While new innovations and technologies have made our lives easier in a myriad of ways, they have also brought significant changes to the optometric profession since the turn of the century. In 2019, we’re able to have virtually anything we desire with a mere tap on a smartphone. Today, regardless of our practice setting, we’re seeing these changes occur on a more frequent basis. From constantly growing online optical sales, to the endless array of new ophthalmic equipment, there is no shortage of technology at our (and our patients’) disposal.
In this article, we’ll explore some common disruptors to the optometric profession in 2019.
Online optical sales & eye exams
Online optical sales, refractions, and “eye exams” are obviously the elephants in the room. In some cases, these services can cost more than the insurance copay for a complete in-person eye exam. According to a 2018 Forbes article, only 4% of total eyeglass sales in 2017 were completed online. As online vendors continue to make it cheaper (or free!) and more convenient for patients to place orders, this percentage could rise dramatically.
While online contact lens sales have decreased optometrists’ revenue for many years, most private practice ODs still make a significant portion of their profit through the sale of eyeglasses. While we’d prefer our patients exclusively buy glasses through us, let’s be serious, people want to purchase things in a quick and low-cost manner. Having your eyeglass prescription sent directly to your front door for less than $10 is hard to compete with.
In the optometric profession, it is our job to explain to patients the difference between an in-person glasses fitting and sale as compared to going online. The 18 year-old low myope may not be able to tell a difference in the final product. The 60 year-old with a history of strabismus surgery, multiple sclerosis, or trauma that needs large amounts of vertical and horizontal prism may be a different story.
Along this same vein lies the conundrum of patients asking for their pupil distance measurements. It is important to explain that there are many fine measurements that go into the creation of each patient’s final pair of glasses. While the typical spectacle prescription we give is one measurement, it’s not the only measurement. Most patients do not understand this. It is important to educate them on the numerous other necessary measurements that are specific to the frame they choose (which your office cannot measure if they buy online).
If your patients insist on obtaining their PD/buying online because they cannot afford your prices, you can have your office get set up with Essilor’s “Changing life through lenses™” program. Based on your patient’s income, they may be eligible for free glasses.
Unfortunately, we’ve all seen patients return to us dissatisfied with the glasses they bought online, asking us to promptly solve the issue. This scenario is frustrating and invariably eats up everybody’s time, especially when you find the same results on repeat refraction.
It is important for your office to have a policy in regards to dispensing the patient’s PD measurements. Some optometric offices may not want to risk the bad Yelp review and, therefore, give everyone their PD, while others will simply say no. Some online eyeglass retailers today even have built-in features that measure the patient’s pupil distance for them.
In 2019, online refraction companies continue to push the boundaries with reckless abandon in their marketing efforts. For example, 1-800 Contacts’ website offers an ExpressExam that boasts “No dilation or puffs of air required – Skip the trip to the doctor’s office.” Their panel of board-certified ophthalmologists will review the patient’s exam findings and authorize an updated prescription. Despite the AOA’s letter to the Federal Trade Commission, 1-800 continues to use phrases that may confuse patients and jeopardize what’s in their best interest. These misleading statements also undermine the standard of care and the doctor-patient relationship.
Do consumers think they're receiving real eye exams?
While you may think it’s obvious to the general public that we’re not comparing apples to apples here (online vs. in-person eye exam), let’s pause for a second. A recent online health care terminology survey of 1000 subjects showed that 56% of consumers thought an ExpressExam was the same exam/testing they’d receive at an in-person office visit, but just in less time. Mic drop…
The survey results also showed 49% of people thought they’d have the opportunity to discuss their eye issues with a doctor, which, unfortunately, is a type of communication that does not exist through the ExpressExam.
Towards the end of 2018, the online refraction giant Opternative changed its name to Visibly in an attempt to salvage its reputation after receiving a warning from the FDA for misbranding their services as a mobile “eye examination.” On the homepage of Visibly’s current website they continue to use phrases like “Visit the doctor. Anywhere. Anytime.” While it may not overtly say “eye examination,” the message may still allude to this. When a layperson learns they’re able to visit an eye doctor anywhere, anytime, they may still believe that they’re getting an eye examination and not just a refraction.
Optometrists across the country are able to have their name and practice information added to Visibly’s “Find a Doctor” feature. In the event that patients do not meet their test criteria, patients are given the option of finding a local eye doctor in their area.
Visibly’s new test requirements do preclude a multitude of patients, including those under 18 or over 55 years of age, or those with preexisting systemic disease, pregnancy, or history of previous ocular surgery. While these criteria may cover some of the bases, primary care optometrists frequently detect undiagnosed ocular and systemic disease on routine exams in the asymptomatic patient (of all ages).
As of August 26, 2019, the FDA issued a recall of Visibly's online vision screening test, following ongoing confusion over whether Visibly offered a comprehensive vision exam or simply a refraction eye exam. Visibly had not received authorization from the FDA to market their online refraction eye exam.
Overlooking underlying health issues
A 2016 survey by the AOA showed that optometrists detected over 300,000 new cases of undiagnosed diabetes during routine eye exams in the United States. This stat illustrates the importance of an in-person eye exam with the optometrist and is great to point out to patients. When these patients simply receive a pair of corrective eye glasses and do not have the health of their eyes thoroughly checked, the growing chronic disease epidemic continues to evade not only those of us in the optometric profession, but society as a whole.
Optical industry giant, Essilor, is now also offering online refractive services. Their message, however, is very clear in stating that their service does not replace an in-person eye exam.
Unfortunately, many online eye exams and optical retailers are attempting to bypass the eye doctor altogether. Some companies make us out to be a significant barrier in the patient’s urgent search for an updated contact lens Rx. While we all like convenience and automation, patients must be educated on the long-term, potentially harmful effects of online eye care. While it may sound amazing on the surface, it may not be in the best interest for the patient’s long-term ocular and systemic health.
Therefore, whether or not someone purchases glasses online, it is our job to explain to patients what we are doing during each eye exam. When they hear about online “eye exams,” they will have a better understanding on the various steps we take during our exam, which cannot possibly be replicated online at this time.
Wide field retinal imaging
There is no question that today’s ocular imaging technologies have significantly improved the way we provide care and document our examination findings. We all have patients ask “Do you have that special camera so I won’t need dilation drops?” With access to new technology, we run the risk of adopting shortcuts which may not be in our patients’ best interest.
Many practice settings today tend to default to fundus photography or peripheral retinal imaging in lieu of an old-fashioned dilated fundus evaluation (DFE). This approach can be useful in optimizing patient flow while also increasing practice revenue. The crux of the issue here lies in whether or not we’re making an equivalent comparison between our current imaging modalities and the DFE. The best-case scenario with a good quality image is capturing up to 80% of the peripheral retina with a wide field camera. While this is much better than our undilated view, it is not the same as a full dilated exam where we’re able to see essentially 100% of the retina.
So . . . who gets dilated?
Many new grad ODs may be disarmed to find they’re expected to dilate very few of their patients at their first real job in the optometric profession. Sometimes there is pressure from the employer to see a higher volume, other times patients just misunderstand the utility of the DFE and/or refuse it. Sure, some patients are returning to work or need optimal vision immediately upon leaving your office, however, this isn’t always the case. In most non-urgent, asymptomatic cases, it is perfectly acceptable to have patients back for dilation, document their refusal, or simply have the patient continue seeing a different provider for their medical eye care.
For medico-legal reasons, it is important for your office to adopt a protocol as to who gets dilated, who gets a photograph, and who gets both. If you feel uncomfortable or pressured to balance a high volume of patients while dilating most of them, you may need to modify/optimize your exam flow, discuss this issue with your employer (propose less patient volume), or as a last resort, search for a new practice modality altogether. As new grads, we may assume that the first practice setting we find ourselves in is simply “the way things are done”; however, each practice is different, and it’s important to be working somewhere that aligns with your standards and comfort level in terms of patient care.
A comprehensive assessment of the retina is also usually required when billing for a complete eye exam. When billing for a complete exam on most insurance plans (vision and medical), you’re specifically asked “was the patient dilated?”
In OD/MD settings, ophthalmologists may do a majority of the medical billing (and DFEs). It is especially important for ODs in these settings to have their own dilation protocol in place—regardless of insurance plan, the patient’s age, or their systemic health. Use your best clinical judgment on who gets dilated when they’re in your chair (eg. new patients, myopes, diabetics, adults, etc). Once a patient gets what they want (contact lens or glasses Rx), you may find they’re quickly lost to follow up when they should have returned to have their eyes dilated by you or the ophthalmologist.
Cost of education
No surprise here—the cost of becoming an OD has increased exorbitantly over the past few decades. Today, the average cost of becoming a Doctor of Optometry is well over $225,000. Look no further than the financial aid page of any OD school’s website. The average student debt load has a significant impact on new grads entering the workforce and society today. It influences decisions on practice modality, residency training, and whether or not to take on further debt with new cars and mortgages.
Many new grads in the optometric profession are also opting for commercial and retail settings in lieu of private practice due to guaranteed pay and benefits while avoiding further debt. Unfortunately some private practice ODs are finding it increasingly difficult to sell their practices and retire—resorting to giving their practices away for free, or simply closing their doors.
The growing cost of education also may also discourage qualified prospective undergraduate students from applying to optometry schools.
Is there a solution?
What is the answer? Should we decrease the number of OD schools like the dental profession once did? Decrease the cost of education? Increase insurance reimbursements/salaries? Or increase incentive programs (eg. IHS loan repayment or public service loan forgiveness) to pay back optometry school debt? We may find that a combination of these options will begin to unfold in the coming years.
- One example of a great loan repayment program is the “National Health Service Corps.” Unfortunately, optometry is one of the few professions not currently eligible for loan repayment under this program (which offers a significantly higher stipend). If we make our voices heard that optometrists should be included, this could be another way to help future ODs pay off their debt.
- A very similar repayment program that includes optometry is “Indian Health Service Loan Repayment” which requires you to work at an I.H.S. location on a full-time basis.
- Practice settings that qualify for public service loan forgiveness (PSLF) can also help new grads tackle their debt load.
Lastly, it’s important to keep in mind that even though you are now a doctor, it doesn’t mean you need to go out and buy an expensive car or a house that is outside your means. No matter your debt level getting out of school, practice saving money to set yourself up for a secure financial future.
While the optometric profession is changing, the field of optometry is still an exciting place to be here in 2019. It is important for ODs to acknowledge these changes, educate our patients on them, and continue to move forward. Despite these disrupters, new grad ODs today will still find a multitude of practice settings and professional opportunities as they enter the workforce.
