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.

Looking back on my decision to leave, it would have been much better for my financial situation to stay. In fact, I am going to argue that for any optometrist, the financial rewards for practicing optometry are equal to and most likely better in the Commissioned Corps than in the private sector.

Government optometry work seems to get little attention in optometry school. Most everyone has delusions of grandeur about how comfortable their living will be while working in private practice. Of course, that dream turns into a nightmare when they work for another optometrist paying them little more than a resident but with the hint or promise of a buy in which later fizzles out.

Many people think of government optometry only when they want to go into the military just to get their school loans paid off and then get out. Many do not stay because promotion in the military is limited. Many years ago the USPHS used to have an automatic promotion schedule, but that has been replaced by merit promotions. A recent transformation of the commissioned corps of the USPHS has made it harder to get promoted just for showing up; however, your chances of getting promoted to O-6 (equivalent to a Colonel or a Navy Captain) are much better in the USPHS than other uniformed services.

For an estimate of what monetary compensation you might get in the USPHS, I’ve made this table. It’s a little tough to understand unless you are used to military pay systems. They have what is called base pay which is calculated from your rank and years of service. But then other types of pay like Housing Allowance and Subsistence which are variable depending on where you live. You also get pay for being an optometrist: Optometrist Special Pay and Optometrist Retention Pay which helps equal your pay to private sector optometrists. You can get even more money by getting your FAAO and by hopefully getting loan repayment. Also you get up to $1000 reimbursement per year for travel and tuition expenses for continuing education.

My PHS pay estimate is based on a theoretical advancement in rank. Promotion is not guaranteed nor is it on a set timetable. There has been cases where an officer was frozen at O-5 and wasn’t allowed to be promoted to O-6. I also assume that one stays 30 years in the corps. You can get out as soon as 20 years, but your retirement compensation is less.

Now, I’m no accountant or financial planner, but I believe that my PHS pay estimate table shows that compensation inside PHS is probably better than what you can expect to achieve in the private sector as an optometrist. A private sector optometrist would have to invest ~$24,000 a year just to get the same retirement that a 30-year PHS optometrist gets.

Anyway, this should dispel the myth that PHS optometry pay isn’t comparable to private or commercial optometrist pay. I’d say it’s better based on my calculations.

Now, what can you expect if your join the USPHS? There are a small few who work in the FDA and Bureau of Prisons. You could also work your way up and do non-clinical duties at USPHS headquarters. But the majority of PHS optometrists work in the Indian Health Service. You can work in the IHS as a civil servant or direct tribal hire, but for a career IHS optometrist it is most advantageous to go the commissioned corps route. Same job as an optometrist but different pay system.

Where can you work? Well, here is a map.

But a better way is to browse through the PHS-IHS directory regularly updated here. But not every place has an opening, so you need to look at the current Vacancy Announcement (a.k.a. Recruitment Announcement) regularly updated here at the IHS Optometry web page.

You can find optometry job announcements in IHS by going to their website job page and then selecting “Optometrist” in the Professional Categories pick list. I find that this page isn’t updated as quickly as the IHS optometry page, though.

In my next few posts, I’ll talk about non-monetary benefits of working for PHS-IHS, tips and tricks for applying with the PHS-IHS, more about rank advancement, and the Loan Repayment Program.

For more information about calculating pay in the USPHS system, see these sites:

• USPHS.gov benefits overview
• Military Pay Calculator
• Military Basic Pay table or USPHS Basic Pay Table
• Basic Allowance for Housing is the biggest variable, estimated in table it at ~1200.
• Basic Allowance for Subsistence now at $202.76