Smaller Practices Can Be Technology Leaders

They're investing in analyzers that may be setting a new standard of care for glaucoma evaluation.

Smaller Practices Can Be Technology Leaders
They're investing in analyzers that may be setting a new standard of care for glaucoma evaluation.
By Jerry Helzner, Associate Editor

Marguerite R. Billbrough, M.D., the owner of a two-doctor practice in Folsom, Pa., was one of the first ophthalmologists to recognize that an investment in optic nerve and/or retinal nerve fiber layer analysis (RNFL) technology to detect and monitor glaucoma could bring a wide range of benefits to a smaller practice and its patients.

Dr. Billbrough chose this advanced scanning technology because it's patient-friendly, takes no more than 10 minutes to complete, and produces objective, reproducible images that can be easily interpreted. Some ophthalmologists now view scanning technology as part of a glaucoma evaluation "triad" that also includes visual fields and fundus photography. However, most of the doctors Ophthalmology Management interviewed for this article, including Dr. Billbrough, say they're now using their analyzers instead of fundus photography with the great majority of their glaucoma and glaucoma-suspect patients.

"I have a significant glaucoma practice," says Dr. Billbrough. "In 1999, I was looking to buy a fundus camera. But when I saw a demonstration of Heidelberg Engineering's HRT II, I realized I could get so much more for my money that I put in my order right away. I got the fifth HRT II that Heidelberg made."

Now, three years later, Dr. Billbrough says her initial expectations of the value of the analyzer to her practice and patients have been more than fulfilled.

"The three-dimensional images that I obtain essentially serve as an early warning system to confirm the probability of glaucoma in glaucoma-suspect patients," says Dr. Billbrough. "In a number of patients I've been able to begin treatment for glaucoma before the visual fields showed a vision loss. In confirmed glaucoma patients, I use the scans to track the progression of the disease and the effectiveness of treatment. And the instrument paid back my investment in it in about a year."

Based on her experience with her analyzer, she believes optic nerve and RNFL analysis should be recognized as standard of care for glaucoma detection and monitoring.

"I felt that way in 1999. I feel that way today," she says.

Though makers of optic nerve and RNFL analysis equipment estimate that only about one-third of ophthalmology practices have thus far adopted this technology, more and more doctors are coming to share Dr. Billbrough's belief in it.

Ophthalmology Management interviewed 10 general ophthalmologists for this article. All operate solo or relatively small practices, and all of them have successfully incorporated optic nerve and/or RNFL analysis analyzers into their practices. Without exception, they're satisfied with the investment they've made in this equipment and believe that if the information-packed scans produced by this technology aren't yet accepted as essential for glaucoma detection and monitoring, they're fast approaching that status. In this article, I'll explain why these ophthalmologists are enthusiastic about using optic nerve and/or RNFL analysis for testing glaucoma-suspect individuals and monitoring confirmed glaucoma patients.

Meeting your needs

It's important to note at the outset that four types of optic nerve and RNFL analysis equipment are currently in wide use in the United States. These are:

  • The GDx RNFL analyzer from Laser Diagnostic Technologies
  • The Heidelberg Retina Tomograph (HRT II) from Heidelberg Engineering
  • The Stratus Optical Coherence Tomograph (OCT) from Carl Zeiss Meditec, Inc. (formerly known as the OCT3)
  • The Retinal Thickness Analyzer (RTA) from Talia Technology, Inc.

All of these instruments are primarily used for glaucoma detection and monitoring. The higher-priced Stratus OCT and the RTA are capable of performing additional retinal analysis, while the HRT II also provides retinal information and has a macular edema module that's offered as an option. If you're interested in purchasing this type of equipment, you should carefully compare the capabilities of each machine with your specific needs. Also be aware that while the guidelines and payment for glaucoma testing using optic nerve and/or retinal nerve fiber layer analysis have been essentially set by Medicare under CPT code 92135, reimbursement for retinal analysis varies from state to state and from insurance carrier to insurance carrier. Currently, about 20 states reimburse for retinal analysis as extended ICD-9 codes to 92135. Reimbursement policies in your area will affect how quickly you can expect payback on a piece of equipment that can cost between $33,900 and $49,950.

Though all of the doctors we interviewed expect to earn back the cost of their analyzers within 6 months to 5 years, none of them say they purchased the instrument because they viewed it as a surefire money maker.

But a common thread among all the purchasers is that they believe in incorporating advanced technology into their practices as a way of providing the best possible care.

Doctors cite benefits to patients

"Diagnostic evaluation of glaucoma has been the same for many years; it hasn't changed for decades," says Raj Seetharaman, M.D., of Mid-Ohio Eye Care in Galion, Ohio, who recently purchased the RTA. "This technology represents an exciting new development for evaluating patients for glaucoma, and detecting it sooner than we could before. My practice is in a semi-rural area and most of my elderly patients don't want to travel for eye care. If we didn't acquire this instrument, our patients would have done without it. I felt it was my responsibility to have this piece of equipment. I also feel it's a good investment that should earn back its cost in about 2 years."

By having the RTA, Dr. Seetharaman finds that routine fundus photography has become much less important for his glaucoma patients.

"My OCT is as important as the slit lamp is in my practice," says Michael Korenfeld, M.D., of Comprehensive Eye Care, Ltd., in Washington, Mo. "It gives me quantitative, accurate information on glaucoma-suspect and glaucoma patients. And by using the analyzer to obtain high-resolution, cross-sectional images of the macula and other places within the retina, I'm learning about the mechanics of AMD, unexplained edema and other eye diseases. This instrument makes me look smart -- and I like looking smart."

"Having used this technology, I cannot see practicing without it," says William F. Keeling, M.D., a solo practitioner at the Indiana Eye Clinic in Plainfield, Ind., who early this year took out a loan to purchase a Stratus OCT. Dr. Keeling bought the analyzer because he was moving into a new, more spacious office and wanted it to have state-of-the-art equipment.

"Technology doesn't make your practice, but it does add to it," says Dr. Keeling. "Optic nerve analysis gives us information that we can't get from other instruments. In a glaucoma-suspect patient who has elevated IOP or an increased cup-to-disk ratio, the OCT could show significant thinning of the nerve fiber layer. Based on those findings, I might start treating that patient for glaucoma much earlier than if I waited for a visual field to show vision loss. It's clearly in the patient's best interests for me to have this equipment."

Dr. Keeling says he originally figured that he needed to perform about 12 bilateral scans a month to break even on his investment. He's meeting those projections and expects to earn back the cost of the OCT in about 5 years.

"As the population ages, I believe this type of equipment will become more and more useful to ophthalmology practices," concludes Dr. Keeling.

Glaucoma practices benefit

Solo practitioners Michael C. Stiles, M.D., of Stiles Glaucoma Consultants, Kansas City, Mo., and David P. Frasz, M.D., of Family Eyecare, Dover/Foxcroft, Maine, each purchased a GDx RNFL analyzer early this year. The GDx meets their specific needs because they both have significant glaucoma practices and wanted the technology exclusively for glaucoma testing.

"I needed the nerve fiber analyzer because of the type of practice I have," says Dr. Stiles. "With this technology, the patients don't have to be dilated and a well-trained technician can do the test in about 10 minutes. I sometimes use the test to determine if I should begin early treatment of a patient. If optic nerve analysis isn't yet the standard of care, it's rapidly approaching standard of care."

Dr. Stiles says he gets referrals from both ophthalmologists and optometrists because he has the equipment to perform optic nerve analysis. Because his practice is 90% glaucoma-related and he performs 15 to 20 tests a week at an average reimbursement of $120 (bilateral), he expects to earn back the cost of the GDx in 6 months to a year.

Like the other solo-practice doctors who've purchased optic nerve analysis equipment, Dr. Frasz says he's "always tried to keep up with the latest technologies."

Dr. Frasz practices in rural Maine and has a substantial number of elderly patients.

"With about a quarter of my glaucoma patients I can't rely on visual fields," says Dr. Frasz. "They have short attention spans, or they get tired, or they simply hate the test. I wanted another way to follow them. I bought the new GDx Access early this year for $39,900 and I'll say it's the most significant addition of a piece of equipment I've made to my practice in 20 years. I find it excellent for early glaucoma detection and tracking glaucoma progression. I've also been able to use it to test some patients who have elevated IOP and tell them with a fair degree of certainty that they don't have glaucoma. That's been very reassuring for those patients."

Dr. Frasz is currently testing about 60 eyes a month with the GDx and expects the machine to pay for itself in about a year. He gets some referrals from optometrists and some from existing patients who tell friends and family members that Dr. Frasz has the latest glaucoma-testing technology.

"I'm getting more information"

With 40% of his three-doctor practice glaucoma-related, Edward R. Thomas, M.D., of Ohio Eyecare Specialists, acquired a $45,000 RTA machine in February under a 3-year lease/purchase agreement. Dr. Thomas chose the RTA because it can be used for both glaucoma and macular analysis.

"I'm getting an enormous amount of reproducible information from the RTA," says Dr. Thomas. "I've used it on patients with glaucoma, AMD, diabetic retinopathy, macular cysts and macular holes. With one patient, testing with the RTA showed an early macular hole that I wouldn't have been able to pick up any other way. I've also found macular changes in AMD patients that would otherwise have gone unnoticed. With my glaucoma and glaucoma-suspect patients, I'm picking up changes in the nerve fiber layer and cupping earlier than I would by doing visual fields. This technology definitely serves as an early detection system for glaucoma and enables patients to be treated at an earlier stage of the disease."

Dr. Thomas, who expects the RTA to earn back his investment in about a year, believes that optic nerve and RNFL analysis will be the standard of care in the future.

"Having this technology in my office makes me feel better about taking better care of my patients, he says. "It's also helping me build my glaucoma practice in terms of getting more referrals from optometrists."

Marc E. Bosem, M.D., of Correct Vision Laser Institute in Pembroke Pines, Fla., is a solo practitioner who also purchased the RTA.

"My original goal was to detect glaucoma earlier than I could with visual fields, but I've found the analyzer very useful in treating patients with diabetic retinopathy and diabetic macular edema," he notes. "In treating these diseases, I can perform a scan with the RTA which lets me know, in combination with the fluorescein angiography, which vessels are actively leaking and areas of retinal edema. Those areas get my attention and I can apply the laser to close the leaking vessels. The scan pinpoints the retinal thickening more effectively than fluorescein angiography. The angiogram shows which vessels leak (microaneurisms), but the RTA shows the location of thickening."

Leading the way

Like Dr. Bosem, many solo practitioners and smaller practices are now using optic nerve and RNFL scanning technology in a number of ways that help patients and advance their own practices. These entrepreneurial "early adopters" weighed the costs and benefits of this technology and made the decision to acquire it. Their commitment to state-of-the-art technology puts them in the vanguard of a generation of ophthalmologists who may be helping to create a new standard of care for glaucoma detection and treatment.


If You're Thinking of Acquiring this Equipment

The use of advanced scanning technology to analyze the optic nerve and/or the RNFL as a diagnostic test for glaucoma dates back only about a decade. However, acceptance of scanning technology has grown rapidly over the past few years as the equipment has improved and evolved. If you're thinking of acquiring either a GDx, HRT II, RTA or Stratus OCT analyzer, here are a few answers to some basic questions:

Why do doctors like these instruments? Ophthalmologists who've purchased this technology like the fact that, unlike fundus photography, the information provided is fast, objective, reproducible and easy to interpret. Also, doctors who use this equipment say they pick up signs of probable glaucoma well before a visual fields test shows vision loss. In some cases, this enables them to begin early treatment. The basic diagnostic glaucoma scan takes about 10 minutes and can be performed by a trained technician. Most patients require no dilation, which facilitates smooth patient flow.

Which patients can I test? These analyzers aren't glaucoma screening devices and you won't be reimbursed for using them as such, even on patients with a family history of glaucoma. To be reimbursed, these instruments must be used on glaucoma-suspect individuals who display elevated IOP and/or excessive or abnormal cupping. You can also be reimbursed for scanning confirmed glaucoma patients once a year, alternating scanning with visual fields. In addition to glaucoma testing, some analyzers are capable of performing retinal analysis.

What can I expect in terms of reimbursement? Suzanne L. Corcoran, vice president of the Corcoran Consulting Group and Ophthalmology Management columnist on coding and reimbursement, provides the following reimbursement guidelines: "All Medicare carriers cover this test for glaucoma and some cover tests for retinal diseases (all under CPT code 92135), although this isn't universal. Private insurers vary in their coverage policies. Check with each of your payers to learn what their policies are regarding these diagnostic tests. It's important to note that ophthalmic diagnostic testing has already come under fire from payers who question the medical necessity of some tests. This is fairly new technology, so it's already a red flag."

The national Medicare fee schedule for glaucoma diagnostic scans is currently $66.97 per eye, subject to local adjustment.

How good are the manufacturers in terms of providing training and support to practices that acquire their analyzers? All the physicians interviewed by Ophthalmology Management for this article praised the training and support they had received from the respective manufacturers.

Analyzers such as the Stratus OCT and the RTA, with their additional retinal capabilities, have a steeper learning curve.

What's the outlook for this technology? It should continue to improve and evolve. In fact, some practices that have purchased this technology are concerned that their machines may be obsolete in a few years. This equipment is already fairly compact and can be transported if necessary. However, most doctors say they prefer not to move the units. Expect manufacturers to develop truly portable versions of these instruments in the near future.

Can I buy this equipment used? Because the technology is relatively new, very few used analyzers have become available. Jody Myers, owner of Florida Eye Equipment in Lakeland, Fla., expects a "used" market in optic nerve and RNFL analysis equipment to develop over the next 5 years, but he doesn't foresee used analyzers being offered at bargain prices.



Basic Information on the Leading Analyzers

Laser Diagnostic Technologies' GDx VCC

Warranty: 1-year full
coverage of parts and labor

contract: Information not provided

Training: Onsite training provided by training specialist. Ongoing support.

Purchase or lease: Several options offered

Base price: Information not provided

Other: Laser Diagnostic Technologies will help arrange financing if it's necessary.

Heidelberg Engineering HRT II

Warranty: 1-year full coverage of parts and labor

Service/Maintenance contract: $1,500 a year after first year

Training: Onsite training provided by training specialist. Ongoing support.

Purchase or lease: Several options offered, including 0% lease financing

Base price: $33,900 for basic glaucoma program

Other: A macular edema module is offered as an option. A cornea module will be available in 2003.

Carl Zeiss Meditec Stratus OCT

Warranty: 1-year full coverage of parts and labor

Service/Maintenance contract: $3,000 a year after first year for onsite repairs

Training: A day of intensive training by regional trainer. Follow-up training by sales representative. Ongoing

Purchase or lease: Several options offered

Base price: $49,950

Other: Tailors payment plans to individual purchaser. First payment can be delayed 30 to 90 days to allow initial reimbursement to pay for lease expenses.

Talia Technology, Inc. RTA

Warranty: 2-year full coverage of parts and labor, plus 2 years of software upgrades

Service/Maintenance contract: Company is currently developing a service plan

Training: Two days of onsite training and technician certification. One additional day of follow-up training and ongoing support.

Purchase or lease: Several options offered

Base price: $44,500

Other: Talia offers five free calls to Corcoran Consulting Group for reimbursement and coding questions relating to CPT code 92135.