routine

The metaphysics of dilation

The metaphysics of dilation

Because I am an optometrist I dilate. Or is it because I dilate I am therefore an optometrist? In either case I am allowed, by law in Colorado, to use diagnostic pharmaceutical agents in the course of a patient examination in order to enlarge pupils. I’ve recently come to find out that there’s a wide range of the use of these drugs by others in my profession. My debate over the purpose of routine use of these diagnostics was made clear to me after 16 pages of discussion but ended more in how often a patient should be seen for a regular eye exam than how often a patient should be dilated.

First, the drugs. Dilating can be done with different chemicals. There are kinds that vaguely dilate pupils and others that can maximally dilate your pupils for a week or more. Why would one doctor use one drop and another doctor choose the stronger or weaker one? That, my friends, is based on your doctors training and beliefs or needs. You see, doctors are people. There isn’t one way to do things so we pick the way we personally want it done. And that’s ok. Here are a few types of dilating drops if you want to look them up: tropicamide, paremyd, phenylephrine (also found in some OTC redness relievers), homatropine, cyclopentolate and atropine. And most of those drugs can be in different strengths (ex., 0.5%, 1%, 2.5%, 5%, 10%).

In the 16 pages of discussion I finally got to the bottom line of when to dilate a healthy person with very low or no prescription who has no complaints or known medical conditions leading to eye disease. It would be done in their next recommended visit…..in 5-10 years! See the link below if you want to read the guideline. That lengthy period was an eye opener. Honestly, telling a patient to come back in 5 – 10 years basically sounds like we don’t want to see them again. But that’s what the guideline says. My own profession’s main association (American Optometric Association, AOA) says eye exams are recommended every 1-3 years for the same healthy individuals. That’s a conflict right there. There’s something even stranger about this. These vision plans that I accept, many times they allow an eye exam every year. There’s an incentive for everyone involved to possibly over-utilize health care here. And why not? Don’t companies want you to use things more often because they will make more money? That’s the American way.

Why dilate anyway? The main reason is an attempt to see the various “parts” of the back of the eye. We have to look through the pupils to do that, to see the retina, and the bigger the pupil opening the easier it is to see back there. It’s like peering into a mystery world that is unknown until we spelunkers go check.

Before anyone jumps to conclusions about what their eye doctor does or doesn’t do, you should be in good hands. This post isn’t about covering all the reasons for dilating either. Each doctor has their own routine for your routine eye exam. Just remember to tell them of anything you can recall about your eyes and vision. That will make it easier for your doctor to decide whether they may or may not dilate you. And just an interesting note about eye (iris) color….blue eyes generally dilate with less drugs than brown eyes and the length of dilation for blue eyes is also generally shorter but the same drop might work as well on both eye colors.

http://www.guideline.gov/content.aspx?id=25644

dilated vs undilated

dilated vs undilated

 

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Vision plans, benefits, insurance games

Vision plans, benefits, insurance games

I just had a patient finally come in and pay their bill from last year. The vast majority of my patients come to my office expecting their vision plan to pay for the majority of the costs of services and materials (glasses and contact lenses). We do our best to determine coverage before the appointment. This patient made an appointment to have another exam today. Since we’ve been unable to collect by phone or bill or from her insurance company we waited until she arrived to present our evidence of money due. And did this in a careful manner I was told.

Guess what happened? She paid for the past due amount which was for her husband as well. Then she was told that her current insurance which is different from last year was not going to cover a routine eye exam today. I don’t know what the patient’s state of mind was this morning but after paying for the previous balance, I was told she broke down and cried. I can understand. She left without doing the exam today. No one felt good about all of this. And this all was for a simple routine eye exam from last year and today. Geez! There’s rarely or never any excitement when paying for health care is there.

Let me make a case for why vision plans are terrible and say something later about how medical benefits handle this. You can make your own case for why medical benefits are terrible I’m sure. My fee is $115 for a comprehensive eye exam for a private paying patient. If a patient has one of those vision plans like VSP or Eyemed they usually get their exam covered and just pay a co-pay of maybe $10 or $20. I also, by accepting that vision plan, get a significantly reduced reimbursement for that service. I guess I win and so does the patient but there’s another winner. It’s the vision plan.

I heard from someone or somewhere that vision plans survive because they can sign up a business with a large number of employees knowing that only 30-35% of those employees will use those annual benefits….at all. The employer may pay for a part of the cost of benefits and the employee may (probably) also be paying out of their paycheck for the benefits.

In a way, the whole thing works out for most people and we don’t even think about what the vision plan is getting. It’s a silent partner in this whole deal. Yeah, those vision plans can tell you a good story how great they are because they tell the employer how their eye doctors (in the plan) can potentially help with diagnosing all kinds of systemic diseases. And, of course, they tell the employer that the health of their employees is important.

Let me just say this. In my area, my patients are mostly well-educated, seem to be getting their medical visits regularly, so I rarely find any disease, I mean rarely, rarely, rarely, that is systemic. But I’m supposed to report to the vision plan if the patient reports they have some condition like hypertension that they are being treated for by their medical doctor. These vision companies are building reasons for the next time they try to sell the employer why they need to buy that vision plan again. As an example, uncontrolled hypertension could lead to certain eye problems but obviously it can lead to lots of other problems. But a pretty simple test to measure blood pressure is in every doctor’s office and in the grocery stores and in the drug stores and all kinds of other places. An eye exam is not needed to see if a person has hypertension.

Well, let me get to the bottom line. It’s all a dirty job I think to sell this bs to employers because the vision plan gets to keep the 65-70% of those payment the employees make through deductions in the pay checks and amount the employer pays them on your behalf. That’s a pretty good return on investment!

I do recommend eye care but it’s not necessary every year for most people. I did say most people. What we ought to do is just educate people and let them decide when they need to come in. Contact lens patients are a little different though. My state, Colorado, says I can only write a prescription for 1 year for contact lenses. So maybe the vision plan helps for those patients. But wait until you read the next paragraph.

One more dirty little secret and it has to do with soft contact lenses. The manufacturers recommend a certain replacing period for them which has a lot to do with what they asked the FDA approval for. The contact lenses are considered medical devices by the FDA so they have to have a usage period designated in these FDA approvals of them. But it has little or nothing to do with how long the contact lenses can actually last without causing complications. I feel conflicted here because the contact lenses that are made today are significantly better than the ones made 10 or more years ago. Many years ago patients kept the same lens for one whole year! Now some brands today are disposed of every 2 weeks or even daily! I am allowed to make a replacing schedule determination based on my findings but every doctor fears the lawsuit so it’s hard to stray from what the manufacturers recommend.

Back to my patient this morning. Her expectations of her benefits were like most. She expected she was covered. Her particular plan was through a medical type insurance and when we call those guys we get this kind of response, “they have the benefit available but this is not a guarantee of payment.” Vision plans are a little different and we get paid. Her plan didn’t pay. We called this company and still they refused payment. We can spin our wheels a little and try some things with the insurance company but they make it so difficult and time-consuming that we’ve grown tired of the charade.

My recommendation is if you don’t need annual vision exams, you don’t need a vision plan. Just pay out of pocket. Ask for a discount too. Maybe ask the doctor directly. The staff might not have the authority to do that. What a world we have to deal with. Don’t get me started!

retinal drawing

Retinal drawing