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Feature Story | May 2010

The Case for Fee-Based Diagnostic Testing

Why such charges make sense in an ophthalmic practice.

As physicians, we routinely send patients to laboratories and diagnostic centers to undergo testing prior to a scheduled surgery or so that we may confirm a diagnosis. When patients have these tests, they pay a fee for the staff’s time and the use of the equipment. In contrast, when we perform diagnostic tests in our practices, they are typically part of the examination fee. We should change this practice for a number of reasons.

Capital Costs
As technological advances have created better, faster, more accurate diagnostic tools, the capital costs have increased. For example, a spectral-domain ocular coherence tomographer (SD-OCT) can easily cost a practice $60,000.

Point-of-Care Testing
The term point-of-care testing refers to tests that patients undergo within the physician’s practice. Point-of-care diagnostics enable us to provide better care more rapidly, because we do not need to send the patient to a separate diagnostic facility.

According to a recent article in Executive Healthcare Management Magazine,1 new point-of-care diagnostics permit lab-quality testing anywhere, which makes state-of-theart technology available even in small, rural practices. For example, the TearLab Osmolarity System (TearLab Corporation, San Diego, CA) recently received 510(k) clearance from the FDA. Although this type of diagnostic test has been used in other areas of medicine for many years, it is new to the field of ophthalmology. The TearLab system’s lab-on-a-chip carries out the test and then provides a measurement once the system is docked onto the base.

New high-technology diagnostic devices have information technology systems on board that enable easy, seamless wiring with a practice’s electronic medical records system. Such connectivity allows us to show patients the results of their ocular coherence tomography or other tests on a monitor while they sit in the exam chair. In addition, new data management tools for images such as EyeRoute (Topcon Medical Systems, Inc., Paramus, NJ) enable the pooling and storage of information from various diagnostic devices in an easily accessible database, which can communicate with whatever electronic medical records system our practice has.

At Durrie Vision, we have decided to change how we use and charge for diagnostics tests. We now offer patients a high-technology comprehensive examination, which we call advanced ocular analysis. This package includes SD-OCT, wavefront aberrometry, slit-lamp photography, fundus photography, and corneal topography. For patient populations that are more prone to dry eye disease, we have introduced what we call advanced ocular analysis +, which includes the TearLab Osmolarity Test as well as the Optical Quality Analysis System test (OQAS; Visiometrics, Terrassa, Spain). We describe the advanced ocular analysis as state-of-the-art technology for patients’ eye care. Our patients pay a premium for these examination packages, a choice they seem happy to make. They receive a take-home package with the images and printouts as well as an explanation of the results.

In order for the practice to provide this premium service, the staff needed careful training on appropriately screening patients to determine which should be brought in for advanced ocular analysis versus a clinical visit that will be covered by insurance. For example, someone calling about a red, itchy eye can be seen in the clinic without a premium workup and have insurance billed accordingly. If findings during a regular clinical examination would justify imaging (eg, an epiretinal membrane as an indication for optical coherence tomography), we can provide that test as a service that is billable to a third-party payer.

There is no doubt that current diagnostic technology is sophisticated and will become more so. In recent years, manufacturers have introduced SDOCT, the OQAS, the Ocular Response Analyzer (Reichert, Inc., Depew, NY), and the Pascal Dynamic Contour Tonometer (Zeimer Ophthalmic Systems AG, Port, Switzerland). The TearLab System will be widely available in the United States after it receives Clinical Laboratory Improvement Amendments clearance. Plus, the ORange intraoperative wavefront aberrometer (WaveTec Vision, Aliso Viejo, CA) now enables on-the-table, real-time refractive measurements, which should substantially improve the accuracy of limbal relaxing incisions, toric IOL implantation, and IOL power calculations, particularly in eyes with a history of refractive surgery.

It is reasonable to believe that these exciting technologies will become as indispensible as corneal topography and wavefront aberrometry are today. These diagnostic systems cost money. It makes sense for ophthalmologists to charge a fee—as our colleagues in other medical specialties do—to make offering these tests to our patients cost effective. Looking for ways to improve revenue based on diagnostic tests does not make us bad physicians, particularly when Medicare reimbursement levels are facing downward pressure yet again.2

Daniel S. Durrie, MD, is the director of Durrie Vision in Overland Park, Kansas. He is a consultant to TearLab Corporation; Topcon Medical Systems, Inc.; Visiometrics; WaveTec Vision; and Zeimer Ophthalmic Systems AG. Dr. Durrie may be reached at (913) 491- 3330; ddurrie@durrievision.com.

  1. Diagnostic Testing.Executive Healthcare Management Magazine.November 2009;9.http://www.executivehm.com/article/Diagnostic-testing.Accessed April 22,2010.
  2. Zhang J.Medicare plans to cut specialists’payments.The Wall Street Journal.July 2,2009.http://online.wsj.com/article/SB124646885862181139.html?KEYWORDS= Medicare+plans+to+cut+specialists+payments.Accessed April 9, 2010
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