Most manufactures of disposable contact lenses offer rebates on annual supplies of their newer contact lens brands. Many of these offers expire December 31. Many of the rebate offers become lower the following year. We have found this especially true of Johnson and Johnson Acuvue brands. The company comes out with new brands each year, and lowers or discontinues rebates on their older brands. There are still some excellent rebates available on the Bausch +Lomb Ultra series of contact lenses, which now includes expanded parameters in Ultra for Astigmatism. Alcon is still offering $200 rebates on Dailies Aqua Comfort Plus and Dailies Total 1. We don't know what offers might be able in 2018. See latest contact lens rebates available at Rebates & Specials on Dr Elman's www.1800MyEyeDoc.com
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires the Centers for Medicare and Medicaid Services to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.
he solution for SSNRI must provide the following capabilities:
1. Generate MBIs for all beneficiaries: Includes existing (currently active and deceased or archived) and new beneficiaries
2. Issue new, redesigned Medicare cards: New cards containing the MBI to existing and new beneficiaries
3. Modify systems and business processes: Required updates to accommodate receipt, transmission, display, and processing of the MBI CMS will use a MBI generator to:
• Assign 150 million MBIs in the initial enumeration (60 million active and 90 million deceased/archived) and generate a unique MBI for each new Medicare beneficiary
• Generate a new unique MBI for a Medicare beneficiary whose identity has been compromised
The Medicare Beneficiary Identifier will have the following characteristics:
• The same number of characters as the current HICN (11), but will be visibly distinguishable from the HICN
• Contain uppercase alphabetic and numeric characters throughout the 11 digit identifier • Occupy the same field as the HICN on transactions
• Be unique to each beneficiary (e.g. husband and wife will have their own MBI) • Be easy to read and limit the possibility of letters being interpreted as numbers (e.g. Alphabetic characters are upper case only and will exclude S, L, O, I, B, Z)
• Not contain any embedded intelligence or special characters
• Not contain inappropriate combinations of numbers or strings that may be offensive CMS anticipates that the MBI will not be changed for an individual unless the MBI is compromised or other limited circumstances still undergoing review.
How will the MBI look on the new card?
The MBI will contain letters and numbers.
Here’s an example: 1EG4-TE5-MK73
• The MBI’s 2nd, 5th, 8th, and 9th characters will always be a letter.
• Characters 1, 4, 7, 10, and 11 will always be a number.
• The 3rd and 6th characters will be a letter or a number.
• The dashes aren’t used as part of the MBI. They won’t be entered into computer systems or used in file formats.
MBI Format Pos. 1 2 3 4 5 6 7 8 9 10 11
Type C A AN N A AN N A A N N
Where will the MBI’s characters go?
C – Numeric 1 thru 9 N – Numeric 0 thru 9 AN – Either A or N A – Alphabetic Character (A...Z); Excluding (S, L, O, I, B, Z)
Position 1 – numeric values 1 thru 9 Position 2 – alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 3 – alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z) Position 4 – numeric values 0 thru 9 Position 5 – alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 6 – alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z) Position 7 – numeric values 0 thru 9 Position 8 – alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 9 – alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 10 – numeric values 0 thru 9 Position 11 – numeric values 0
CMS’ will complete its system and process updates to be ready to accept and return the MBI on April 1, 2018
• All stakeholders who submit or receive transactions containing the HICN must modify their processes and systems to be ready to submit or exchange the MBI by April 1, 2018. Stakeholders may submit either the MBI or HICN during the transition period
• CMS will accept, use for processing and return to stakeholders either the MBI or HICN, whichever is submitted, during the transition period.
• In addition, beginning October 2018 through the end of the transition period, when a HICN is submitted on Medicare fee-for-service claims both the HICN and the MBI will be returned on the remittance advice
• The transition period will run from April 2018 through December 31, 2019
CMS will begin issuing new Medicare cards for existing beneficiaries after the initial enumeration of MBIs; roughly 60 million beneficiaries
• The gender and signature line will be removed from the new Medicare cards
CMS will provide outreach and education to:
− Approximately 60 million beneficiaries, their agents, advocacy groups and caregivers − Health Plans − The provider community (1.5M providers) − States and Territories − Key stakeholders, vendors & other partners.
As a provider I am trying to get the word out to the public on these changes. I will be speaking on it at the Malibu Rotary Club on October 11, 2017 (see maliburotary.org).
I am excited that next week I am installing a new instrument in my office--the Optos Daytona with autoflourescence. As with the original Optos Optomap, we are able view a wide angle image of the retina, up to 200 degrees with a single image, but with autoflourescence technology we can view changes in the deeper Retinal Pigment Epithelial (RPE) layer in a wide angle view. We can offer this new technology to every patient for a moderate fee of $39.00 and be able to detect early stages of disease as never before.
We have offered Optos Wide Angle Retinal scanning since 2013, but the new instrument with its ability to detect the natural autoflourescence of the cells of the retina allows us to see the activity of cells undergoing degenerative changes, as in cancer, and which hopefully can be treated, and also identify cells that have died.
Autofluorescence (AF) is caused by the presence of lipofuscin, an aging pigment fluorophore thought to be produced by the outer segments of the photoreceptors and stored at the level of the retinal pigment epithelium (RPE).
Autoflouescense is defined as the spontaneous emission of a wavelength of light by a substance, such as lipofuscin, after illumination with light of a different wavelength. AF uses the excitation of fluorophores, which are inherent in the retina, and also a barrier filter, which blocks most of the light that would reflect off the retina in a typical photo. Different AF systems use different excitation sources and barrier filters, but all demonstrate a uniform glow to the normal retina.
AF often reveals when a disorder is progressing before the cells have actually died. Two abnormal states of lipofuscin exist, hyperautofluorescence (hyper AF) and hypoautofluorescence (hypo AF).
In hyper AF, the image in the area that’s affected will be brighter than the corresponding normal zones, and this is typically thought to be due to the increased metabolic activity of the retinal pigment epithelium. Hyper AF highlights cells that are exhibiting abnormal activity and indicates an early state of disease. This can be seen in early stages of macular degeneration, Best’s disease, Stargardt’s disease, cone dystrophy, retinitis pigmentosa and melanoma.
In contrast, with hypoautofluorescence, there’s no normal glow of the fluorescence; it’s actually just completely dark or even black. This suggests that there’s no lipofuscin present because the retinal pigment epithelial cells have died, along with the corresponding photoreceptors. Hypo AF is a marker for dead cells.
Lipofuscin cells, in normal, healthy tissue, show luminance in themselves, and will appear gray in the images. This is the way it should look in normal healthy patients.
When differentially diagnosing a metabolically active melanoma vs. an inert choroidal nevus. nevi are invisible with AF because the RPE is intact, but melanomas are typically hyper AF.
The Optos Daytona AF provides a wide angle autoflourenscent image to detect abnormal cell activity over a large area of the retina in a quarter of a second. I am very exited to have this new technology in my office.
The Daytona with AF reveals a layer of the retina not visible with the previous instrument. Anyone who has had the previous Optos imaging done in our office this year can have the imaging done with the new instrument at no additional charge. We will be making autoflourescense part of Optos exam starting July, 2017.
Voyage LA Magazine Interview of Dr John W. Elman Optometrist
I was interviewed for the June 12 2017 issue of Voyage LA Magazine. The magazine features articles about people and businesses in the Los Angeles area. It breaks down what's happening in various neighborhoods, and in the West LA section, they decided to do section on me, as an entrepreneur in Santa Monica. Besides talking about my early interest in optometry I am asked about where I think this sector of healthcare profession is headed, and I give my opinion about on line eye exams.
The link to the interview is
UPP Abandoned by Alcon, B + L, Johnson & Johnson--Game On
Alcon was the first manufacturer to implement unilateral pricing policies (UPP) with the introduction of DAILIES TOTAL1® Water Gradient Contact Lenses in 2013. It set a minimum price at which this product could be sold by contact lens retailers to the public. B+L, Johnson & Johnson and CooperVision put UPP in effect with the introduction of their new products. New products take time and money to develop, and the cost of this development often makes the cost of the new products greater than the old. The companies felt that eye care professionals would not try the new products unless they were assured that it would be profitable for the eye care professionals to prescribe the new products. If consumers had no economic incentive to purchase lenses from discount sources, they would be more likely to go to the eye care professional, the eye doctor, to get them, and also be examined for any adverse effects that the contact lenses might produce in the eyes.
1800Contacts influenced legislators in Utah to establish the Contact Lens Consumer Protection Act in that state which prohibited UPP.
By the beginning of 2017 most of the contact lenses which were released with UPP pricing were no longer UPP priced. The manufactures could see that it would not work if the prices of an online retailer in Utah was different than others across the country.. There were law suits and appeals against the controversial Utah legislation, but the apparent result is that UPP no longer exists for mot brands of contact lenses.
So how has this affected the eye care industry? Perhaps contact lens consumers are the winners. I don't see how 1800Contacts are the winners. They may be the most famous contact lens retailer, but they certainly aren't the cheapest or most conveinient.
When Bausch & Lomb introduced its monthly ULTRA® contact lenses in May, 2014 its UPP price was $60.00 per box of 6 lenses. That is the price eveyone sold it for, although it is possible retailers could charge more.
This week I dropped the price of a box of ULTRA® contact lenses to $55.00 per box, and there is an $80.00 in manufactures rebates on an annual supply of 4 boxes of 6, so that the annual supply of lenses (4 x $55.00 = $220.00) before the manufactue's rebate. In my office, after the rebate, a year supply of ULTRA® contact lenses is only $140, which is $35.00 per box.
1800Contacts sells a box of 6 ULTRA® contact lenses for $57.99 per box and advertises that ordering an annual supply of 4 boxes the cost after rebate is $42.99 per box, which is $7.99 per box more than I charge ($31.96 per year more than I charge). It should also be noted that I generally have these lenses in stock to pick up at my office, and offer free shippng on annual supply for people that perfer home shipping.
So who was the winner of all the law suits created by 1800contacts and the contact lens manufacture's?
It is obviously the contact lens consumer. Does 1800Contacts want to fight? Bring it on!
While manufactures such as Johnson and Johnson Acuvue have lowered their end of year 2016 rebates on annual and semi-annual supplies of contact lenses ALCON has announced an increase of rebates on its contact lenses--$200 for annual supply of Dailies AquaComfort Plus and Dailies Total 1, and with the $60.00 rebate on Annual supply of AirOptix series of monthly contact lenses there is a certificate to get 2 pair of free AirOptix color contact lenses and $50.00 in coupons for Alcon contact lens and eye care supplies--drops for dry eyes, allergies, and eye vitamins--some of the best deals we've seen on these products. Of course the free colored contact lenses are not available in powers for people who have astigmatism or need multifocal lenses. For people who need these kinds of corrections the free AirOptix Colors lenses may be more for cosmetic reasons than for vision correction...but Halloween is coming up! For a summary and links to current manufactures' contact lens rebates go to Rebates and Specials page on this website.
I have two stories to relate about my recent experience with online ordering of glasses and contact lenses:
Story #1: This week I saw a patient who came in to to get a new eyeglass prescription. The lenses, or at least the anti-reflection coating on the lenses, were starting to scratch off. It was a bit worse on one lens and he thought that was the reason he didn't see as well with that eye.
He not only had the glasses with him, but the two year old prescription from which the glasses were made. With the glasses on his vision was 20/20 with the left eye and 20/25 with the right. When I compared the glasses to the written prescription I found the axis of the astigmatism correction was about 5 degrees different between the written Rx and the glasses that were supposedly made from that Rx. The written Rx had an axis of 100 in the right eye; the axis measured in the right lens in the glasses was 95. The amount of astigmatism in the right eye was significant enough that the 5 degree difference between the written Rx and lens could make a difference in his vision.
When I asked the patient if he had gotten the glasses in the same place as his exam he replied that he hadn't--after he had examination from his optometrist he had ordered the glasses on line from Warby Parker.
My exam showed that the axis in that eye was 105. With that axis the patient's vision was 20/20. When I put my prescription in a trial frame and had the patient compare the vision with vision in his previous glasses the patient could see the one I had created was better.
Although a 5 degree axis discrepancy in axis isn't much, the fact that his axis was really 105, the 95 degree axis of his previous glasses meant the glasses were really 10 degrees off from his true astigmatism axis. The result was he was missing one line of acuity.
Story #2: Today there was a call that had been left on my office voice mail at 2:00 a.m. this morning. Then there was another call at 5:00 a.m. They were both from 1800Contacts, each for a different patient contact lens order. The first one was for a contact lens prescription that was expired. The second was for a different contact lens than was prescribed for the patient. It was asking for lenses in the same base curve and power I had prescribed for the patient, but it was for a different brand lens, that was cheaper and isn't even available in the base curve I prescribed. This vender usually sets their automated calls for Friday evening or hours when most doctors are closed. The reason for this is because the Fairness to Contact Lens Consumers Act (heavily paid for and supported by 1800Contacts) gives prescribers only 8 business hours to respond to a prescription request from a seller (exact wording is below):
"Prescriptions are verified automatically if the prescriber doesn’t respond to the seller’s verification request within “eight-business-hours.” A business hour is defined as one hour between 9 a.m. and 5 p.m., Monday through Friday, excluding federal holidays, in the prescriber’s time zone. If a seller determines that a particular prescriber has regular Saturday business hours, the seller also may count those Saturday hours as business hours under the Rule.
"When calculating “eight-business-hours,” begin the verification period the first business hour after the prescriber receives a complete verification request and end it eight-business-hours later. For example, if the prescriber receives a request at 10 a.m. Monday, the prescriber must respond by 10 a.m. Tuesday. If there’s no response, the seller can provide the contact lenses at
10:01 a.m. Tuesday. If the verification request is received at 10 p.m. Monday, the response would be due by 5 p.m. Tuesday. If there’s no response, the seller can provide the lenses at 5:01 p.m Tuesday."
The cryptic after hours requests are done in such a way to make it difficult for a prescriber to respond (the beginning of the request has a minute of unnecessary information and the name of the patient isn't announced umtill the end of message) so that the lenses can be sold to the consumer whether they are appropriate or not.
Prescribers like me and my colleagues take time to decide on the proper eye glass prescription and contact lens prescription and the materials appropriate for those prescriptions. When we order either glasses or contact lenses from our laboratories we check everything to make sure it is correct and verify lenses before dispensing them to patients. We recommend anti-reflection coatings combined with anti-scratch features that have a 2 years warranty against scratching. Because we order our products from reputable companies it usually is correct, but in the rare instants when either glasses or contact come in wrong we send the job back to be redone.
When you order on line who checks the work?
I often attend the Wednesday UCLA Stein Eye Institute Grand Rounds which has lectures on topics of interest to eye care professionals. The program on May 25, 2016 featured Kouros Nouri-Mahdave, MD speaking on Glaucoma in African Americans. A couple years ago I attended a Grand Rounds at Stein Eye Institute which featured Simon Law MD, PharmD. on how glaucoma affects people of various Asian races.
Although we Americans are taught by our Constitution that everyone has equal rights and should be treated equally, Mother Nature does not abide by this law.
These lectures inspired me to do some of my own research on the subject. Does glaucoma discriminate by race? And if it does, how does it discriminate?
We have known for years that glaucoma discriminates by age (although it is possible for babies to have glaucoma older people are more likely to develop glaucoma than younger people). The study of how glaucoma discriminates against different races is a more recent topic for research.
The doctors at the UCLA Stein Eye Institute have done a yet to be published 5 year study comparing 135 African American eyes to 135 Caucasian eyes to find not only the prevalence of glaucoma in each group, but how each group responds to various drug and surgical therapies.
There have been many studies showing racial differences in glaucoma, and the kind of glaucoma in different racial groups.
There are two main types of glaucoma, primary open angle glaucoma (POAG), and Primary angle-closure glaucoma (PACG). Primary open angle glaucoma (POAG) is more prevalent among people of European and African descent. A sub-group of primary open angle glaucoma is Normal Tension Glaucoma (NTG). NTG is form of glaucoma where optic nerve damage occurs even though pressures in the eye are not elevated (high eye pressure is the most significant risk factor for open angle glaucoma). A Japanese study found NTG accounted for 92 percent of open angle glaucoma cases in Japan.
In studies such as the Baltimore Eye Survey and the Barbados Eye Study, researchers have investigated how glaucoma affects different black populations.
Glaucoma occurs about five times more often in African Americans. Blindness from glaucoma is about six times more common. In addition to this higher frequency, glaucoma often occurs earlier in life in African Americans — on average, about 10 years earlier than in other ethnic populations. It urns out that medications that work in lowering the pressure in the white population are less effective in the black population.
A study conducted by a group from the Wilmer Eye Institute, Johns Hopkins University in residents over the age of 40 years residing in two counties of Southern Arizona indicated that open-angle glaucoma is the leading cause of blindness among Hispanics. This study, named Proyecto Ver, also reported that only 38% of Hispanics with glaucoma were aware of their disease.
The Los Angeles Latino Eye Study (LALES), another large prevalence study funded by the National Eye Institute reported an overall prevalence of open-angle glaucoma among Hispanics to be nearly five percent — similar to that found amongst African Americans.
The LALES, like Proyecto Ver reported that Hispanics over age 60 are at particularly high risk of glaucoma. Approximately 75% of Hispanics with glaucoma in LALES were not aware that they had the disease.
EyeCare America, a public service program of the Foundation of the American Academy of Ophthalmology, has highlighted the fact that most Hispanic Americans are unaware they are at higher risk for glaucoma than Caucasian Americans. The recently conducted National Americans Eye Health and Eye Disease Survey found that 76 percent of Hispanics did not know that their ethnicity was a risk factor for glaucoma.
Although Primary Angle Closure Glaucom (PACG) is less frequent among Caucasians and blacks it is the most common glaucoma among Chinese. For Chinese living in urban areas, the ratio of those with PACG to POAG is 2 to 1 — twice as many Chinese living in bigger cities have angle-closure glaucoma than the open angle type. PACG is a more aggressive form of glaucoma and accounts for 90 percent of all cases of blindness from glaucoma in China.
There is great racial diversity among Asian populations, and these differences are represented in the presentation of disease among Asian patients. Studies have found that South Asians, ethnic Chinese, and Intuit Eskimos are at significantly higher risk for angle-closure glaucoma, whereas a study of a population of Japanese patients found ACG incidence to be much lower than in their Asian counterparts, but as stated above, the Japanese have the higher percentage on Normal Tension Glaucoma (NTG).
A study published in the February 2009 Archives of Ophthalmology looked at a large Japanese American patient group in San Francisco and found that the proportion of patients with normal tension glaucoma was 4 times greater than those with high tension glaucoma.
Although it is not known why certain racial groups have a higher percentage of people with Primary Open Angle Glaucoma (POAG) there is a reason that primary angle-closure glaucoma is so much more prevalent in East Asian populations.
In Asian eyes, the iris (the colored part of the eye) attaches to the sclera (the eye’s white, protective covering) in such a way as to form an anatomically narrower angle with less trabecular meshwork exposed.
Angle-closure glaucoma occurs when the iris blocks the trabecular meshwork, the eye’s drainage system, which leads to increased intraocular pressure (IOP). The increased IOP eventually causes damage to the optic nerve, which transmits visual signals from the retina to the brain. If the angle closes suddenly, there can be a sharp increase in eye pressure. Symptoms of acute angle-closure may include headaches, eye pain, nausea, rainbows around lights at night, and very blurred vision.
This does not explain why Japanese have less Primary Angle-Closure Glaucoma than Chinese.
What we can derive from all this is that Glaucoma definitely discriminates among the races and everyone should have their eyes checked regularly by an optometrist or ophthalmologist because primary open angle glaucoma may not have any symptoms.
Many people have Health Savings Accounts (HSAs) or employer sponsored Flex Spending Accounts (FSAs) that have dollars in them that can be used for health services and materials.
FSAs can be used for extra pair of prescription glasses, or special purpose glasses that you have been putting off, polarized sunglasses or to stock up on contact lenses. Many of these type of accounts have to be used before the end of the year or the money is lost. In other words "Use it or lose it."
Sometimes people want glasses for a specific purpose--just to see in the far distance or just to use for reading, or just to use for computer or to read sheet music at the piano or on a music stand. Usually these special purpose glasses are for presbyopes--that is, people who are over 40 years old. Generally younger people can see at all distances with the same single vision lenses in their glasses. As people age, it takes a different power to see at different distance (see presbyopia). Presbyopes may do well with multifocal lenses such as bifocals or progressive lenses. The disadvantage of multifocal lenses is that the lenses are divided into different parts, and this division of the lenses limits the amount of area on lenses that is useable to use for different distances. This may bother the wearer who is moving around, who is walking and only wants the far distance corrected, or the wearer who is only using the glasses to view large computer monitors for a long period of thime. While most people find they adjust to multifocal lenses for these special purposes other people are bothered by the fact that they may have to move their head to get into the proper section of their lenses for the distances they are trying to see.
These people may be well served by having glasses for their specific purpose. It is important for patients to tell their optometrist their specific needs.
If reading glasses or computer glasses are made, patients need to indicate to their optometrist the exact distance where they read or the exact distance where their computer monitors are positioned. Each lens will have a certain range of use, or depth of field, but it is important for the optometrist to know what distance the patient likes to read or use a computer. These distances are not universal, and depend on many things, including arm length and habits that have developed by the patient. Does the patient generally hold reading material in his or her lap, or hold it 10 inches away? Is the patient generally using a laptop computer or a desktop? Not communicating these specific factors and needs to the eye doctor often will result in dissatisfaction with the specialty glasses prescribed and necessitate the glasses to be redone.
An experienced optometrist will know how to tailor special use glasses for each patient.
Dr. John W. Elman is an optometrist in Santa Monica, California.
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