying around $650 per case, and if you are co-managing, this puts your personal collection at about $500. To add insult to injury, the SGR is slated to cut the compensation rate each year, with the goal being to pay the same dollar amount to ophthalmologists for the total cost of cataract surgery, despite a dramatic rise in number of cases from the baby boomer generation. As a current third year resident, it is scary. The government is putting the squeeze on ophthalmology along with other specialties and despite our (WEAK) political action group, we are getting the proverbial shaft. I however propose a solution.

I may get flamed for this post per my normal routine, but I propose that the only way to get real action from congress is to form a water-tight labor union for ophthalmology. It would likely be in everyone's best interest if optometry were included in this union so as to form a collective front on reimbursement issues. As DrGreggory pointed out in a past post, decreased cataract compensation is stressing optometry to supply more and more cataracts to the cutters, with less margin for comanagement. Also, by having a united front with optometry we could solve scope of practice issues internally. We must remember that although we are professional healthcare providers held in high esteem in our community, we are really just highly trained laborers who are being taken advantage of by our employers (i.e. medicare and other third party payers). We have been taking this abuse for too long, and I believe we need to band together and leverage what power we have for the future of our profession. Any and all comments are welcome regarding this issue from all eye care professionals.

I agree that a united front is the only solution for the various issues facing eyecare (scope of practice, reimbursement, practitioner numbers). How best to accomplish this is the tricky part. I like unions for the very reason they exist (to prevent unfair leverage), but if they are really illegal for docs, then what are some other options? In the past I've proposed merging the fields, too much wasted energy is expended fighting turf wars, and reimbursement issues with third party mediators (legislator, public opinion) that dont have a clue what they are doing. Additionally supply numbers seem out of skew with demand (despite boomers). In the meantime, the house of eye remains divided, and nothing is solved. No one here can tell me that merging the fields is valueless, or impossible. It may represent the best/only option for controlling our own marketplace.

 

[Free Radicle]

Looks liket his idea has been hashed around at the AMA level - not sure what came of it though (http://query.nytimes.com/gst/fullpage.html?res=9E03E0DF103BF932A15755C0A96F958260)

 

[luxpara]

why are unions illegal for doctors? Is there some way to change this?

 

[orbitsurgMD]

Looks liket his idea has been hashed around at the AMA level - not sure what came of it though (http://query.nytimes.com/gst/fullpage.html?res=9E03E0DF103BF932A15755C0A96F958260)

Cataract surgery may become less readily offered (if it pays not to go to the OR), except by surgeons with very streamlined high-volume practice operations who employ extenders (optometrists) and who are able to recapture losses in fee income through their surgery center operations. Greater emphasis may be placed on up-selling combined refractive and cataract procedures (presbyopic IOLs, Lasik, keratoplasty), not necessarily a good thing.

We may learn to operate more like dentists if things get too bad. Leaving the insurance to a minimal number of practice services, even excluding Medicare if that became a significant liability. Functioning outside of the insurance world would be a return to typical practices that predated Medicare part-B, circa 1967. (Note the irony that cataract reimbursement has now dropped below the actual number of dollars paid in 1967; who knows what that amounts to in constant dollars, $108.00 by my internet-enabled calculation. That makes your speculation of $300 per case (2006) about $48 in 1967 dollars.)

In the end, this will hurt ophthalmology, make practice most difficult for the youngest doctors who also start with the greatest debts, and reduce incentives to innovate.

 

[Ben Chudner]

why are unions illegal for doctors? Is there some way to change this?

"As a group of highly skilled workers, doctors seeking to unionize face barriers in antitrust laws, which protect consumers against monopolies of professional services. (The effect of these laws, in limiting physician unions to doctors in nonmanagerial positions, resembles the effect on private-college faculty of the Supreme Court's 1980 decision in the case of Yeshiva University. In that decision, the Court ruled that professors are managers and therefore ineligible to form unions under the National Labor Relations Act, under which collective bargaining occurs at private colleges.)

To avoid antitrust barriers, the AMA, in its initial efforts is focusing on the 17 percent of physicians who are nonmanagerial employees rather than those who are in private practice or who occupy executive or supervisory positions."

Quoted from http://findarticles.com/p/articles/mi_qa3860/is_199911/ai_n8856726

 

[hbs]

We have to voice our opinion people. Lobbying power is the way to go. We have to have an organization who can represent us. I think it's totally unfair for our reimbursements to go down while all other income is being adjusted for inflation. Although less effective, I think if we all get in touch with our congress members to voice our opinion it may help. Just read my previous post.

 

[Paulie]

I'm a PGY-1 currently but will be doing ophtho in the same hospital system. I have no choice but to be in a union. I'm sure many residency physicians are. I know it is residency, but if I can be in a union now, why would unions be illegal for attendings?

 

[VA Hopeful Dr]

I'm a PGY-1 currently but will be doing ophtho in the same hospital system. I have no choice but to be in a union. I'm sure many residency physicians are. I know it is residency, but if I can be in a union now, why would unions be illegal for attendings?

Dr. Chudner's quote from 2 posts up says that the anti-trust stuff only applies to doctor's in manager positions. Since residents are hospital employees, you're not in a managerial position.

Least that's what I'd assume.

 

[idoc]

"As a group of highly skilled workers, doctors seeking to unionize face barriers in antitrust laws, which protect consumers against monopolies of professional services.
Quoted from http://findarticles.com/p/articles/mi_qa3860/is_199911/ai_n8856726

Why then can Pilots have a union? Are they not a monopoly of profesional service providers?

 

[Free Radicle]

I believe anybody who receives a W-2 form at the end of the year can unionize, physician or not.

 

[MacGyver]

We may learn to operate more like dentists if things get too bad. Leaving the insurance to a minimal number of practice services, even excluding Medicare if that became a significant liability. Functioning outside of the insurance world would be a return to typical practices that predated Medicare part-B, circa 1967.

Unfortunately thats not going to work. Medicare has sufficient monopoly control over the healthcare industry to arbitrarily set rates any way they see fit.

By 2020, Medicare will control 70% of all healthcare dollars spent in the USA.

The dental industry has no comparative monopoly entity to deal with. Source I looked at claimed only 40% of dentistry is controlled by the insurance sector. For medicine, its over 90%.

 

[MacGyver]

"As a group of highly skilled workers, doctors seeking to unionize face barriers in antitrust laws, which protect consumers against monopolies of professional services.

If thats the law, then how the hell do pilots and engineers get to form unions? they must have specific exemption clauses. Stinks like **** to me.

 

[VA Hopeful Dr]

If thats the law, then how the hell do pilots and engineers get to form unions? they must have specific exemption clauses. Stinks like **** to me.

Because neither of those are essential to the common welfare, were I to guess.

 

[orbitsurgMD]

Unfortunately thats not going to work. Medicare has sufficient monopoly control over the healthcare industry to arbitrarily set rates any way they see fit.

By 2020, Medicare will control 70% of all healthcare dollars spent in the USA.

The dental industry has no comparative monopoly entity to deal with. Source I looked at claimed only 40% of dentistry is controlled by the insurance sector. For medicine, its over 90%.

The dental profession enjoys a significant amount of independence of Medicare and even third-party interference to no apparent ill effect.

For medical professionals it works only at the cost of "opting out" of Medicare, which is legal (and at present, probably economically impossible for most practitioners). But if average reimbursement for the typical practice's "basket" of Medicare services came in below an economically sustainable level, such that it did not make sense to provide services for risk of losing money, then opting out might become a forced choice. Then you are in the same boat as dentists and others whose services depend on cash payment. If a large segment of your practice is insured by a carrier whose capped payments do not cover the costs of delivery, then you either refuse that form of payment and hope enough of your patients remain and are able to pay you fairly, or you close up shop. The last option hasn't happened in any significant measure anywhere I have heard of, but that doesn't mean it couldn't ever happen.

Opting out obviously works only if doctors do so in large numbers, over wide areas and without exceptions. Refractive surgeons and pediatric ophthalmologists could probably choose this without much consequence even today, but most general ophthalmologists and other subspecialists clearly could not, as the typical practice population is heavily skewed toward the Medicare-eligible age group, and the practices depend on Medicare for a significant proportion of their revenues.

 

[drgregory]

Opting out obviously works only if doctors do so in large numbers, over wide areas and without exceptions. Refractive surgeons and pediatric ophthalmologists could probably choose this without much consequence even today, but most general ophthalmologists and other subspecialists clearly could not, as the typical practice population is heavily skewed toward the Medicare-eligible age group, and the practices depend on Medicare for a significant proportion of their revenues.

my partners (ophthalmologists) and myself (optometrist) had 78% of our 2005 surgical revenue from Medicare. dropping them now would be suicide. but, like orbitsurg says, continued falling of reimbursement or the reimbursements getting too far behind covering overhead/chair time would lead to large scale dropout. problem is, right now we'd see only 1 out of the 4 patients we see now, and we wouldnt make the mortgate on our surgical suite.

 

[3rdeye]

Sorry.

 

[idoc]

I found a very good article that explains the legality of physician unions at the link below.

http://www.physiciansnews.com/law/497union.html

My take after reading this is that the ability and right for people including doctors to unionize is based on their status as an employee. The federal government has little jurisdiction in telling Delta what they can pay their pilots. So the pilots can unionize, and hold out for better contracts knowing that the parent entity Delta has the option to fire all the pilots and hire new pilots at the rate they feel the market will sustain.

As doctors, we are a group of thousands of individual small businesses that provide the same services. If we came together and fixed a price, there would be no outside competition, and we would have an unfair monopoly.

However, if a conglomerate were formed that allowed each ophthalmologist to be considered an employee of the conglomerate, we would as employees be able to bargain with the parent conglomerate about what compensation would be fair. The simplest solution would be for doctors to form a "Big 3" type HMO situation where each parent conglomerate could absorb 33% of all physicians. This would allow for adequate competition between the 3 big conglomerates. These parent companies could allow each physician to "eat what they kill" minus the administrative fees/dues required to run an HMO. We would be able to then have our parent company decide a fair compensation package for each procedure. These HMO's would essentially be the only game in town, forcing companies who offer health benefits and even medicare to take or leave the deal.

Currently, the HMO game and Medicare in general are positioned against doctors, and in my opinion are guilty of price fixing and monopolizing on their power, with the lame excuse being "you don't have to accept medicare, or HMO's", knowing that no one could survive doing that. The idea of unionizing is complex, and likely will never happen because most physicians are too greedy and egocentric to realize the benefit of working as a group. Ophthalmologists are probably the worst, as you could have 95% agreement on a union and the 5% scabs would just keep cutting.

One further, and more devious way to express our dissatisfaction is for all training programs to finish the training of all current residents but set a deadline that until problems are fixed, no further residents will be trained in the US. That would likely take the cooperation of only about 100 program directors. I think that would shake things up sufficiently to get our point acrossed. Sorry for the long message, but this is an important matter. And remember until something really changes, we have no voice in congress. They will keep screwing us until we stand up.

 

[Ben Chudner]

optometrists, who are taught the values, ethics, and practices of effective salespeople.

I am not really sure how to respond to this uneducated assessment of optometric training. We are taught the same values and ethics as ophthalmologists. To assert that OD's are less ethical than MD's is ridiculous. Both professions have their share of questionable doctors. The difference is when an unethical OD pushes for a larger sale in optical the only risk is to the patient's wallet, but when an unethical OMD performs LASIK on a less than ideal candidate, the risk is a little more severe.

Ophthalmologists are some of the most greedy physicians out there. Look at LASIK! It could have been a cash cow for so many of us for quite a while, if it had been properly utilized as a cosmetic procedure, but because of the greed of a few, it has become akin to a haircut with the price-cutting ultimately taking a toll on its profitability.

Thanks for helping to prove my point about ethics.

How can you justify OMDs and Optoms getting paid the same under Medicare? I have read several threads and postings regarding this and I'm amazed at the capitulation so often expressed by those in medicine. This just shows the difference in mindset between those in medicine, who want only what's best for their patients, from those in optometry, who want only what's best for their wallets.

Let me see if I follow this. You say that ophthalmologists are some of the most greedy physicians out there, but it's the OD's that only want what's best for their wallets? You have no idea what the heck you are talking about. As for getting paid the same under Medicare, I am not sure how you can justify unequal payment. You obviously have no idea about this, but OD's actually do the exact same things that MD's do when examining a patient. We have to meet the same requirements when billing a particular level of exam and therefore we are rightfully paid the same.

There's a lot more I want to say and I'm already sorry I took so much space for this posting.

Believe me, you have said enough.

 

[3rdeye]

Sorry.

 

[Andrew_Doan]

What would we all do if this was the headline we woke up to from the AAO tomorrow.

Go work for Kaiser as an ophthalmologist! Starting comprehensive ophthalmologists start at $180K/year in Southern Cal and peak around $250K/year. Paid vacations/40-hour work week/Less business-admin headaches. Also, contribute more money to our PAC and get politically involved.


Seriously, this is a serious issue. If decreasing reimbursement bothers you, then you all should get more involved politically! If you're going to the AAO meeting in Las Vegas, check this session out:

Crisis! How to Manage the Political Crisis in our Profession

Monday Nov. 13
12:45 to 2:45 p.m.
The Venetian, Marcello Ballroom

The profession of ophthalmology is in crisis, as exemplified by the time and resources expended to rescind the directive that allowed optometrists to perform laser surgery in Veterans Administration Hospitals, ongoing legislative battles in Oklahoma to repeal legislation that authorizes optometrists to perform incision surgical procedures, and recent cuts in Medicare payments, the flawed SGR formula, and stalled tort reform legislation. This symposium will educate and provide you the advocacy tools necessary to strengthen our profession and protect our patients. FREE!

Optometry scope of practice is one aspect of advocacy, but reimbursement and Medicare budget cuts are also part of advocacy.

Also, keep in mind that EVERY specialty in medicine are subject to cuts. Just because radiology gets paid more now, does not mean the reimbursements will be the same when you finish training.

My advice is learn as much as you can about political advocacy for your profession, get involved, and start contributing our PAC.

As a resident, I gave $100. As an attending, I'm giving more. The average ophthalmologist gives $100/year. The average optometrist gives $1000/year. The average lawyer gives thousands per year. Guess who has the strongest lobby here...

 

[VA Hopeful Dr]

If you feel like you want to talk as an equal with me, do the following:

1. Go to a top-tier, undergraduate University on a Merit based scholarship w a 4.0 GPA in the hardcore sciences
2. Spend four years at a top 25 Medical School - not Optometry School - all at a cost of about $170K
3. Spend ONE year learning the nuts and bolts of internal medicine - that's right - can you say "medicine"?
4. Then do THREE years of SURGICAL training making less than minimum wage and getting no sleep - we real doctors call that being "on call"
5. After all this, spend an extra year doing a Fellowship getting grilled endlessly by some of the smartest DOCTORS in their field.

During all this, don't forget to take all 3 Steps of the Medical Licensing Exam.

Oh yeah, then there's something called the Boards , which inlcudes both written (that means you take a test) and oral exams.

So, pardon me if I'm upset that some schmuck in Congress thinks we should get paid the same.

But, then again, you wouldn't know what all this means because you probably couldn't get into medical school, so you figured you could go to "Optometry School" and call yourself a "doctor".

Why don't you post in the Optometry section, where you belong.

Actually, having just done some quick math, residents tend to make about 9-10 an hour, assuming 80 hour week is followed. So it could be as much as 15 if you do more like 60 hour weeks.

That aside, you seem awfully angry and I can't help but wonder why that is. There's another thread a few down where all the other ophthalmologists (attending and resident) have nothing but praise for the profession. What are they doing that you're not?

I'm certainly no expert, but I think ophthalmology training is so much more intense because of, maybe perhaps, the surgery. Residency time would be alot less if there was a medical opthalmology tract. That's also why opthalmology is so competitive. There aren't too many other specialties where you can make 4 grand in 15 minutes (going rate for lasik in my area).

As a fun side note, there's no need to be such a jerk when presented with a reasonable counter-argument to something you've said. Why not try civil debate to show that your opinion is the valid one. As a medical student, I'm always disheartened when attendings behave badly. Reflects poorly on the rest of us to the rest of the medical community (ie. why nurses are often short with us poor students).

 

[PBEA]

If you feel like you want to talk as an equal with me, do the following:

1. Go to a top-tier, undergraduate University on a Merit based scholarship w a 4.0 GPA in the hardcore sciences
2. Spend four years at a top 25 Medical School - not Optometry School - all at a cost of about $170K
3. Spend ONE year learning the nuts and bolts of internal medicine - that's right - can you say "medicine"?
4. Then do THREE years of SURGICAL training making less than minimum wage and getting no sleep - we real doctors call that being "on call"
5. After all this, spend an extra year doing a Fellowship getting grilled endlessly by some of the smartest DOCTORS in their field.

During all this, don't forget to take all 3 Steps of the Medical Licensing Exam.

Oh yeah, then there's something called the Boards , which inlcudes both written (that means you take a test) and oral exams.

So, pardon me if I'm upset that some schmuck in Congress thinks we should get paid the same.

But, then again, you wouldn't know what all this means because you probably couldn't get into medical school, so you figured you could go to "Optometry School" and call yourself a "doctor".

Why don't you post in the Optometry section, where you belong.

Oh boy, this is the type of rant I hate to see. I'll try and keep to the "high" road here, but I am bound to swerve and knock your teeth out. You see, you start out OK, what with some of the problems facing ophthalmology, but you lose ALL credibility when you try and drag optometry down into the mire you are so obviously caught in. If i'm a "salesperson" then so are you pal. You got excellent training, good for you, but in the many "medical" areas that optometry overlaps with ophthalmology, optometry delivers EQUAL outcomes (so much for your pathetic comments regarding equal reimbursement). Your whining in regard to OD greed, is mirrored exactly in OMD greed. There is no difference here. People choose to do the wrong thing for one of the following: money, pride, or power, and NOT because of the initials at the end of their name (so much for your pathetic comments regarding optometry's wallet). In the future refrain from including optometry as one of the reasons for your discontent with your field, it is misguided (you know inaccurate), and makes you sound like an ass.

Oh, and whatever subspecialty you fellowed in, I hope it suffers the most from reimbursement cuts, this way your "outrage" will manifest and you will change fields. Maybe your money-centric arrogance will be better served.

 

[Andrew_Doan]

Medicare cuts affect both optometry and ophthalmology. It's not all about scope of practice, but more to do with a shrinking pie. As I stated above, every physician needs to:

1) participate at the State Level with their state ophthalmological society;
2) become members of their PAC;
3) and learn more by attending courses at the AAO and Mid-Year Forum.

Your contributions will affect the landscape in which we all practice together.

======================
Put this on your AAO agenda
======================

Crisis! How to Manage the Political Crisis in our Profession

Monday Nov. 13
12:45 to 2:45 p.m.
The Venetian, Marcello Ballroom

The profession of ophthalmology is in crisis, as exemplified by the time and resources expended to rescind the directive that allowed optometrists to perform laser surgery in Veterans Administration Hospitals, ongoing legislative battles in Oklahoma to repeal legislation that authorizes optometrists to perform incision surgical procedures, and recent cuts in Medicare payments, the flawed SGR formula, and stalled tort reform legislation. This symposium will educate and provide you the advocacy tools necessary to strengthen our profession and protect our patients. FREE!

 

[idoc]

I think that we all need to try to focus on the bigger picture. Infighting between ophthalmology and optometry degrades both professions. I must admit some guilt in this as my record of posts may reflect. However, I think I have come to a new opinion about the profession of eye care in general. We could be much stronger if we could approach congress as a united front for increases in compensation. If as ophthalmologists we start trying to play "hard ball", and for instance stop performing surgery for a given period of time, it would strengthen the case for optometry to train in surgery. I honestly believe that if compensation for cataracts alone went up, it would stop much of the current controversy about scope of practice for optometry. We need to face the fact that we are getting squeezed collectively, which stresses the system and the symbiosis of the two professions. Ophthalmologists want to open optical shops to generate extra income, and optometrists want to do laser procedures etc for the same reason. I think optometry's best move would be to lobby congress to increase cataract reimbursement and fix the SGR. This would likely be an incredible olive branch move that may actually benefit both parties involved. Just a thought.

 

[VA Hopeful Dr]

I think optometry's best move would be to lobby congress to increase cataract reimbursement and fix the SGR. This would likely be an incredible olive branch move that may actually benefit both parties involved. Just a thought.

I think this would be an excellent joint venture. Obviously MDs benefit from the increased rate. ODs would as well, since post-op care is a set percentage of the fee. Its win/win.

 

[indytx]

I think this would be an excellent joint venture. Obviously MDs benefit from the increased rate. ODs would as well, since post-op care is a set percentage of the fee. Its win/win.

Are you suggesting that OD's should do the post-op checks on cataract patients operated on by OMD's?

 

[VA Hopeful Dr]

Are you suggesting that OD's should do the post-op checks on cataract patients operated on by OMD's?

What I suggest doesn't matter, it is already happening quite a bit out there.

 

[PBEA]

I think that we all need to try to focus on the bigger picture. Infighting between ophthalmology and optometry degrades both professions. I must admit some guilt in this as my record of posts may reflect. However, I think I have come to a new opinion about the profession of eye care in general. We could be much stronger if we could approach congress as a united front for increases in compensation. If as ophthalmologists we start trying to play "hard ball", and for instance stop performing surgery for a given period of time, it would strengthen the case for optometry to train in surgery. I honestly believe that if compensation for cataracts alone went up, it would stop much of the current controversy about scope of practice for optometry. We need to face the fact that we are getting squeezed collectively, which stresses the system and the symbiosis of the two professions. Ophthalmologists want to open optical shops to generate extra income, and optometrists want to do laser procedures etc for the same reason. I think optometry's best move would be to lobby congress to increase cataract reimbursement and fix the SGR. This would likely be an incredible olive branch move that may actually benefit both parties involved. Just a thought.

Hey IDOC, don't post in red! JR ("Big Brother") just PM'd me to inform me that all my red posts would be changed to black (you'll note his edit on my last post). Just wanted to give you a heads up, so he doesn't have to PM you. I told JR red was the color of love, but JR doesnt seem to agree.

 

[Ben Chudner]

If you feel like you want to talk as an equal with me, do the following:

I'm sure your patients love you.

 

[JR]

That's funny, I thought you told me before that red is the color of opression of your field and of the fight to expand scope . But if its the color of love, I may just have to change my mind .

Hey IDOC, don't post in red! JR ("Big Brother") just PM'd me to inform me that all my red posts would be changed to black (you'll note his edit on my last post). Just wanted to give you a heads up, so he doesn't have to PM you. I told JR red was the color of love, but JR doesnt seem to agree.

 

[KHE]

I'm sure your patients love you.

Its a shame that this thread is starting to take on the tired tone that so many of these threads do because if there was ever an issue that affects both ophthalmology AND optometry and for which the collective power of the professions could be effectively utilized, this one is it.

 

[orbitsurgMD]

If you feel like you want to talk as an equal with me, do the following:

1. Go to a top-tier, undergraduate University on a Merit based scholarship w a 4.0 GPA in the hardcore sciences
2. Spend four years at a top 25 Medical School - not Optometry School - all at a cost of about $170K
3. Spend ONE year learning the nuts and bolts of internal medicine - that's right - can you say "medicine"?
4. Then do THREE years of SURGICAL training making less than minimum wage and getting no sleep - we real doctors call that being "on call"
5. After all this, spend an extra year doing a Fellowship getting grilled endlessly by some of the smartest DOCTORS in their field.

During all this, don't forget to take all 3 Steps of the Medical Licensing Exam.

Oh yeah, then there's something called the Boards , which inlcudes both written (that means you take a test) and oral exams.

So, pardon me if I'm upset that some schmuck in Congress thinks we should get paid the same.

But, then again, you wouldn't know what all this means because you probably couldn't get into medical school, so you figured you could go to "Optometry School" and call yourself a "doctor".

Why don't you post in the Optometry section, where you belong.

Do yourself a favor and abandon your idea of achievement-driven career expectations. Honestly, I have come to think of this as a mental trap that leads only to unhappiness and frustration. And I don't say that patronizingly, but as a fellow practitioner who like you has invested heavily in my training and like you sees the future less remunerative than it appeared to me several years ago. I worry too. Ours is a profession that demands costly and constant professional upkeep, in continuing recertification (took my DOCK yesterday, so this has been at the front of my mind), in expensive medical equipment and technology, and in time and effort. That isn't likely to change. Yet control over the reimbursement for our services has largely been wrested from us, by the government and indirectly by our patients, and the government that makes the payment allocations seems indifferent to the consequences, at least to us.

It is hard to look at the AAO lobbying effort and think it has come to much, given the history of downward reimbursement and the predictions of further relentless reduction. But supporting the AAO lobbying effort is really the only choice we have before the forces joined to reduce our compensation even further. So I agree with Andrew on this.

As for the threat of optometry making gains into procedural activity, all I can say is that a falling knife cuts any hand that reaches. I see little advantage to their seeking these privileges. Third parties like the VA, which as a government agency enjoys shelter from liability and which responds largely to budgetary pressures might see advantages in reducing their ophthalmology staffing burden, but there is little reason to think commercial or private practice would enjoy much benefit in a falling reimbursement market. Selling upmarket glasses is still a better bet, financially, and not as fraught with risk.

 

[Ben Chudner]

Its a shame that this thread is starting to take on the tired tone that so many of these threads do because if there was ever an issue that affects both ophthalmology AND optometry and for which the collective power of the professions could be effectively utilized, this one is it.

True, this issue is one that both sides should be able to fight on the same side, but you cannot expect comments like those made by 3rdeye go without rebuttal. It is people like him/her that make it difficult for both sides to work together. Maybe the issue of reimbursement will be exactly what we all need to look past the initials at the end of our names.

 

[EYESURG]

I'd say we start billing like dentists do and essentially a cataract procedure would become like doing a crown. Why people are willing to pay 1000+ for a crown and not the same for a cataract??? After all, I believe my vision is more important then my teeth. On top of that, cataract procedure is more risky and has the potential for more complications.

 

[idoc]

The average price for a crown based on an n of 1 (my father) is about $4,000, which is about 7 times the current reimbursement for cataracts....I think I just puked. sorry.

I have to give it up to all the dentites, they are getting paid! Should have gone to dental school.

 

[PBEA]

I'd say we start billing like dentists do and essentially a cataract procedure would become like doing a crown. Why people are willing to pay 1000+ for a crown and not the same for a cataract??? After all, I believe my vision is more important then my teeth. On top of that, cataract procedure is more risky and has the potential for more complications.

I think this is a great idea, but the only way this works is if it is de-listed from medicare (and other mutates). Period. Vision is second to life (and maybe limb) in terms of our greatest fears, so i definetely agree with you here. Stands to reason that people would pay for the privilege of seeing (I mean thats the american way, right?) The most realistic measure of demand is in the fee market. C'mon, these dentites are makin' serious coin, and we are dickin' around with chump change. Exert some self restraint on our marketplace, the hell with the rest. These issues are ALWAYS underestimated here.

 

[orbitsurgMD]

my partners (ophthalmologists) and myself (optometrist) had 78% of our 2005 surgical revenue from Medicare. dropping them now would be suicide. but, like orbitsurg says, continued falling of reimbursement or the reimbursements getting too far behind covering overhead/chair time would lead to large scale dropout. problem is, right now we'd see only 1 out of the 4 patients we see now, and we wouldnt make the mortgate on our surgical suite.

I don't know how accurate the target of $300/cataract really is. Interesting that it is about equal to the sum of all the after-surgical care fees (under present E/M) during the 90-day inclusive postoperative care period. It might make not claiming for surgery and instead charging for all the postop care a more worthwhile alternative from a practice revenue perspective.

 

[idoc]

So, how could the ophthalmology/optometry groups lobby to drop just cataract surgery from the covered procedures in medicare? This would be a golden goose from my standpoint. You could charge what you want for cataract surgery, and still accept medicare/ private insurance for all other procedures and office visits. This would surely allow the politicians to balance the medicare budget, since cataract surgery is one of the largest single expenses they pay for. Political suicide, yes. But it would balance the budget.

 

[PBEA]

I don't know how accurate the target of $300/cataract really is. Interesting that it is about equal to the sum of all the after-surgical care fees (under present E/M) during the 90-day inclusive postoperative care period. It might make not claiming for surgery and instead charging for all the postop care a more worthwhile alternative from a practice revenue perspective.

Yeah, you might be right, but it still pales in comparison to the crown his father purchased. I'd like to see the free-market exude some influence on the retail cost of an IOL, now that would be fun.

Let me politely comment on the "legend" of comanagement that frequents this board. As an OD who actively engages in comanagement (like many other ODs) , I really am not too concerned with the "fee-splitting" that occurs between surgeon and primary doc. Like many ODs I see referrals quite a bit (ingoing and outgoing), but comanagement fees certainly do not constitute any significant portion of my revenues. I'd be inclined to let the surgeon complete the global period (and collect the entire fee), but mainly I see them within the global because the surgeon chooses to have me do so. I have no problem with this so I do so. I can/will/do see any post-op complication, and manage it to the limit of my comfort/ability. If keeping the comanagement fee would provide ophthalmology greater renumeration for CE(the "olive branch") then I say, have at it (although I contend the entire global fee is paltry, and that's the OP).

 

[PBEA]

So, how could the ophthalmology/optometry groups lobby to drop just cataract surgery from the covered procedures in medicare? This would be a golden goose from my standpoint. You could charge what you want for cataract surgery, and still accept medicare/ private insurance for all other procedures and office visits. This would surely allow the politicians to balance the medicare budget, since cataract surgery is one of the largest single expenses they pay for. Political suicide, yes. But it would balance the budget.

Of course I cant answer that. My guess is that cataracts would have to be cast in a similiar light as say refraction (in terms of disability). If you cant see because you need 10 diopters, then that's similiar to saying your 20/400 with your cataracts and you need an implant (i know not exactly the same). How does dentistry escape "public" coverage for oral issues (that might affect your ability to eat) when we the taxpayers cover someones ability to see. I mean if I have to eat out of a straw then thats a disability right? Same goes for vision IMHO.

 

[EYESURG]

The average price for a crown based on an n of 1 (my father) is about $4,000, which is about 7 times the current reimbursement for cataracts....I think I just puked. sorry.

I have to give it up to all the dentites, they are getting paid! Should have gone to dental school.

Everyone, I think this is a serious issue. Maybe we should not deal with medicare all together. We will basically do less procedures, but get paid more per procedure just like dentists. I am not kidding! Can this happen if reimbursments come down to $300?

 

[7ontheline]

Everyone, I think this is a serious issue. Maybe we should not deal with medicare all together. We will basically do less procedures, but get paid more per procedure just like dentists. I am not kidding! Can this happen if reimbursments come down to $300?

I think it depends on how united the ophthalmology community becomes. (My guess - not very) If everyone agrees, then I think something can happen. However, if there are still MDs performing surgery for Medicare they are going to be super busy while everyone else wonders why no one will pay them $2k out of pocket for their cataracts.

I bet if we MDs do unite then there will be a firestorm of bad press also. "Rich, arrogant doctors abandoning their elderly patients so they can make more money!" and other similar headlines. Given the continued perception that doctors are overpaid (which is really beginning to frustrate me, especially as I search for a damn job) I have little hope that the Academy or AMA could actually blunt this. I think we have always lost the battle of public opinion.

 

[7ontheline]

Also, don't forget that Medicare pays for more than just surgery. Most of your patient visits are Medicare also, so forgoing that seems financially unviable.

 

[Olddog1]

Also, don't forget that Medicare pays for more than just surgery. Most of your patient visits are Medicare also, so forgoing that seems financially unviable.

And of course don't forget my favorite thing; everything needs to be "budget neutral". Money for new technology (OCT, avastin, accomdating IOLs, etc..) means taking a chunk out of something else to preserve neutrality.

 

[idoc]

What if we lobbied congress to only cover cataracts if the best corrected visual acuity was less than say 20/70. This would prevent the cutters from undermining the efforts of the collective ophthalmology voice, and would allow the free market to reign for all of those people who don't want to wait for there vision to get to 20/70 as it would be considered a "refractive procedure" under that level. Any thoughts?

 

[VA Hopeful Dr]

What if we lobbied congress to only cover cataracts if the best corrected visual acuity was less than say 20/70. This would prevent the cutters from undermining the efforts of the collective ophthalmology voice, and would allow the free market to reign for all of those people who don't want to wait for there vision to get to 20/70 as it would be considered a "refractive procedure" under that level. Any thoughts?

The problem with this is that (at least where I live), you have to be able to correct vision to 20/40 or better in 1 eye to get a driver's license. If medicare waiting wil 20/70, you'd have lots of older folks who couldn't drive and couldn't afford the surgery out of pocket.

 

[idoc]

although driving limitations are a consideration, what about eating? Isn't it more important to be able to chew your food than to drive? The procedures the dentists are performing are considered elective, meaning that they are not considered "rights". It would be painfull and annoying to live with a cracked/rotten tooth, however it can be done. Similarly, driving a car is not a human right considered to self evident by our forefathers. Therefore, they can either wait until it is 20/70, or get on the cataract payment plan. Seriously though, it would be somewhat unfair to those people who cannot afford to pay. The real problem this highlights are the number of people who have medicare, but can afford to pay. The system unfairly prevents doctors from charging those who can afford their treatments more, to offset the patients who cannot pay. In India, they charge wealthy patients much more, so they can subsidize treatment of those who cannot pay anything. Once the poor patient gets their cataract surgery, they send a picture to the wealthy patient showing them who they helped. I think that is a great idea, but it wouldn't work in America where everything has to be fair, and not burdened by logic.

 

[Olddog1]

In India, they charge wealthy patients much more, so they can subsidize treatment of those who cannot pay anything. QUOTE]

They do the same thing in the US. It's called taxes.