Nice logo, Walmart!

I intend to blog about my experience daily. As one of the few selected, I imagine there will be an occasion for me to express concerns and ask questions. If you have any comments or questions you would like me to consider voicing in Bentonville, then please write it in the comment section below. (Please be serious and civil.)

Here’s that e-mail:

Dear David Langford

Historically, the annual Doctor meeting was primarily focused around Optometry. As our health and wellness businesses continue to become more integrated, we seek to further expose the important work of health care professionals to the greater Walmart organization. We also want our senior leadership to better understand the difference you are making every day in the lives of our patients. With that in mind, we will be hosting the Health & Wellness Conference May 3-5th, 2010 in Bentonville Arkansas.

You have been chosen through a nomination process to take part in this exclusive gathering of professionals; you’ll hear from the executive leadership of Walmart on our company’s ongoing growth strategy; discussion from governmental and NGO’s on health care reform in America as well as inspirational messages from medical visionaries on the impact they are making within their communities.

We have made several changes of this conference design from years past. For example a smaller more intimate gathering will facilitate the opportunity for you to interact with and learn from key leaders as well as your peers. Representatives from all of the Walmart Health & Wellness business units will take part including professionals from the practices of Optometry and Pharmacy as well as our Clinic Operator partners in addition to select representatives of our internal support teams.

In addition we elected to conserve time and resources in an effort to present a holistic message around health care and the challenges that our customer, health care professionals and company is facing today, therefore CE credits will not be offered at this meeting. And as this meeting has been limited to a select group of attendees, we are asking that spouses not attend.

We look forward to having you take part in the Health & Wellness Conference 2010. Please click the View Event Summary link below, view the event details, and respond by clicking either the Yes or No button at the bottom of the invitation. Or you can simply select the register button on the Event Summary website. Registration will close on March 13th, 2010

Thank you,
Health & Wellness Professional Affairs

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care is “insurance free medicine.” The term “insurance free medicine” captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance.

Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like “boutique,” “concierge,” and “cash only” might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. Previously, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies.

With more frequent use of the term “insurance free medicine,” patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

I calculated the other day that I spent about $2000 a year to be set up and able to bill insurance. Further, I spent all that time and money for about 538 patients, or close to one-fourth of my patients per year. Now that Walmart no longer bills many vision plans for me, both numbers will go up, and so will my accounts receivable. In anticipation of this, my fee went up by $5 per patient at the beginning of the year.

I would lower my price if we could all convince the general public that routine medical office visits should be paid out of pocket. Your car insurance doesn’t pay for oil changes.

The not so simple question...

There is a not-so-simple question that pretty much every patient asks, “How much is your eye exam.”

While the medical model has varying levels of exam, like Level II-New vs. Level IV-Est, which depend upon the history, exam, and complexity of that particular case; however, there are some among our profession that make it an especially hard question to answer, and this issue raises concern over the ethics of a fairly popular fee structure.

For example: the price in front of the Big Box says “Eye exams starting at $45!”
But are they really? Sure, for a “routine eye exam” where nothing is wrong and you just want your glasses updated, then it’s the $45. But what if I have some allergy eyes, so the doctor gives me a prescription for Pataday as well as my glasses Rx? All the sudden the exam somehow costs $120!?!?

Huh, something funny going on around here. I think big box doctors are more likely to do this since their exam fees are so low, they make up for it by gouging in other fees. I have no problem with a doctor who says their S0620 is $100 and their 92004 is $120. However, I think there is something wrong if the S0620 is $45 and the 92004 is $140.

It’s like some among us in the optometric profession are playing the windshield chip repairman scheme.

But what really happens? Patients won’t typically notice this bait-and-switch. It’s really the insurance companies who get hammered. The patient pays their copay, and if the doctor can come up with any excuse to bill a medical code, they use their medical model fee structure to justify it.

Ethics applies when we realize that, for some reason, private pay patients are rarely charged the same high fees as the insurance companies. Huh. Oh well. It’s a victimless crime because those big, bad insurance companies won’t miss the extra cash. Until we realize that the more insurance companies pay out, the more the patient’s premiums will be raised next year. Whoops. Sorry, Mrs. Smith, that you can’t afford to keep your medical insurance in the future because I wanted to get paid double or triple my usual fee because you have insurance today.

By the way, it cost me about $2000 to bill insurance last year (PIM software license, E-filing charges, and postage/paper for mailing statements/refunds). Also add to that the cost of time spent filing claims and handling overpayment and underpayment. If I didn’t have to deal with insurance, I could drop my exam fee by at least $5 per person.

I have an idea: All patients should pay for office visits out of pocket. If they have insurance, get reimbursed later. The doctor won’t know about their insurance, so there won’t be a conflict of interest about what exam fee structure he’ll choose. The doctor can lower his fees since filing claims is expensive and time consuming. Everyone wins. Another idea, insurances should allow me to charge either them or the patient a $5 claim filing service fee.

Take home point: I don’t believe it is ethical to have one fee structure for insurance patients and another drastically different one for private pay. Yes, I’m all for charging more money if something is more work and more time. That’s why a contact lens evaluation is paid on top of the routine eye exam. That’s why there are different levels of 99*** office visits. But sneaking a huge fee onto an insurance claim just because there is some medical code excuse is something I don’t think our profession should feel comfortable with.

The retail clinic era is over, and … pharmacy-based clinics are doomed to fail.
Corporations are finding out what primary care doctors already know: it’s hard to make money only doing office visits.

Ophthalmologists make bank doing procedures. I guess the problem with the retail medical clinic is that the doctor is paid so much. I guess optical shops are lucky that optometrists aren’t as high up on the whole pay scale totem pole.

I have to wonder about the optometric profession, though. The student loan debt percentage delta outpaces optometrist’s pre-tax net percentage delta. How much longer will anybody want to apply for optometry school?

I guess we need Obama to bailout the optometry schools. Socialized medicine, here we come. Thanks for reading, comrades.

How does the perk of working every Saturday sound? How do you like getting home many nights at 8:00 PM, (just in time to tuck your kids into bed)?

Unless an optometrist is employed by a big chain or there is some extreme emergency, hours are generally restricted to Monday through Friday with no on-call duty needed.

That’s not true in today’s market. Only government workers get Saturdays off now. More and more private practices offer extended hours and Saturday hours to stay competitive in today’s market. People don’t take time off work anymore just for routine eyecare (but of course they’ll do it for the dentist, but not you…a lowly optometrist).

Oh, and other doctors don’t have to worry about their scope of practice being legislated away.

And how do you like having a cap on potential income? You can only see so many patients a day. Get rich selling an unlimited number of widgets that everyone wants. Only become an optometrist because you love it…but, that begs the question how do you find out that you love optometry without going to expensive optometry school? By the way, when I went to optometry school (PUCO 2003), it cost about $22,000 per year for tuition, including fourth year when you’re not even at school because you are on preceptorship. Last I heard it’s up to $27,000 per year.

So my question is, at what price point does optometry school become unfeasible?

Hat tip to Kevin, M.D. who commented on this story and said,

“This is why the private practice model of medicine is dying. More practices are being bought by hospitals where the physicians are salaried. This relieves the burden of administrative tasks and supervising ancillary staff, so that the doctor can focus on medicine.”

Rob at VSP says that “[private practice doctors] provide the best care.” Well, if I’ve got the weight of a business on my shoulders, doesn’t that detract from patient care? Additionally, in our field where the private practice doctors sell what they prescribe, can you totally rule out any conflicts of interest which potentially detract from patient care?

Again, independent doctors of optometry in a Wal-Mart setting don’t have the conflict of interest and their administrative duties are much less than private practice.

What’s funny to me is that every CE event I’ve been to always has some talk about why optometrists should start the “medical model” in their practice and watch the money role in. Well, how is adding more third party payers going to help you make more money? Primary care medicine is dying according to Kevin M.D., and yet the roboconsultants are telling us to join more insurance panels. I think getting rid of insurance companies in your practice is the way of the future.

The roboconsultant woos you buy saying that for one case of dry eye you can milk an insurance company for $500-$800 in office visits and procedures. Well, do you do that for every dry eye patient, even the poor self pay patient or the patient with insurance but poor benefits? I would think that doing it just for those with good insurance would be unethical as well as probably insurance fraud.

I think the more your appointment book is filled up, the more you should be able to charge for your services. It’s the old supply and demand of free economics. I think a better system would be for patients to have to front the money to pay the doctor for office visits at the time of service. The patient would have to get reimbursed what they can from their insurance company. Maybe then insurance companies would be forced to have a faster turn around time on processing claims for their patients and be watched more closely for just rubber stamping a denial based on some frivolous billing exercise (or at the least the patient has to worry about it instead of me.) I simply provide the best care for the patient, recommending only the products and services that they need, since now I don’t have to worry about getting paid.

…these [private practice] doctors consistently have the longest relationships with their patients and provide the best care.

Rob, people aren’t buying what you’re selling anymore. I see VSP beneficiaries out of network all the time in my Wal-Mart setting. I guess they aren’t loyal to a practice setting, but rather they factor in price and convenience while assuming, correctly, that any doctor they see in my area is competent.

Oh, and I remember when Intel in the Hillsboro/Beaverton, Oregon area was buying your VSP, and then they switched to EyeMed. Does that mean they thought your private practice network of doctors couldn’t “provide the best care?”

But I see what he’s trying to do. Any roboconsultant will tell you that you need to differentiate yourself from the competition; however, I take exception when he lies.

They seem to be saying that I’m a flip flopper and must be some unhappy individual who is lost. You can’t discredit me because I’ve experienced three major forms of practice. Someone who has experienced government, private, and various flavors of commercial is not a lost soul, but rather he is an experienced voice.

I implore all students and new O.D.s to listen to my words. If you would like the security of government work and don’t mind living in remote locations, then by all means be a government optometrist. If you want to be able to live in more populated areas, than choose commercial practice over private and choose Wal-Mart over all other commercial options.

In my previous posts advocating private practice and demonizing commercial, I had been drinking the private practice cool-aid that I’d been served since optometry school. Some of the disparaging remarks against commercial hold true for many brands of opticals, but not Wal-Mart.

Private practice is too risky. Sure, you know or have at least heard about successful private practice businesses, but you can’t assume that things would go well for you if you were to hang up a shingle. The money it takes now days to start cold could be better invested in Vegas. It’s a crapshoot, heavy on the crap because the frame vendors, the lens suppliers, ophthalmic equipment companies, the financing company, the advertising people, the landlords, the employees and more all get their money from you. But when do you get paid? Paying all of those people doesn’t automatically bring patients in the door. And when will you actually get enough patients to break even? That could be never, you know. You may just have to close shop when the money dries up, like I did.

Wal-Mart makes it risk free. There will always be patients coming to your door. Your success is only limited by the number of hours you are willing to work. That’s why if you want to be rich, make and sell widgets. If you want to do eyecare, work for the government or Wal-Mart, depending on where you want to live.

Anyway, just because I’m giving advice from my experience doesn’t mean I’m somehow lost or unhappy. I have family, religion, and a great job inside a Wal-Mart Vision Center. Of course I’m happy.

Can the doctor physically be at two places at once or work eight days a week? No, so he hires someone. Let’s call the multi-contract owner Dr. Fingers and the two doctors who work for the contract owner we’ll call Drs. Desperate and Disgruntled. Wal-Mart needs three locations filled: Bountiful, Ghetto, and Rough Diamond.

So let’s say Dr. Fingers works Bountiful and hires Dr. Desperate at the Ghetto location and Dr. Disgruntled at Rough Diamond. The contract is similar to “I’ll pay you 70% of your gross receipts.” Dr. Desperate says fine because she just needs a job and doesn’t care about a long term commitment because she’s willing to relocate in a moments notice. Dr. Disgruntled is in a bind because he really wants to live in the city of Rough Diamond forever, but he doesn’t want to pay Dr. Fingers 30% of his gross receipts, especially when he finds out that Dr. Fingers is only paying Wal-Mart 10% or if the contract is some ridiculously low flat fee not even based on receipts.

So what happens? Usually Dr. Disgruntled will leave and try to find his next best ideal location. Dr. Fingers will probably have to funnel in and out doctors every couple years. The vision centers stagnate and never grow because the doctors who work there have no vested interest in growing the practice since they know they won’t be there long term since Dr. Fingers takes so much of their money.

I believe that it is a mistake for Wal-Mart to give any doctor a contract for more than one location just so he can suck cash from other doctors for no reason other than, “Hey, I own the contract.”

Now, I can see how some of you might say, “But what if you had a multi-doctor parnership share multiple locations equitably?” Well, you’d still have the problem of the last location not growing because the doctors rotate every day, and then which of the doctor partners would volunteer to work at the last location on its poor performing days?

It’s better for the vision centers, the doctors, and even the community to have each doctor own the contract for the vision center that they work in.

“But what about vacation days?” you say. Well, wouldn’t it be cool if each area could have it own full time fill-in person? Maybe the fill in person could always keep 100% of his receipts and not have to pay rent to subsidize the days when there isn’t an opportunity to work? I don’t know, I’m just thinking out loud here. Or you can probably find a private practice doctor who needs supplemental income to work for you.

“But our store needs someone, and we can’t find anyone, so thank Heaven for Dr. Fingers,” you say. Well, that’s a short term solution that defeats you in the long run. None of your sub-contracted doctors would be motivated to grow the practice (an thus increase vision center sales) like a contracted doctor would. This scenario will just stagnate you at mediocrity. If you must hire Doctor Fingers, I think the terms should explicitly say that Wal-Mart has the option to not renew Dr. Fingers contract at the satellite location if they can find a permanent doctor when the contract expires in three years. I don’t care if Dr. Fingers is taking a “risk.” He has three years to recoup his “risk.” Take it or leave it, Fingers.

But let me restate. Multi-location contracts for a lone doctor who invariably gets greedy and pockets cash for not doing any work: BAD. Allowing a doctor to own the contract where he actually works in order to change it from slow to crazy-busy: GOOD.

So the message to optometry students is that private practice optometry isn’t the pinnacle of our profession- it’s just another way of practicing. Choose your mode of practice based on your goals. Do you really want to be a “savvy businessperson” with all the headaches of running your own practice? If so, get out of optometry and start a business where you can make some real money since optometrists have a cap on their income potential since we can only see so many patients a day.

Anyway, most of the criticism to my recent post has been words to the effect of “your exam fees are so low it disgraces the profession.” Um…why are your exam fees so high? Oh yeah, your overhead is ridiculous. Let’s say your solo private practice pretax net is $118,800. That means your practice had to gross around $396,000 (a generous 30% net-to-gross ratio), $475,200 (25%), or $594,000 (at 20%).

The Wal-Mart doctor just has to gross $132,000 or $148,500, depending if the lease is 10 or 20 percent. No problem. Oh, and the Wal-Mart doctor can gross $11,000 a month just working 4 days a week. And he doesn’t have to kill himself explaining to every single person that enters his practice why his glasses cost so much and why his exam fees are so high.

So, your ridiculously high exam fee, caused by ridiculously high overhead, is part of the problem with rising health care costs in this country while Wal-Mart optometry is helping people to save money and live better.