Seeking Treatment/Evaluation Advice for Advanced Glaucoma

Discussion in 'Optometry Archives' started by meloan, Aug 10, 2005.

  1. meloan

    meloan Guest

    I'm posting this for a friend. He's a very talented artist, and has
    been told that he may well soon go blind from advanced glaucoma. He's
    now 55 years old. He was first diagnosed with glaucoma in his mid-20's
    but did nothing about it until his mid-40's, when he first began to
    notice vision loss. He's seen an ophthalmologist since 1999, who, upon
    her initial examination, proclaimed that he had severe optic nerve
    damage, and advanced glaucoma. The pressure at that time, in each eye,
    was over 30. Through the continued use of alphagan p, cosopt and
    xalatan, the pressure has dropped substantially and now ordinarily
    hovers between 10 and 15.

    His doctor mentioned the possibility of surgery (a trabeculectomy), but
    this was prior to the stabilization of the pressure, with which she
    seemed relatively pleased. She suggested that although surgery could
    bring the pressure down even further and could last several years
    before another surgery would be necessary, it would definitely cause
    even further vision loss. He recently saw another MD, who looked over
    his records, did a pressure check, surveyed the optic nerves, and told
    him that his glaucoma was now in the end stage. On the other hand, he
    can still see well enough (at least in one eye) to paint.

    He's only seen two doctors for his condition, and I don't believe
    either were at world class medical centers. (He's in the LA basin
    area.) Any recommendations as to possible new treatments, clinical
    trials, evaluations he should have, etc.? Any suggestions would be
    greatly appreciated!

    P.S. In addition to waiting far too long to seek treatment (partly
    driven by financial considerations and no health insurance), he also
    engages in a number of likely lifestyle no-nos for glaucoma patients.
    He smokes a pack of cigarettes a day, and drinks 2-3 cups of coffee a
    day. Also, about three times a month, he parties, and drinks a six
    pack of beer at a setting.
    meloan, Aug 10, 2005
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  2. meloan

    gudrun17 Guest

    Were either of these doctors a glaucoma specialist? I get the feeling
    they were not. That's the first thing he should do--see a glaucoma
    specialist. Or two. If they decide that he is still losing vision
    despite reasonably low pressures, they will probably suggest the
    trabeculectomy. I'm not sure it's true that trabeculectomy always
    causes further vision loss, in terms of visual acuity. I've heard of
    some people that were still 20/20 afterwards.
    gudrun17, Aug 10, 2005
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  3. meloan

    Dr Judy Guest

    Unfortunately, by delaying treatment for 20 years, he developed the severe
    nerve damage. Nerve damage cannot be reversed, the best that can be hoped
    for is that further damage is delayed. This is made more difficult by the
    fact that damaged and dying nerve cells release chemicals that stimulate
    nearby non damaged nerve cells to self destruct and die. Once the damage
    passes a critical point, it is very difficult to halt further damage.

    The pressure at that time, in each eye,
    With end stage glaucoma, there is little left to treat. Damagaed or dead
    nerve cells cannot regenerate and, at end stage, there are few non damaged
    cells left. He could ask his doctor for referral to a glaucoma specialist
    or specialty clinic for a second opinion, but the outlook is bleak.
    Stories like these make me glad I live in Canada. We may have some waiting
    lists (short), but at least there is a line to wait in.

    he also
    Smoking is never good and is a factor in glaucoma. Quitting smoking is
    always a good idea, not just for the eyes but for all organ systems.
    However, with end stage disease, there is little more to damage.

    See the following link for lots of glaucoma info
    Dr Judy, Aug 11, 2005
  4. meloan

    drfrank21 Guest

    Judy, if you carefully read the original post there was nothing
    said that treatment was delayed 20 yrs for no good reason but for
    proscrastination and not due to financial hardship. To me glaucoma
    is a lot like diabetes in that many/most times there are no
    obvious outward symptoms and it's easy for people to ignore
    that they have any problems. I'm sure you have patients that
    glaucoma medication compliance is an issue (at least I do)-
    they run out of the med or don't use the drops properly, etc.
    It has nothing to do with the status of the health care model,
    whether in Canada or the U.S. (or anywhere in the world for
    that matter).

    drfrank21, Aug 11, 2005
  5. meloan

    Quick Guest

    Well, yes it does. The OP said something to the effect
    "in part, due to financial reasons because of no health
    insurance". It's socialized in Canada.

    Quick, Aug 11, 2005
  6. Would you care to make a quick comparison of the situations for o.d.s
    and o.m.d.s under the Canadian vs. the U.S. vs. the U.K. systems? I
    think our system (U.S.) is headed for some changes and I wonder which
    direction we should take. If I understand it correctly, Canadian docs
    cannot offer anything outside the national plan? U.K. docs can, at
    extra cost? I probably have a misunderstanding, but while I look
    forward to the day all serious medical expenses are covered for all in
    the U.S., I'd like to retain the freedom to treat outside the system on
    a private fee basis. Also, are practitioner incomes set, or can
    individuals make more if they excel or work harder than the average doc???

    w.stacy, o.d.
    William Stacy, Aug 11, 2005
  7. meloan

    drfrank21 Guest

    I stand corrected. The last part does state "partly due"...
    But it's tough to speculate whether or not this
    individual would have sought treatment whether he lived
    lived in Canada vs the U.S.. I'd venture a guess that the
    rate of non-compliance in glaucoma management is pretty
    much the same in the U.K. and Canada compared to the U.S.
    and is not solely dependent on health care models.
    And I venture a guess that this individual (based on the
    overall tone in the op) would have still lost vision
    due to glaucoma. And I think it's unfair to blame
    the health care model in the U.S. for this person's
    loss of vision.

    drfrank21, Aug 11, 2005
  8. meloan

    Quick Guest

    One can certainly encourage the other. "It's going to
    cost me a good chunk of cash (which I could afford
    but would feel it) so I'll just put it off." If it was "free"
    you'd be more likely to deal with it.

    I didn't take the comment to imply any sort of blame
    or judgement on the different health care systems.
    I just took it at face value. OP said cost was a factor
    without insurance. Dr. Judy said that wasn't a factor
    in Canada. No implication that the system was better
    or worse. Have I missed some history here?

    Quick, Aug 11, 2005
  9. meloan

    Dr Judy Guest

    Health care in Canada is private delivery, public pay, it works like one
    insurance company with everyone living in the country insured. Instead of
    individuals paying premiums, the insurance is covered by taxes. No one is
    denied coverage based on pre existing conditions. Health care is
    administered by the provinces, so in Ontario, where I practice, the payor is
    called Ontario Health Insurance Plan -- OHIP.

    Ninety percent of doctors are in private practice, with the rest employed by
    hospitals, community health centres, public health units or in teaching
    facilities. No doctors are directly employed by the government, except for
    a few involved in administration of the plan. Hospitals likewise are not
    owned or operated by the government, all are independantly owned and
    operated, most by non profit groups. Hospitals are funded by a global
    payment from the Ministry of Health to cover insured care, hospitals can
    charge patients directly for uninsured care or for extras like TV service,
    semi private or private rooms.

    Doctors are mostly paid fee for service, they are paid by OHIP whenever they
    see a patient and provide an insured service. Patients have an OHIP card
    that they must show when requesting service. OHIP and the doctors
    association negotiate what fees will be paid for what services. OHIP
    decides which services are insured. For example, cosmetic surgery is not
    insured, circumcision of newborns is not insured, contact lens related
    services are not insured. Billing is done monthly by computer to OHIP and
    OHIP deposits payment directly into doctor's bank accounts. There are no
    insurance forms to fill out, no coverage to check and less than 3% of the
    cost of health care is related to OHIP administration (for comparision, the
    US private insurance model consumes about 15% of cost in insurance

    Doctors maintain their own offices, hire and pay their own staff, and pay
    their own overhead out of the fees paid by OHIP. If a doctor wants to make
    more money, he or she can cut office expenses or work more hours. There is
    no premium paid for doctors with more experience/ better reputations but the
    fees for service are set so that the fees for more difficult and/or time
    consuming procedures are higher.

    Doctors can opt out of OHIP and charge patients directly for insured
    services, however they are forbidden by law to charge patients more than the
    OHIP rate. Doctors are free to provide uninsured services to patients, and
    can charge any fee they want, but the patients, not OHIP, pays for them.
    Medical care provided for the benefit of third parties such as care for
    injuries sustained from a work related accident or from a motor vehicle
    accident are not OHIP insured but are paid for by Workplace Insurance
    (another government program funded by levies on employers) or by car
    insurance companies. The fees paid by Workplace Insurance and private auto
    insurers are generally higher than those paid by OHIP.

    As far as optometrists services go, insured services varies by province.
    When the system was first set up, only MD services were covered. Eventually
    ODs could also bill OHIP for medical eye care. Most provinces have
    limitations on the definition of insured eye care. Most province insure
    children 19 and under and seniors 65 and over for most services. The 20 to
    64 age group has variable coverage. In Ontario that age group is covered
    for eight specified conditions (diabetes, glaucoma, retinal disease etc).
    In addition, any MD or nurse practioner can request in writing (or fax) to
    an OD, an eye examination for a patient if the nurse or doctor thinks it
    necessary and it will be insured. The request is all that is needed, the
    patient doesn't need to get special permission from OHIP. Refraction is
    specifically excluded as a reason for an insured exam of a person between 20
    and 64, refraction is covered for the other age groups. Optometrists bill
    the patient for uninsured services like refraction and for health assessment
    when no problem is found.

    Ophthalmologists almost all work on referral and patients cannot directly
    make appointments with them. Since they are in short supply, most of them
    do no refractions at all, only do surgery and medical management. The
    optometrists provide first line care and refractions; in my city, the local
    ophthalomogists usually ask the family doctors to refer to an OD first, so
    the family doc sends the red eye, sudden blur, floaters and so on to us
    first and we then make the referral to the ophtho if needed.

    The "line ups" for health care up here are exaggerated. The system responds
    very quickly for urgent care and emergency care. It bogs down for elective
    care like cataract, where delays, although annoying do not result in
    morbidity or mortality. The waits are largely government created as both
    provincial and federal levels of government have been underfunding hospitals
    for the past fifteen years in an effort to keep taxes low. And ten years
    ago, a neo conservative government cut medical school enrolment by 25% when
    some whiz kid noticed that the more doctors there were, the more health care
    cost. Unfortunately, the government was unable to cut the population (ie
    patients) by a similar percent and we now have a doctor shortage. Many
    hospitals have closed wards and closed operating rooms because they are not
    funded or can't find doctors. Current governments have started to address
    these issues, but it will take a few years to undo the damage.

    As far as quality goes, various studies have shown that the Canadian models
    delivers better quality at lower cost than the private system in the US.
    And in a recent news report, the automotive industry stated that the cost of
    private health insurance for US workers adds over $1000 per car to the cost
    of cars made in the US vs those made in Canada.

    Dr Judy
    Dr Judy, Aug 11, 2005
  10. Wow! Thanks for the extensive review. I'll cut and paste my way through
    to a few observations and questions I have:

    Would that be an income tax, or some other? Any idea what % of income
    or whatever source the program costs?

    No one is
    I love that part.

    What about offering more non-covered items? I mean couldn't a doc buy a
    retina camera and take pictures for a fee, esp. if he/she knew it would
    not be covered by ohip?
    So why would they, and do any?

    Doctors are free to provide uninsured services to patients, and
    Are glasses, contacts covered, and under what circumstances/limits. Can
    patient purchase more expensive items than are normally covered? I think
    you once stated that doc's can't profit from "sale" of eyewear or
    contacts, but opticians could. Is that right? Seems unfair to me,
    although I'm aware of the potential conflicts of interest in our system.

    Refraction is
    Does ohip pay separately for refraction and exam when disease is
    present? If so, what's the breakdown?

    It bogs down for elective
    Is it illegal for a doc/patient to go around the system and do a cash
    deal for surgery that is not "covered"? E.g. questional cataracts or
    outright clear lens exchanges. If ok, are the fees limited?
    Tough thing to measure, medical quality, so I'm not convinced one way or
    the other on that, but for sure more people (%) have access to medical
    care up there than down here, which is why I hope we go toward your
    system. I'd just hope that they leave room for private initiative and
    freedoms to choose.

    Thanks for the post and for any additional answers you might care to give.

    w.stacy, o.d.
    William Stacy, Aug 11, 2005
  11. Thanks Dr. Judy. That was one of the most comprehensive, and yet
    concise, explanations of the Canadian health care system I have had
    the pleasure to read.

    Glenn Hagele
    Executive Director

    "Consider and Choose With Confidence"

    Email to glenn dot hagele at usaeyes dot org

    I am not a doctor.
    Glenn -, Aug 11, 2005
  12. meloan

    Dr Judy Guest

    There is no special tax levy for health care. Government revenue is mostly
    income tax, though there are also sales taxes, duties etc. All government
    revenue is pooled and all government expenses including health care costs
    come out of the pool. I think health care costs, including drugs, home
    care, nursing homes (drugs for everyone over 65, drug costs in excess of
    $1000/yr per person, cost of home care for all, cost for basic 4 per room
    nursing home is about 20% to 25% of government expenses.

    The cost of providing health care in Canada including drugs, nursing homes,
    gov't insured and non insured services is about 9% of GNP. The similar
    number for US (remembering that about 40 million Americans are not insured)
    is about 13% of GNP.
    Yes, and we do.

    A few people did in the early years, just on principle because they were
    opposed to socialized medicine. It makes no financial sense since you
    charge the same fee and have added on the collection costs.
    Glasses etc are not covered by OHIP. The patient is always free to pay for
    uninsured items. Social services covers the cost of glasses but not
    contacts for those on social assistance or on disablity. Contacts can be
    covered for those on social assistance in rare conditions, for example,
    aphakia or keratoconus.

    We not forbidden to "profit", but we must provide materials for a fee, not a
    markup. All health professions have this rule. For example, when I go to
    the dentist for a crown, he charges a flat fee for crown prep and his
    actual invoice cost of the crown, when I go to the pharmacy, the pharmacist
    charges a flat fee for dispensing and his actual cost of the drugs and when
    someone gets glasses or contacts from me, I charge a flat fee for fitting
    and my actual cost.
    No. If refraction is necessary for diagnosis of the condition it is
    included in the exam fee. If the only reason a person between the ages of
    20 and 64 presents is for refraction, OHIP doesn't pay anything. If during
    the course of an exam, a disease is discovered, then the visit is covered.
    Clear lens extraction for refractive reasons is not insured so it can be
    billed to patient. But if the reason for surgery is cataract, even if
    questionable, then it is insured and OHIP must be billed, not the patient.
    Dr Judy, Aug 11, 2005
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