Optometry practice alongside MD clinic?

[q1we3]

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Since my brother will finish his residency by the time I finish my optometry school I was thinking of opening a practice alongside his clinic? How beneficial will it be for an optometry practice to be located with a MD clinic?

 

[Shnurek]

I think this is an excellent idea especially if you are into the medical side of optometry. Any patients with eye issues he can immediately give to you and any patients with systemic issues you can give to him. Also, the classic optometrist reputation of a glasses peddler will be close to nil.

 

[optsuker]

Almost zero new physicians, regardless of specialty, will "hang a shingle" and start solo private practice. They all join a hospital-based clinic or a group specialty practice, so the odds that you can practice side by side are extremely low.

 

[Meibomian SxN]

Since my brother will finish his residency by the time I finish my optometry school I was thinking of opening a practice alongside his clinic? How beneficial will it be for an optometry practice to be located with a MD clinic?

That would be an ideal practice setup, as you would have his referrals for eye exams coming in and also a PCP to comanage systemic disease patients. Hope it works out. 👍

 

[optom123]

That would be an ideal practice setup, as you would have his referrals for eye exams coming in and also a PCP to comanage systemic disease patients. Hope it works out. 👍

But, are there really that many referrals by physicians to ODs? (in general)

Usually if someone has eye related problems they would go to an Optometrist I believe.

 

[Meibomian SxN]

But, are there really that many referrals by physicians to ODs? (in general)

Usually if someone has eye related problems they would go to an Optometrist I believe.

Yeah, PCPs typically refer to their MD colleagues but if its his brother thats the PCP then that shouldn't be a problem.

 

[Shnurek]

There are referrals from MD/DOs to ODs even in New York. I'm sure in states that allow ODs to do even more there are more referrals. ODs are gaining ground on ocular disease.

 

[Visionary]

There are referrals from MD/DOs to ODs even in New York. I'm sure in states that allow ODs to do even more there are more referrals. ODs are gaining ground on ocular disease.

Speaking for KY, I'd say this is an incorrect assessment. The medical community here has rallied around the ophthalmologists after the recent bill passage, because they see the same thing happening with NPs and PAs. You won't find many PCPs referring to optometrists in KY, unless they are ophthalmologists running kickback schemes, er, I mean comanagement. Not saying it's right, but I've had multiple PCPs over the past year refer patients to me for second opinions after they saw optometrists.

 

[Tippytoe]

In the real world, MD to OD referrals do exist. But they are very much on a personal level. I get referrals primarily from urgent care centers and a few local family docs. Mostly because I got to know them on a personal level and they trust me. At one point, I rented a room in a small family doc rural practice.

Any OD hoping they will blindly (pun intended) open up and begin to get referrals from MDs will be HIGHLY disappointed. 99% of referrals will be to OMDs by default (even if they are terrible docs). Probably out of fear of the referring doctor....they don't want to risk sending a pt to an 'unknown' OD as our skills and interests as a profession vary wildly. Meaning there are still many ODs that are scared to death of an 30 IOP and will just turn around and send the pt to the nearest ophthalmologist. Sad, sad, sad....but true. ODs in warehouse and department stores don't want to be bothered with red eyes. They are refraction ******.

A family member MD (family doc/internist I presume) would be good to join in practice. Still have to play by the rules to avoid any 'kick-back' deals where there is an automatic or inappropriate referrals are made.

You would probably be busy enough just doing exams on the thousands of diabetic patients that will be walking through the door.

P.S. For the previous poster. The only OMDs that don't want to co-manage are the ones that are afraid of someone seeing their work (ie. not very good). I've been co-managing next day cataract surgeries for 12 years now. No big deal. Never a blind eye. Even co-manage retinal patients with a good retinal surgeon (local and out of town). Glaucoma as well. No rocket since in eye care. Really pretty boring overall.

My goal is to have MY patient in the surgeon's office for the shortest possible amount of time. Since they all have opticals now, the last thing I want MY patient to do is to sit for 2 hours looking at the surgeon's optical shop while waiting to be seen. It's very easy for them to say, "Well hell, they have everything here. I might as well just come here from now on". This happens all the time and of course, I have no doubt it intentional.

But on the whole, the OMD/OD fights are usually reserved to the national level and politics. On the local level, we are just docs trying to make a living and get along. We enjoy each others company and don't even talk about the silly turf wars.

 

[speyeder]

The only OMDs that don't want to co-manage are the ones that are afraid of someone seeing their work (ie. not very good)

That's nonsense. The fact that you have such an arrangement and it has worked out well for you and your patients doesn't mean that every optometrist is capable of this. OMDs are trained to perform eye surgeries and provide post-op care. Optometrists are not. This is not to say that all ODs aren't capable of providing post-op care. The bottom line is, if I operate on someone's eye, I want to be the one who sees that patient post-operatively. Every single ophthalmologist that I know feels this way too. It cannot be argued that the best post-op care is provided by the surgeon who actually performed the procedure. The fact that none of your patients have had complications does not negate this. Put it this way, if a family member of yours had brain surgery would you want him or her to be seen by the neurosurgeon who performed the operation or someone else?

 

[optom123]

Interesting...this thread, among other things, has unfortunately, forced me to question my choice of becoming an Optometrist.

Is it true that most ODs just turn dials? I would freakin hate doing that after advanced education. Really, how much truth is there to this? In reality, is an OMD an OD who is able to perform eye related surgery?

I was just at an OMDs office today for a general examination. There were always 20 ppl in the waiting room for as long as I was there, and I assume thats how it is for the majority of the day. Of course, these people were probably there for serious conditions as they were all over 50 - the overall atmosphere was impressive. But were these individuals referred to by GPs or by an OD, since the OD is the primary eye care guy/gal that patients go to see...

I went to an OD 2 years ago, before I was even attending university. To say the least, I wasn't satisfied by my examination, but that might have been because I had no issues. Its funny, I can still remember who was in the waiting room - a father and his child. The atmosphere here was very boring and unprofessional due to the extensive display of glasses/contacts which was basically enclosing the waiting room.

The OMD has been at his current location for over 20 years, while the Optometrist has closed down/relocated in the last 2-3 years since I saw him.

I hate it how even as a pre-optometry student, I went to my GP and they referred me to an OMD. Why would I go to my GP instead of an OD? Probably because I feel that ODs are in the business of selling glasses. But, would you practitioners say this is REALLY the case for the majority? I am beggning to wonder if as a whole, this perceived unprofessionalism in Optometry is part of the nature of the profession or the practitioners themselves? Or maybe its just me.

 

[KHE]

Interesting...this thread, among other things, has unfortunately, forced me to question my choice of becoming an Optometrist.

Is it true that most ODs just turn dials? I would freakin hate doing that after advanced education. Really, how much truth is there to this? In reality, is an OMD an OD who is able to perform eye related surgery?

I was just at an OMDs office today for a general examination. There were always 20 ppl in the waiting room for as long as I was there, and I assume thats how it is for the majority of the day. Of course, these people were probably there for serious conditions as they were all over 50 - the overall atmosphere was impressive. But were these individuals referred to by GPs or by an OD, since the OD is the primary eye care guy/gal that patients go to see...

I went to an OD 2 years ago, before I was even attending university. To say the least, I wasn't satisfied by my examination, but that might have been because I had no issues. Its funny, I can still remember who was in the waiting room - a father and his child. The atmosphere here was very boring and unprofessional due to the extensive display of glasses/contacts which was basically enclosing the waiting room.

The OMD has been at his current location for over 20 years, while the Optometrist has closed down/relocated in the last 2-3 years since I saw him.

I hate it how even as a pre-optometry student, I went to my GP and they referred me to an OMD. Why would I go to my GP instead of an OD? Probably because I feel that ODs are in the business of selling glasses. But, would you practitioners say this is REALLY the case for the majority? I am beggning to wonder if as a whole, this perceived unprofessionalism in Optometry is part of the nature of the profession or the practitioners themselves? Or maybe its just me.

I think you need to do some more shadowing. I don't get the sense you really understand what the majority of optometrists do on a day to day basis.

 

[KHE]

That's nonsense. The fact that you have such an arrangement and it has worked out well for you and your patients doesn't mean that every optometrist is capable of this. OMDs are trained to perform eye surgeries and provide post-op care. Optometrists are not. This is not to say that all ODs aren't capable of providing post-op care. The bottom line is, if I operate on someone's eye, I want to be the one who sees that patient post-operatively. Every single ophthalmologist that I know feels this way too. It cannot be argued that the best post-op care is provided by the surgeon who actually performed the procedure. The fact that none of your patients have had complications does not negate this. Put it this way, if a family member of yours had brain surgery would you want him or her to be seen by the neurosurgeon who performed the operation or someone else?

I have had three surgeries in my lifetime.

I had my tonsils out as a kid.
I had a varicocele removed from my groin.
I had my gallbladder removed.

In all three cases, I never saw the surgeon for any post operative care. It was all done by my GP. In fact, in all three cases, I didn't even see the surgeon in the hospital after the procedure. I was just discharged.

 

[Visionary]

P.S. For the previous poster. The only OMDs that don't want to co-manage are the ones that are afraid of someone seeing their work (ie. not very good). I've been co-managing next day cataract surgeries for 12 years now. No big deal. Never a blind eye. Even co-manage retinal patients with a good retinal surgeon (local and out of town). Glaucoma as well. No rocket since in eye care. Really pretty boring overall.

You seriously believe this line of garbage? Is this what your docs tell you? I have to say that most of your posts seem well-informed, but this is ludicrous!

Here's my experience:

The ophthalmologists I know who do not co-manage do so because they want to take care of their patients. They have relationships with their patients. They want to be the ones who discuss the pros, cons, and risks of surgery, so their patients can make informed decisions. They want to be the ones who see the patients post-op day one, many even calling them the evening of. They are excellent surgeons with excellent results.

The ones I know who do co-manage do so because they want to make money. They are in the OR 3-4 days/week, often meeting their patients for the first time in the pre-op area, then never seeing them again once they leave the surgical suite. They do 4-5k cataracts/year in addition to LASIK and the like and have annual collections of $2-3 mil. They do a lot of 20/25 cataracts that have been teed up by their optometrist "feeders" who are incentivized by the kickbacks they get as a result of the co-management relationship. They, too, are excellent surgeons with excellent results.

For those of us who went into medicine to care for patients, the former are admirable, while the latter turn our stomachs.

 

[KHE]

The ones I know who do co-manage do so because they want to make money. They are in the OR 3-4 days/week, often meeting their patients for the first time in the pre-op area, then never seeing them again once they leave the surgical suite. They do 4-5k cataracts/year in addition to LASIK and the like and have annual collections of $2-3 mil. They do a lot of 20/25 cataracts that have been teed up by their optometrist "feeders" who are incentivized by the kickbacks they get as a result of the co-management relationship. They, too, are excellent surgeons with excellent results.

Clearly I'm doing something wrong.

What are these "kickbacks" you speak of? I haven't seen any of them.

 

[speyeder]

I have had three surgeries in my lifetime.

I had my tonsils out as a kid.
I had a varicocele removed from my groin.
I had my gallbladder removed.

In all three cases, I never saw the surgeon for any post operative care. It was all done by my GP. In fact, in all three cases, I didn't even see the surgeon in the hospital after the procedure. I was just discharged.

Why would your GP, who is not a surgeon, provide post-op care? It doesn't make sense to me. Did you have a say in the matter? Were you given a choice? Most importantly, is that the standard of care? Additionally, in each of the above cases, the most likely complications would be swelling, post-op pain and infection. Those are relatively easy to manage. But if there's an infection after eye surgery, the consequences are more dire.

 

[Visionary]

Clearly I'm doing something wrong.

What are these "kickbacks" you speak of? I haven't seen any of them.

Come on, man. Don't be coy.🙄

 

[KHE]

Come on, man. Don't be coy.🙄

I get no kickbacks from my surgeon. None at all. What kickbacks are people getting? Vegas junkets? Weekends at the Four Seasons? What?

If you're talking about the actual comangement fee, then


In my office, my average revenue per office encounter is $320.

The amount of comanagement fee that I get is $162 for a cataract. And I get that from the insurance carrier, not from the surgeon directly. We file the comanagement with the appropriate modifiers.

Our surgeon likes to do is own one day post ops in most cases. I don't care about that. Fine.

So for a one week, one month and three month visit, I get $162. That's $54 per visit. Or about $270 LESS PER APPOINTMENT than I could by NOT comanaging.

If it's a great result and I decide to not bother with the three month visit (I almost always do it anyways) I would get paid $81 per visit or $240 LESS PER VISIT than I otherwise could have made.

Ohhhhh yea.....please.....sign me up for more of those "kickbacks." 🙄

 

[thiaeyemd]

I think KHE to be honest, you are an exception to the rule. A large number of optometrists where I used to practice comanage with OMDs who agree to comanage. There are some MDs who don't want to comanage because in principal they don't think it is necessary or "right". Comanagement was created so a patient in podunk, Tx could get cataract surgery in Dallas or wherever and f/u back in podunk with their OD. Not so an OD on 23rd st in manhattan can f/u post op patients of a surgeon who works on 30th st. I don't do cataract surgery but I can see how a cataract surgeon wanting to follow their own patients etc.. from a follow a patient you operated on perspective and a legal perspective. In NJ there is a group called OMNI which does a lot of comanagment and optometry support. They have optometrists sending their patients to them from 30-50 miles away when people who are considered "cataract experts" by the OMD community are nextdoor. At the end of the day it does come down to money. It isn't just the 20% surgical fee. As has been mentioned in these posts a lot of optometry practices are not 100% full. Your citing the revenue of an average patient is great and makes sense for you if you are seeing 40 patients like that all day. However, for an optom who is seeing 15 people a day, the reimbursement for a routine post op check is simple, fast and better than an empty spot on the schedule. Plus there will be the new set of glasses the patients may get eventually etc... As an orbital surgeon I don't comanage and this doesn't affect me but I see the point of what visionary is saying...

As for the surgery you underwent, I have never heard of a surgeon not following up on their patients. I am not sure where you live but it is definitely not standard of care. Also, I am sure the GP did not get a "comanagement" fee for it anyway.

I agree with Visionary. The OMDs who comanage do so, because simply they want more patients to operate on and they can get more referrals that way. The ones who don't comanage garner enough patients from their own practice where it isn't necessary, feel that since they operated on the patient they should follow them etc, or feel that they are losing the doctor patient relationship and if god forbid something did go wrong, the patient is less bonded to them and more likely to sue. It is definitely true that if you have a practice as a surgeon where you show up on game day, meet the patient, operate on them and never see them again, things are fine until you have a complication. Then the patient is like "he abandoned me and never saw me after the surgery". Doesn't sound that good in front of a jury. That's why ophthalmologists are now much more gunshy of joining the lasik corporate systems where they are hired to fire the laser on 40 patients in 1 day. They meet people day of surgery and never see them again...until its in front of a jury.

I think most MDs view comanagement as a kickback essentially..a finder's fee of sorts...After cataract surgery there are no sutures to remove, wound dressings to change..its basically a check to say everything is ok and if it isn't send it back to the MD who operated on them..Its patient conveniece if the patient lives miles away but on the east coast comanagement occurs with people who practice next door to each other...can't be anything but the money in that situation.

Just being honest..

 

[speyeder]

In my office, my average revenue per office encounter is $320. The amount of comanagement fee that I get is $162 for a cataract.

The above can be misleading for the following reasons:

1) Post-op visits are relatively quick. Maybe 5 minutes perhaps? What about the $320 routine encounter? I bet you spend more than 5 minutes with those patients. Routine eye exam, dilation, refraction, etc. So on a time unit basis, the post-op visits might make you more.

2) I doubt that your schedule is packed seeing 40 patients a day that each generate $320. If you are, then great. But probably not, so that means that these post-op patients are helping you fill your schedule.

3) The co-management fees still bring in revenue that you would not have had otherwise if you were not involved in a co-management situation, and that adds to your bottom line.

 

[KHE]

The above can be misleading for the following reasons:

1) Post-op visits are relatively quick. Maybe 5 minutes perhaps? What about the $320 routine encounter? I bet you spend more than 5 minutes with those patients. Routine eye exam, dilation, refraction, etc. So on a time unit basis, the post-op visits might make you more.

I book the same amount of time regardless of appointment type. I don't book "exam" and "post op" slots.

2) I doubt that your schedule is packed seeing 40 patients a day that each generate $320. If you are, then great. But probably not, so that means that these post-op patients are helping you fill your schedule.

I do not see 40 patients a day. I limit them to 25. I am booked out reasonably well. Do I have an empty slot or two on my schedule every day? Usually cancellations and such. But NO, I would rather NOT fill it with a $54 post op check on grumpy 85 year old Mrs. Buckley who is complaining that she's only 20/20-.

3) The co-management fees still bring in revenue that you would not have had otherwise if you were not involved in a co-management situation, and that adds to your bottom line.

Rather than seeing a $54 comanagement patient with all the attendant hassles of trying to convince them that YES, they really ARE seeing better, I'd much rather have that time to devote to getting more of the $320 patients. Or surfing on SDN. Or updating my fantasy hockey team.

We can all agree with disagree on a lot of issues for this whole optometry/opthalmology thing but seriously......if you all honestly think that 99% of optometrists can be "bought" with a $54 "kickback," you're completely out to lunch. The fact that you even call it a kickback is grossly offensive. Optometrists can be pretty lame sometimes but we ain't that lame.

 

[optsuker]

I think KHE to be honest, you are an exception to the rule. .

KHE's situation is about the same as mine, and most OD's I know.

I practice in an area where my patients need to travel ~45 min to see an OMD and there are about 6-7 different cataract surgeons to choose from.

I refer to 3-4 different surgeons and usually allow the patient to choose from a short list. One releases patients at 1 day, one @ 1 week, one @ 3 weeks, and the last doesn't co-manange. The co-management schedule has little to do with where I send them. I only insist that they return for their eyewear from me (since I'll be doing all the adjusting/fitting) and that the patient is released back to me for continuing routine care.


There is a % of OMD's who will recall yearly after cat surgery ("stealing" the patient from the doc who referred them) and another % that are politically motivated to bad-mouth OD's at every opportunity, telling patients they're unqualified to do anything but refractive care.
There are the surgeons who don't see my referrals (and sounds like some of them like to post here are well).

When asked about their refusal to co-manage, I usually don't hear the altrusitic answers I've read here. It's usually that reimbursement for cataract surgery has taken such a hit over the last 5-10 years that they don't want to share the measley fee they're getting now.

 

[speyeder]

I book the same amount of time regardless of appointment type. I don't book "exam" and "post op" slots.



I do not see 40 patients a day. I limit them to 25. I am booked out reasonably well. Do I have an empty slot or two on my schedule every day? Usually cancellations and such. But NO, I would rather NOT fill it with a $54 post op check on grumpy 85 year old Mrs. Buckley who is complaining that she's only 20/20-.



Rather than seeing a $54 comanagement patient with all the attendant hassles of trying to convince them that YES, they really ARE seeing better, I'd much rather have that time to devote to getting more of the $320 patients. Or surfing on SDN. Or updating my fantasy hockey team.

We can all agree with disagree on a lot of issues for this whole optometry/opthalmology thing but seriously......if you all honestly think that 99% of optometrists can be "bought" with a $54 "kickback," you're completely out to lunch. The fact that you even call it a kickback is grossly offensive. Optometrists can be pretty lame sometimes but we ain't that lame.

You can call it what you'd like. Here is the legal definition of a kickback:

A form of bribery in which a percentage of the revenues from a contract or other financial award is illicitly returned to the person awarding the contract or benefit.

 

[optsuker]

You can call it what you'd like. Here is the legal definition of a kickback:

A form of bribery in which a percentage of the revenues from a contract or other financial award is illicitly returned to the person awarding the contract or benefit.

Where do you get the illicit part?
What dollars are returned? Both parties are paid by the insurance carrier for the portion of the service they provided.

Here's a definition: Comanage: to manage jointly

 

[KHE]

You can call it what you'd like. Here is the legal definition of a kickback:

A form of bribery in which a percentage of the revenues from a contract or other financial award is illicitly returned to the person awarding the contract or benefit.

Are you nuts?

 

[VA Hopeful Dr]

I have had three surgeries in my lifetime.

I had my tonsils out as a kid.
I had a varicocele removed from my groin.
I had my gallbladder removed.

In all three cases, I never saw the surgeon for any post operative care. It was all done by my GP. In fact, in all three cases, I didn't even see the surgeon in the hospital after the procedure. I was just discharged.

As an FP (since GPs are getting more uncommon by the year), I would be pretty pissed off if the local surgeons pulled that with me.

Also, if the surgeons do post-op care its included in the global fee, as everyone here is well aware (see other thread). If I'm shafted with post-op care, I'm going to bill for it. Did your GPs have some sort of comanagement thing like the surgeons and you guys have?

 

[speyeder]

Where do you get the illicit part?
What dollars are returned? Both parties are paid by the insurance carrier for the portion of the service they provided.

Here's a definition: Comanage: to manage jointly

No co-managing is obviously not illegal. But it does create a financial incentive for some but not all ODs to refer patients to certain ophthalmologists over others.

 

[Tippytoe]

Clearly I'm doing something wrong.

What are these "kickbacks" you speak of? I haven't seen any of them.

Yes, these "cataract kickbacks" are awesome. I get $130 from Medicare for 90 days of post op care which usually includes 2-3 visits ($43 per visit). What a "kickback"! Very nieve statement. Perhaps he's talking about Lasik. In that case, I get $300 per eye for follow up care which is much better. But that includes 5 visits (1d, 1w, 1m, 3m and 6m). So in this case, I'm making $120 per visit. The surgeon is making $3,400 for his 10 minutes of time (and expensive laser). I have no problem with this. I'm doing the work so it's not a "kickback" in any way, shape or form.

The point of my posts is that the patients I send are MY patients. I've seen them for years. I know their problem. I know what they like and don't like. I know what we've tried optically. I do not want to send to a surgeon who is going to throw in a monovision IOL or multifocal IOL when I KNOW the pt will not like it. I give my recommendation based on what the patient wants because I actually have time to talk to them (going full circle back to the vast oversupply of ODs giving me plenty of time).

In my case, the surgeon is (respectfully) simply a technician doing a very highly skilled job that I am not qualifed to do. They do their job and send the pt back. Sorry if that rubs anyone the wrong way. But that's the way it is. Remember, they are MY patients. And cataract surgery is NOT brain surgery. I was fully trained to provide post op care during my education and have been in the OR with every OMD I comanage with.

 

[speyeder]

Are you nuts?

I'm about as nuts as you are honest in asserting that comanagement doesn't have the potential to alter referral patterns of some ODs. Whether or not you "want" these measly comanagement fees is beside the point. You cannot deny that there is a direct financial benefit for ODs who are part of a comanagement arrangement.

 

[optsuker]

No co-managing is obviously not illegal. But it does create a financial incentive for some but not all ODs to refer patients to certain ophthalmologists over others.

Then why did you throw out the term kickback and bribery?

We all want to get paid for what we do. There are tons of reasons why doctors refer to one qualified specialist over another:

• Reputation
• convenience
• Insurance issues
• Doctor's alma mater (a big one among MD's!)
• backlog
• because they refer patients to you. (financial)
• employed by same hospital system. (financial)

I have no trouble with you using other criteria when deciding between 2 qualified specialists.

I refer to a particular retinologist over another because he returns them back to my care sooner (financial!), patient can get in sooner, and he is quick to call me/fax his findings.

Get the chip off your shoulder and be careful about accusing anyone of illegal activity.

 

[east]

Yes, these "cataract kickbacks" are awesome. I get $130 from Medicare for 90 days of post op care which usually includes 2-3 visits ($43 per visit). What a "kickback"! Very nieve statement. Perhaps he's talking about Lasik. In that case, I get $300 per eye for follow up care which is much better. But that includes 5 visits (1d, 1w, 1m, 3m and 6m). So in this case, I'm making $120 per visit. The surgeon is making $3,400 for his 10 minutes of time (and expensive laser). I have no problem with this. I'm doing the work so it's not a "kickback" in any way, shape or form.

The point of my posts is that the patients I send are MY patients. I've seen them for years. I know their problem. I know what they like and don't like. I know what we've tried optically. I do not want to send to a surgeon who is going to throw in a monovision IOL or multifocal IOL when I KNOW the pt will not like it. I give my recommendation based on what the patient wants because I actually have time to talk to them (going full circle back to the vast oversupply of ODs giving me plenty of time).

In my case, the surgeon is (respectfully) simply a technician doing a very highly skilled job that I am not qualifed to do. They do their job and send the pt back. Sorry if that rubs anyone the wrong way. But that's the way it is. Remember, they are MY patients. And cataract surgery is NOT brain surgery. I was fully trained to provide post op care during my education and have been in the OR with every OMD I comanage with.

Ditto.

 

[east]

MY patients are so very grateful for the "kickbacks" It means that 80 year old Judith doesn't have to drive an hour and a half back to the Ophthalmologist(the nearest one by the way) to have a 5 minute check. MY patients ask for my input and we choose a surgeon together. I thought I was running an successful optometric practice, I am deeply saddened to learn that I am a mere "finder of potential cataract surgeries" and a mere receiver of "finders fees"

I do the cycloplegic pre-op exam for lasik, review RBAs, do all of the post op care and golly things seem to work out great.

 

[speyeder]

be careful about accusing anyone of illegal activity.

I just said it's not illegal so how am I accusing anyone of illegal activity? I put up the definition because there are parallels between the two, minus the obvious parts about bribery and it being illicit. There are many gray areas in medicine, not just with comanagement.

 

[thiaeyemd]

I dont do cataract surgery but if I am planning an optic nerve sheath fenestration or thyroid decompression on a patient and their optometrist, endocrinologist, or FP said "Hey they can just followup with me" I wouldnt be into it even if they said they wont take a comanagement fee etc.. Its just about taking care of your patients and not dumping them to someone else. I worked residents and it is definitely considered bad etiquette to operate on a patient and have another resident followup with them. On top of that if a patient comes as a followup from surgery from someone else to my office, I send them back to the surgeon. How the heck am I going to know what they did in the OR even if I know the procedure that was done. There are ad infinitum variations of technique for almost all we do that makes surgical followup unique to the surgeon themselves. Maybe lasik is different or even cataract but a trab? I am not sure...

One counterpoint ..the fact that one poster here said they give all patients the same amount of time in their office scheduling is unique and frankly strange. If a patient books with a problem with complaint about how their contact fits they don't get the same time as a patient with a new visit or a patient who is scheduled for an IOP check. That just doesn't make sense in any office practice.

I agree with the poster who has MDs that are 45 minutes away and that's fine..Unfortunately that is not how it works out in the east coast like NYC etc.. Remember here patients are sent 45 minutes away to a surgeon who comanages and not to the guy who is better down the street because he does not. It makes it hard to believe it is not about money when you see that...and I have seen that.

I think most surgeons feel like they are forced to "comanage" even when everything in our training and the training of most surgeons teaches us that it is a compromise of care and not right for the patient. If they want to see the patient themselves etc.. (which we have always done) a large number of ODs won't refer to them regardless of their surgical skill etc.. If that person is the best surgeon and "best for the patient" why would anyone care? The money has something to do with.

Everyone here compares the surgical f/u fee with a new patient who gets glasses. Comeon..We know that most OD offices don't just have two empty spots etc.. like KHE. There have been tons of OD posts here stating that. Regardless of what different OD posters are saying I know for a fact that many ODs in my area see those patients for 5-10 min max (which is totally normal and expected). They don't spend 1/2 hour or whatever with them.

I am not sure why people are posting with "MY patient" etc.. When I send a patient to an oncologist or an endocrinologist I don't view the patient as my property that I am loaning out to someone else. I see it as a person who needs the services of this other doctor. At that point it is like " hey do what needs to be done...if the patient needs me again they will find me". To me its very wierd...

Maybe the comanagement thing also comes down to control also. When I send a patient to a neurosurgeon or whoever I give up control of that patient and say "here take over, this is beyond my scope". I think with the differences between optometry and ophthalmology, ODs don't like the idea of referring out the patient and losing that control..Comanagement gives control to the OD as the controller of the patient etc..Just an idea.

 

[east]

I am not sure why people are posting with "MY patient" etc.. When I send a patient to an oncologist or an endocrinologist I don't view the patient as my property that I am loaning out to someone else. I see it as a person who needs the services of this other doctor. At that point it is like " hey do what needs to be done...if the patient needs me again they will find me". To me its very wierd...

Maybe the comanagement thing also comes down to control also. When I send a patient to a neurosurgeon or whoever I give up control of that patient and say "here take over, this is beyond my scope". I think with the differences between optometry and ophthalmology, ODs don't like the idea of referring out the patient and losing that control..Comanagement gives control to the OD as the controller of the patient etc..Just an idea.[/QUOTE]


With all due respect, does your consulting oncologist or endocrinologist have an optical department?

Here's the deal, It is obvious by your post that you are unaware of some of the realities in the OD/Ophthal interaction. We both take care of people's visual needs, and (to the extent our scope of practice overlaps), your comparison of other medical specialty referrals is simply apples and oranges.

I can tell you with certainty that every private practice OD in my local optometric society has had this or a very similar thing happen to them (multiple times).

Pt. has been well taken care of for years by OD. Pt. needs cataract surgery. Pt. and OD discuss which potential MD for surgery. Pt. is sent to MD for surgery. Pt. is told post surgery that he/she now needs to f/u yearly with MD because.....

1) they have now had surgery on their eyes
2) they need to be checked for glaucoma yearly
3) they need to be checked for macular degeneration yearly
4) they have (insert you favorite relatively benign ocular condition) my favorite is pinguecula, and need an MD to follow said condition.
5) insert myriad of other B.S reasons.

Sometimes not even any reason is brought up to the Pt. and they are simply pre-appointed by the MD office for their routine eye exam the following year. Pt. will often call my office and ask why they need to see two eye doctors now? We get the thrilling opportunity of trying to parse this out.

I have worked hard, very hard, to build a successful practice, and I greatly appreciate the help and care that my Ophthal. friends give my patients. This is in part why my practice is so successful, but in the end, Ophthal. should not attempt to take my patient away to sell them glasses at their optical, or get their fundus photos, OCT, TVF, etc.

Now I know I will hear that maybe the patient wanted to stay with the MD. This does happen and that is absolutely fine and fair. Also I will hear that the MD probably didn't even know they were keeping the Pt. (RIGHT!)

I have had patients stay with the MD just because their office had a better frame the patient liked, again, fine, great. But don't B.S my patients into believing that they now need full time routine care from you for something we both know is a bogus reason.

This happens all the time!!

If it's a legit patient keep by the MD, great, I encourage that, I don't want to manage even on the fringe of my scope. But please if the patients ocular condition falls well within the scope of my practice, just give them back.

This is why I say MY patient.

 

[east]

sorry double post

 

[thiaeyemd]

totally agree.. if people are stealing patients from you, not cool and I wouldnt send patients to them ever again. As an oculoplastic surgeon I have zero interest in refracting anyone..( I don't have optical or even a phoropter in my office) so my viewpoint is different.

 

[Visionary]

I stayed away from this over the weekend. Interesting commentary. Here's where I'm coming from. As others have stated, there is a difference between a co-management situation where there is a clear patient convenience aspect, such as distance traveled, and one where there is clearly not or where it is the exact opposite (as thiaeyemd described).

The former is fine, and it's why co-management was developed. I was actually referring to the latter. I'm talking about the super high volume cataract/LASIK mills that have a network of optometrists feeding them surgical patients. They essentially just operate and have limited clinic time. Optometrists to all the pre- and post-op management and the surgeon usually meets the patient for the first time in pre-op holding.

Yes, co-management is legal. But, yes, there is a financial incentive. I don't get the "every patient is booked for the same amount of time" argument. Fact is that a routine cataract/LASIK post-op shouldn't take more than 5 minutes or so. There should be a printed out plan for tapering of topical meds. Unless there is a problem, it's a cake walk. It's similar to when I'm seeing a general patient versus a retina patients. I can see 3 of the former in the time it takes me to see one of the latter.

I also understand the co-management fee coming from the insurance carrier. That's one piece of the pie. They should also be coming back to you for post-op specs. Then, how about the cut of the cash-only premium IOL fee and the cash-only LASIK fee, so the patient can be glasses-free? If you don't see some of that action, you ARE doing it wrong. Then there are the oft-mentioned other perks, such as tickets to sporting events, vacation packages, etc. That's clearly not legal, but we all know it happens. The docs in question, and they are the minority, do it to try and corner the cataract/refractive market in their respective areas and it's completely financially-motivated.

That's what I was getting at. Again, I am not in the "optometrists are incompetent goons" camp. I respect your training and ability. Co-management has it's place, but it does get abused more than some like to admit.

 

[east]

I will admit that I have very little first hand knowledge of "cataract/LASIK" mills, I do however know that they exist and feel very sorry for ODs who work in these situations. In my opinion these unfortunate ODs are the B*tch*s of high volume OMD practices. Don't get me wrong some of the ODs prefer it that way. Less responsibility, and frankly less critical thinking. This is just one ODs opinion.

Anyway, I am in a truly needed co-management situation, and I believe that traveling distance should not be the only metric to determine whether co-management is needed. Believe it or not our patients actually like and trust us to take care of their eyes. Perhaps our patients would prefer to see us for cataract surgery follow-up. In my opinion if the consulting surgeon does not have enough confidence in the OD sending the patient for cataract surgery, then maybe he/she should think twice about taking on that surgical case. I mean the MD knows he/she is now entering into a likely 3 way management situation (i know I actually just used the phrase 3 way) .....just a thought.

Also, what some may call "financial incentive" for co-management, I choose to properly call "fee for services" provided to a patient that falls well within the scope of optometric practice. The reason this thread got me goin' a little is that it mirrors a lot of the themes some MDs espouse in this and the ophthalmology forum, which is, ......

Optometry is a relatively classless profession, and many if not most optometrists are,

1) flat out liars
2) quack glasses salesmen
3) only in it for the "kickbacks"
4) "blatant ******" to use a direct quote from an ophthalmologist describing a friend of mine Dr. Les Walls.
5) the list could go on and on.

Look there are crap practitioners in every health care profession, but from what I have seen, ODs tend to be a fairly timid, quick to refer, quite deferential group on the whole, and I don't understand why all of the rancor on SDN. In "real life" my experience with ophthalmology has been much more amicable and respectful.

One might think that this is naivete on my part and "this truth is being discussed behind my back" but, I know more that half a dozen ophthalmologists on a personal friendly basis...i mean sit down and tell it like it is basis.

Basically most of us ODs and MDs are relatively intelligent people, unfortunately we are in a tough business and are usually direct competitors for patients health care dollars.

 

[Jason K]

The reason this thread got me goin' a little is that it mirrors a lot of the themes some MDs espouse in this and the ophthalmology forum, which is, ......

Optometry is a relatively classless profession, and many if not most optometrists are,

....
4) "blatant ******" to use a direct quote from an ophthalmologist describing a friend of mine Dr. Les Walls.
....

i hate to be the bearer of bad news, but there are many ODs out there, and I'm included in this pool, who also consider Les Walls *****. He's whoring himself out to the new school in MA and if that's not a blatant display of optometric promiscuity, I don't know what is. The guy is old enough to be an Egyptian mummy and yet he somehow feels the need to fire up another OD program? Does he really need to be doing this? If you know him, please ask him to answer that question, preferably here if he's willing.

Les is an intelligent guy. He's not unaware of how destructive his actions will be for optometry in the long-term, he just doesn't seem to care. I used to be a fan of Les - he's a likeable guy in person, but when I learned what he's been up to, my opinion changed. The guy is a windbag full of hot air and he's willing to blow it out to whomever will eat it up. It's all about the money for the guy, and if that's not the definition of "*****," then nothing is.

 

[east]

I agree with you about the oversupply of ODs and schools, and I agree that for some it is all about the money. But the term blatant ***** used to describe les was not used in that context. You shouldn't use your beef with him to justify an attack on him made for in a different reason. Do you agree with any of my other thoughts..... disregarding the blatant ***** part, and les walls.

 

[Jason K]

I agree with you about the oversupply of ODs and schools, and I agree that for some it is all about the money. But the term blatant ***** used to describe les was not used in that context. You shouldn't use your beef with him to justify an attack on him made for in a different reason. Do you agree with any of my other thoughts..... disregarding the blatant ***** part, and les walls.

Personally, I think OMDs who speak ill of ODs usually do so in terms of competence, not so much in terms of being liars or thieves. Older OMDs came up in a time when ODs were given little training in ocular health. It's no surprise that many older ophthalmologists would melt down at the thought of one of them getting behind the wheel of a laser or waving a scalpel. I've worked with some older ODs (age 70s and up) who have no idea how to use an indirect and simply have one on their wall for show.

Younger ODs, ones who are often trained along side OD residents/fellows in some settings, realize that our training goes well beyond what it once was. That's not to say they don't still take dumps on us when we're not around 🙂

I also believe that there's also a wider range of competence in optometry than in ophthalmology. You've got good OMDs and bad ones just like ODs, but the range from top to bottom is higher in optometry, in my opinion and it stems back to the lack of standardization of our programs. Some are good, some are terrible, and NBEO does not weed out the ones it should.

 

[speyeder]

Personally, I think OMDs who speak ill of ODs usually do so in terms of competence, not so much in terms of being liars or thieves. Older OMDs came up in a time when ODs were given little training in ocular health. It's no surprise that many older ophthalmologists would melt down at the thought of one of them getting behind the wheel of a laser or waving a scalpel. I've worked with some older ODs (age 70s and up) who have no idea how to use an indirect and simply have one on their wall for show.

Younger ODs, ones who are often trained along side OD residents/fellows in some settings, realize that our training goes well beyond what it once was. That's not to say they don't still take dumps on us when we're not around 🙂

I also believe that there's also a wider range of competence in optometry than in ophthalmology. You've got good OMDs and bad ones just like ODs, but the range from top to bottom is higher in optometry, in my opinion and it stems back to the lack of standardization of our programs. Some are good, some are terrible, and NBEO does not weed out the ones it should.

I agree with what you wrote. I only know of two OMDs who are openly anti-OD and both are near retirement age. These older docs practiced in an era when optometric education wasn't as advanced as it is today. And their opposition, for lack of a better word, was along the lines of OD competency and nothing else. I believe the newer generation of OMDs by and large is more OD-friendly and in the real world, we get along better than our leaders would have us believe.

 

[thiaeyemd]

very true...I think there is a lot of variability in OD training and resulting OD attending levels. I have personally interacted with ODs who are no different than MD attendings in terms of medical knowledge and some who are very limited (the question I got was "So when is a situation you shouldn't use steroid drops for a red eye". I feel there is a wider range. Most MDs my generation are very open to working with ODs and have a great relationship. I think there are probably some bad apples on both sides that antagonize the relationship.

 

[Visionary]

I think there are probably some bad apples on both sides that antagonize the relationship.

Key statement here. And, unfortunately, those bad apples tend to be pretty high up on our respective trees.

 

[PBEA]

I just want to point out one HUGE aspect of the so called "comanagement" arrangement for the OMDs here who want to point fingers and burn torches. In every case I've been involved with regard to comanagement", it has ALWAYS been the OMD who initiated contact, they set the terms, etc, so if its about "the money" then it is CLEARLY ophthalmology who is all too concerned with it. The pittance I get to involve myself AT ALL with these cases is an insult, and I generally avoid it. Then to have to hear the loudmouths here call out optometry, as if they are the responsible party? Get Fing real

I practice in the NE and am surrounded by multiple ODs and OMDs, and "comanage" with multiple specialties. The ones who steal pts under the guise of "pt care" are typically no different then the ones who are out spoken anti-OD types. passive vs aggressive. Of course its a bit more complicated then that, isn't it🙄 I'm all for urgent involved cases staying with ophtho but lets face it as other posters regularly point out, that really isn't what happens. Recent example was a pt who went a nearby OMD for exam (he has controlled HTN, and mild complaints). I've seen him before but his insurance changed so he went in network. Anyway insurance changed back and he comes back and tells me the OMD said that he HAD to see an OMD and can't see an OD. When the pt asked why he says "ODs can't check for those things". I got the record release and the OMD records and there was nothing remarkable, my exam was again unremarkable(few vessel changes, etc). I'd laugh at the aburdity of this type of comment, but it happens more then it should, sure maybe the rare ass wants to play politics, but the fact is what that OMD is doing is slander or libel. He is deliberately attempting to undermine my practice (or other OD practices) by making false accusations.........and for what?

Yeah you know the answer...don't you? (hint: it is green)

The jack, the moolah, the scratch, cash money baby, and ophthalmology is intoxicated by its dirty smell.

I've read on a few occasions where the OD gets an attorney involved (with success). I've considered it myself, but I'm not sure which I dislike more, attorney's or big mouth, holier then thou OMD's. So the next time a pt asks you if they can return to their OD who has been following their AMD for the last 10 years, be careful your ego doesn't get in the way of your brain. Since OMD and OD are in oversupply this isn't going to get easier, so either its the high road or the low road, take your pick.

 

[Transition Consultants]

The HHS Office of Inspector General posted an Advisory Opinion a few weeks ago regarding a proposed ophthalmology co-management arrangement with an optometrist. This one pertained to fees related to Premium IOL patients. Running afoul of anti-kickback statutes is probably the biggest concern for many providers who have these arrangements. Here is also a link to the original opinion: http://oig.hhs.gov/fraud/docs/advisoryopinions/2011/AdvOpn11-14.pdf

 

[Visionary]

I just want to point out one HUGE aspect of the so called "comanagement" arrangement for the OMDs here who want to point fingers and burn torches. In every case I've been involved with regard to comanagement", it has ALWAYS been the OMD who initiated contact, they set the terms, etc, so if its about "the money" then it is CLEARLY ophthalmology who is all too concerned with it. The pittance I get to involve myself AT ALL with these cases is an insult, and I generally avoid it. Then to have to hear the loudmouths here call out optometry, as if they are the responsible party? Get Fing real

I practice in the NE and am surrounded by multiple ODs and OMDs, and "comanage" with multiple specialties. The ones who steal pts under the guise of "pt care" are typically no different then the ones who are out spoken anti-OD types. passive vs aggressive. Of course its a bit more complicated then that, isn't it🙄 I'm all for urgent involved cases staying with ophtho but lets face it as other posters regularly point out, that really isn't what happens. Recent example was a pt who went a nearby OMD for exam (he has controlled HTN, and mild complaints). I've seen him before but his insurance changed so he went in network. Anyway insurance changed back and he comes back and tells me the OMD said that he HAD to see an OMD and can't see an OD. When the pt asked why he says "ODs can't check for those things". I got the record release and the OMD records and there was nothing remarkable, my exam was again unremarkable(few vessel changes, etc). I'd laugh at the aburdity of this type of comment, but it happens more then it should, sure maybe the rare ass wants to play politics, but the fact is what that OMD is doing is slander or libel. He is deliberately attempting to undermine my practice (or other OD practices) by making false accusations.........and for what?

Yeah you know the answer...don't you? (hint: it is green)

The jack, the moolah, the scratch, cash money baby, and ophthalmology is intoxicated by its dirty smell.

I've read on a few occasions where the OD gets an attorney involved (with success). I've considered it myself, but I'm not sure which I dislike more, attorney's or big mouth, holier then thou OMD's. So the next time a pt asks you if they can return to their OD who has been following their AMD for the last 10 years, be careful your ego doesn't get in the way of your brain. Since OMD and OD are in oversupply this isn't going to get easier, so either its the high road or the low road, take your pick.

Hey, I'm against stealing patients from anyone, but your description seems flawed. You gripe about the "pittance" you get for co-management, then say that ophthalmologists are stealing your patients for the money? What money? The exam fees? That would be ridiculous. Unless you're in a saturated area where patients are simply hard to come by, most ophthalmologists are going to be looking for patients on whom they can do procedures/surgery. That's where they make their money. Not on exams. Or do the practices in question have optical? If that's the case, maybe you shouldn't refer to them, like KHE says. Fact is, there are crummy, sleazy docs in both our camps. If you go back and read my posts, I was referring specifically to cases of co-management abuse, which I stated are a minority but are more common in metropolitan areas, such as mine. In those cases, it is all about the money . . . on both sides.

 

[thiaeyemd]

I hear what you are saying PBEA and I think you are right the MDs who get involved with comanagement do so because simply they want more referrals. They know that a large number of ODs only refer to people who do comanagement. The question I have are there people here who send to MDs who don't comanage over others that do or mix it up etc?..I think that answer would speak for itself.

Its my experience that a lot of MDs start comanaging because they feel they are missing out on referrals. Of course they have to approach the OD and say "Hey I comanage too!..(lets try to change your practice pattern)". Of course the OD isn't going to approach the MD and say I want to comanage do you? There are enough OMDs who comanage that they would be happy to garner all the referrals . All you need is one person. Why would an OD approach a MD on that topic when all the MDs are clamoring for the referrals? Its just like me, I am an oculoplastic surgeon and I have to go meet and greet ophthalmologists and optometrists. I can't imagine a situation where they would come to me.

I agree with Visionary it comes down to the money on both sides. MDs hear about other MDs who comanage and now are doing 500-1000 cases when they completely sucked surgically and were doing few cases before and are getting referrals now because of the comanagement and think "Shoot...why don't I do that? I would love to do all those cases...is it better I see my own post ops..probably..well...maybe not..I mean think of all those cases I would get... etc..

I think if comanagement didn't affect the decision making you wouldn't see people's surgical numbers go up after deciding to comanage. If the money didn't matter to ODs why would most (Not ALL) refer to only doctors that comanage? If it is a waste of time and an opportunity cost you would imagine that the ODs would refer to people who didn't comanage so they wouldnt be burdened with it in their clinic..

Something doesn't make sense here..I think both groups are motivated by money..afterall we live in America

 

[east]

Visionary,

I'm sure you are well aware that there is more money in eye care than just selling glasses and a yearly routine "eye exam". Many cataract patients have ocular comorbidities such as glaucoma, or diabetic retinopathy. These patients require careful follow-up, and frequent diagnostic testing. Proper care of these patients does generate significantly more revenue than just an "eye exam" Like it or not this is a financial reason for keeping a patient. If managed properly there is more money in managing a monotherapy POAG patient yearly than in cataract surgery for that same patient. By the way I have found your posts to be very fair and informative.

Thiaeyemd,

Of course people are motivated by money. Excellent patient care and revenue generation are not mutually exclusive, on the contrary they usually go hand in hand. I co-manage with several different MDs. It's a bit of a chicken egg thing...the MDs that I co-manage with are good, I choose to manage with them for that reason. I continue to co-manage with the skilled MDs and as I continue, I become more and more comfortable with their skill and manor. We develop a relationship and understand each others technique and patient care style. This is good for the patient. A few MDs I have sent patients to have not been very good (this is rare). These MDs do not co-manage with me anymore.

Bottom line is that my decision to co-manage with an MD is NEVER based on the co-management fee. It's just that if I have the choice of someone I have worked with and trust vs. an MD I know little to nothing about I am going with the one I trust. This should be obvious. The reality is that, most OD interaction with ophthalmology that engenders trust and confidence in skill and patient care is the very cataract co-management situation. For other consulting or referring situations, such as , oculoplactics, cornea, retina, etc. I have a much smaller pool to choose from. In these situations there is no co-management, yet, I refer to those that I know and trust as skilled for the job of taking care of MY patient.

I want both of us (OD and MD)to make money and take care of people to the highest level possible, and in my practice we do it every day.