4 Factors to Consider when Deciding on an Optometric Medical Specialty

Most doctors pursued a career in optometry to improve patient lives by enhancing vision. Expansion of our scope of practice into medical optometry has gifted us with the ability to protect vision by treating sight-threatening pathologies. By providing specialty medical services, we distinguish our practices from corporate optometry refraction mills, provide our patients with all-inclusive care, and fulfill our career passions.

The most common specialties include sports vision, neuro-optometry, pediatric, senior care, dry eye, vision therapy, low vision, contact lenses, myopia, and aesthetics. Personal passion, practice demographics, initial investment, and future reimbursement should be considered when adding a medical specialty to your practice.

1.     Personal Passion

Your passion and interest in a particular medical specialty is likely to guide your choice in pursuing a specialty. Optometrists may have more confidence in the treatment of a certain ocular diagnosis due to clinical background and knowledge or may enjoy working with a certain subset of patients. Passion may be the most important deciding factor.  At the end of the day, profit is only one component of job satisfaction. The doctor’s passion is obvious to the patient. For me, I enjoy fitting scleral and hybrid lenses and treating dry eye. I feel both are equally important and they're complementary factors of patient success

2.     Practice Demographics

It’s extremely important to consider the demographics of our practice. Even if you are passionate about myopia management, if you do not see enough kids in your practice, it may not be a viable option. While you can always market to that demographic, it may be easier to start with an established patient base and add another specialty in the future.  I would recommend using your EHR system to run reports to identify the most common diagnoses, patient ages, and the number of patients you see with each diagnosis in your practice. It may be of benefit to run your insured vs. cash-pay patients also as some specialties are not covered by insurance.

As a cold start-up 8 years ago, my practice demographic is mostly healthy 20–30-year-old computer-using, contact-lens wearers.  I found myself bombarded with end-of-the-day dry eye, headaches, and eye fatigue complaints. In other words, my specialty found me. 

3.     Initial Investment

Several medical specialties require more of an upfront financial investment in both equipment and training prior to implementation of the specialty.  Current cash flow and equipment loans should be analyzed prior to deciding on a specialty. Sports and vision therapy require additional square footage so office space must be adequate (24x16ft).

For sports vision, specializing optometrists recommend a start-up purchase of the Senaptec Tablet and Sensory station, the program Right Eye, and basic vision therapy equipment like the Hart Chart and Brock Spring. To assess investment, you should figure the number of athletes needed to pay for equipment costs.

For senior care, advanced equipment is needed, can cost up to 100K , and you must see at least one thousand patients to break-even.  

Implementing scleral lenses in your practice can be a low-cost addition.  Typical scleral lens kits can be paid for with 2 fittings per year.  While fittings can be performed without the addition of an anterior seg OCT, if you become a big fitter you may decide to purchase one for complicated corneas. Renting one as needed from a manufacturer is also an option; I prefer this option because I’m not committed to a set system as technology changes.  

Myopia management can be expensive to implement depending upon your reliance on a topographer for ortho-k or an Interferometer for axial length. While monitoring axial length is not currently required for standard of care, it may in the future.

Lastly, basic dry eye testing techniques, like Lissamine Green, are inexpensive. Treatment beyond topical drops may require an investment in an anterior segment OCT (40K-150K)  for Meibography or a thermal pulse device (50K).

4.     Future Reimbursement

Reimbursement coverage for specialty services will vary by the insurance company. Myopia management and sports vision are typically not covered by insurance and fees include a primary evaluation and several sessions. Insurance plans may cover some of the cost for specialty contact lenses and low vision services.  Insurance may/or may not cover the costs of neuro-ophthalmology, vision therapy, aesthetics, and dry eye.  Coverage depends on required testing methods, treatment, and diagnosis.

The management of myopia including evaluation, follow-up, and the cost of lenses is set between $2500-$3500 dollars. Initial evaluation costs for sports vision therapy should be set at $100-$300 dollars with therapy costs set by the number of sessions (10-20 per package).

Insurance companies typically cover some or all the cost of low vision aids and specialty contact lenses, depending on diagnosis.  Vision insurance plans will typically reimburse for both the fitting and lens cost at 2-3K. Medicare will cover the cost of the initial evaluation for a low vision aid and a series of therapy sessions. If no progress is made, they will not continue to pay for services. Low vision aids such as a spectacle-mounted telescopic lens are usually not covered, but device training is covered. Typical reimbursements include the eye exam and per therapy sessions.

The coverage for vision therapy depends on insurance plan coverage. If covered, Medicare has reimbursed between $97-$131 depending on code level. Most commercial insurance follows Medicare’s reimbursement rates. If not reimbursed by insurance, billing is set by number of sessions from $1000 to $7000.

Reimbursements and coverage for both neuro-ophthalmology, aesthetics, and dry eye vary greatly depending on the specialty and device. Office visits may be covered, but additional services such as IPL or a binocular vision assessment may be cash pay. Doctors may collect between $700-$1000 per treatment. An analysis must be performed to decide the number of patients you must see to pay the cost of equipment.

Although optometrists are considered primary care physicians, our expanded medical scope, reduction in insurance reimbursement, and medical advancements have led to the development of specialty care practices. Deciding which optometric specialty to pursue can be challenging yet rewarding, both personally and professionally. By evaluating your passion, practice demographics, initial investment, and future reimbursements, an optometrist can make an educated decision on the best practice addition.