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Investing in digital retinal imaging instruments offers entrée into new treatment areas&#;and pays dividends right from the start. Here are the numbers on making it work.
Digital retinal imaging is becoming commonplace in optometric offices. As with digital cameras that are now used everywhere, you can instantly view images, manipulate and transmit images, and take lots of images without the cost of film. These benefits make investing in one of these instruments something your practice should consider.
Synmed CR2 camera
courtesy Synemed, David Whalen
Calculating Revenue-Boosting Potential
The practice can charge an additional fee for digital retinal imaging performed for screening during routine examinations. Charges of $30 to $60 for screening retinal photography are common. These fees are not generally covered by third-party payers. I know of practices in which over 80 percent of patients agree to have digital retinal imaging despite the added cost. To explain to patients what they get in exchange for the added cost, you might say: &#;Digital retinal imaging is my preferred method for evaluating the inside of the eye because it&#;s a permanent record and I have it to compare against in the future. Although I&#;d like to review the images, you should know that your vision plan does not pay the $XX fee, so you&#;d be responsible for it.&#; ROB editors note: If you are a participating provider for a third party, protect yourself by having a signed ABN (Advance Beneficiary Notice) when charging patients for non-covered services or materials.
Code as Medical Eyecare
ODs can bill medical insurance for digital retinal imaging when there is necessity for documentation and an appropriate ICD code. The possible CPT codes for billing are (fundus photography with interpretation and report), (extended ophthalmoscopy), and (extended ophthalmoscopy, subsequent). However, if a practitioner is using the retinal camera for both screening purposes and medical billing, there should be some software function that differentiates the two. For example, the Optos units have a screening function, and also a billing function called Optomap Plus. The Synemed retinal imaging system using the Canon CR2 camera has an analogous software function. ROB editors note: Some third parties only pay for a medical photo if there is a medical reason for the office visit. In these cases, schedule the patient back for the medical photo.
CenterVue DRS
Incorporate With No Added Charge to Patient
When used for screening purposes, one drawback to asking each patient whether they would like digital retinal imaging and would accept an extra charge for the service is some patients may feel like they are being sold something extra and unnecessary and getting &#;nickeled and dimed.&#; The lack of consistent acceptance reduces procedural efficiency in the office. For that reason there are some practices (like mine) that incorporate digital retinal imaging into the routine examination at no additional cost to the patient.
If you choose to not charge the patient extra for digital retinal imaging, you do not need to raise the cost of your comprehensive examination. In my case, the cost of the retinal imaging is &#;financed&#; by:
1. Better operational efficiency of the practice and reduced frequency of dilation (yielding increased capacity to see more patients, and patients that are more likely to purchase eyeglasses the same day rather than come back when not dilated).
2. Patient perception that the practice is cutting edge by incorporation of the technology and word-of-mouth recommendation to friends and family.
Increase Perception of Examination Value
Most of the digital retinal cameras take a 45 degree field of view in the eye. The notable exception are the retinal cameras made by Optos, which can image up to 200 degrees of retina (about 78 percent of the retinal area). The benefits include photo-documentation for future comparison and the ability to examine the tissue while simultaneously showing the patient what&#;s evaluated. When you make digital retinal imaging a regular part of every comprehensive examination, patient perception and sense of value increases because they recognize that there is economic value to the retinal imaging and that they are getting the measurement done complimentarily, which encourages their return visits and recommendation to friends and family. A practice that takes this approach can still bill medical insurance for non-screening photography if they have the right retinal camera system&#;like Optos and Synemed. My office has two of the Synemed Canon CR2 cameras, which cost $24,000 each.
Economical Choices to Enable Universal Screening
Screening all patients with no additional charge is becoming more economically feasible, with low-cost retinal cameras, like the CenterVue DRS ($14,000). But I don&#;t think it is economically feasible with cameras such as the Optos unit for which some offices are paying close to a $20 use-fee per patient. Users can also purchase the Optos P200 units for about $80,000, which is too costly to allow most practitioners to absorb performing screening imaging at no additional fee.
There are several lower-cost options. A neat one is EyeQuick, which soon will be available for $5,995. EyeQuick may have more use for primary care settings and veterinary, but at least some eyecare practices will find it valuable because it is the lowest cost digital retinal camera which allows a practitioner to bill medical insurance. There is also the OIS EyeScan camera, which costs approximately $20,000.It offers a 35 degree field of view. One of its main features is portability and modular use. Note that the aforementioned costs cited for various imaging systems are approximate, since it varies depending on whether the system comes with a computer, software, an instrument table, shipping and handling, etc. OIS recently was acquired by Merge Healthcare.
ROB Editors note: Your strategy for a per-use fee may change with managed care patients who have fixed reimbursements. You cannot include a per-use fee test if you are losing $20 each time you perform it.
Present vs. Future Value
Make sure you are buying present value and not future promise. What I mean by that is if you have two comparable retinal imaging systems where one of them currently integrates with your electronic health record system but the other one does not but promises to do so, obviously the one that currently integrates is preferable. Second, don&#;t forget to consider the maintenance service agreement. One of the retinal cameras has a service agreement that costs $10,000 a year, partially because the camera is so large and bulky that it cannot be readily transported, thereby requiring trained service technicians to come on-site. Third, remember that low cost becomes too expensive if the instrument and system does not do what you want. There is a significant difference in image quality and function between some of the retinal camera systems.
Check for Ease-of-Use
Most of the new cameras are quite easy to operate, which is important because image capture is typically delegated to ancillary staff. In fact, the CenterVue DRS camera is so easy to operate, it is virtually self-administrable. I&#;ve seen a demo of it, and because the measurement is automated (autofocus, auto-alignment, auto-capture) a junior high school student could probably figure it out. Others require more learning but in all cases, the training for image capture is usually minimal. Doctors also have to learn how to use the image review software.
Minimal Time Investment
If digital retinal imaging is done as part of the routine exam, it probably takes staff between two and five additional minutes during preliminary measurements, depending on the system used and staff proficiency. The most efficient systems have capture and review software that integrates into the commonly used electronic medical records, saving the need for double entry. On the back-end, digital retinal imaging saves the doctor several minutes per patient, as it provides them with information about eye health more easily than relying solely on dilation. Digital retinal imaging during routine examination can reduce the frequency of dilated fundus examination, though it certainly does not replace it. The benefit of reduced frequency of dilation is that patients don&#;t have to spend as much time in the office. ROB editors note: The gold standard for an eye exam contains a dilated fundus exam. No matter what the marketing materials say, clearly understand your legal exposure if deciding to forgo a dilated fundus exam.
Improve Patient Eye Health With Additional Screening
Patients appreciate seeing their conditions or lack thereof in the photographs. I&#;ve found digital retinal imaging helpful for gaining patient adherence to treatment, particularly if they have signs of diabetic retinopathy, macular degeneration and other conditions. I think consumers are becoming more skeptical of their doctors&#; advice, relying more on their own online research. If a mechanic finds a problem with a car, many owners would want to know the problem really exists&#;and that the problem was not contrived to gain the sale of unnecessary work&#;before spending more money. The beauty of retinal imaging is that an imaged eye condition reinforces to the patient that the condition is real and that the doctor&#;s recommendation should be followed.
Investing in digital retinal imaging can serve your patients better by spotting eye health conditions faster and by reminding patients of the full value of their annual examination.
Digital Retinal Imaging Resources
A recent article by Dr. Chou on Optomap and dilation:
http://journals.lww.com/optvissci/fulltext///limitations_of_the_panoramic_200_optomap.7
For those who plan to use the instrument mainly for medical billing, this worksheet is helpful:
http://www.calcoastophthalmic.com/pdf/costanalysis.pdf.
Related ROB Articles
EyeMed Vision Care Adds Retinal Imaging Benefit
Do You Have the Tools Needed to Diagnose Glaucoma
Medical Eyecare Opportunity in Optometric Practice
Brian Chou, OD, FAAO, is joining EyeLux Optometry, which opens fall . He is a former partner of Carmel Mountain Vision Care in San Diego, Calif., where he practiced for 11 years. To contact him: .
For most of my time as a photographer, I&#;ve been on a strict budget, from my days as a student to my current attempts to save for a house and car. I&#;m sure I&#;ve spent more than necessary along the way &#; but I&#;ve also learned how to navigate the landscape of gear on today&#;s market and save whenever possible. This detailed guide covers all my tips to spend less money on camera equipment, which is as much of an art as a science.
Choice of Equipment
The best way to save money on camera gear is to choose your equipment intelligently in the first place. On some pieces of equipment, you can &#;cheap out&#; safely; on others, you shouldn&#;t even consider it. I&#;ll go through those considerations here.
Cameras
Your camera can be one of the best places to cheap out as a photographer, as surprising as that may sound. I still strongly recommend a DSLR or mirrorless camera instead of a point-and-shoot or , but beyond that, you may not need much.
The reason is that image quality is no longer an issue with any current DSLR or mirrorless camera. High ISO performance and dynamic range are so good that they&#;re approaching physical limits. Resolution is higher than ever, with a baseline these days of 20 megapixels, more than enough for detailed 16×24&#; prints and larger.
That said, your ability to cheap out on a camera depends on the subject you shoot. You can get away with a lower-end camera more easily if you&#;re a landscape photographer, portrait photographer, macro photographer, street photographer, or studio photographer. For these subjects, most of the improvements on high-end cameras are &#;nice to have,&#; rather than &#;must-have.&#; (One exception is better build quality if you frequently shoot in adverse conditions.)
On the other hand, if you photograph weddings, sports, or wildlife, an advanced camera can be more impactful. Dual memory card slots are one of the biggest things to consider if you shoot weddings for clients. Beyond that, if you&#;re shooting quick-moving action, everything from the camera&#;s autofocus system to its buffer size can make a meaningful difference in the number of keepers you get.
All in all, you&#;re likely to get better results if you buy a cheaper camera and use good lenses, tripods, and accessories than the other way around. But the more demanding your subject is, the more the calculation can lean in the direction of cameras.
Lenses
The common advice in photography is to spend your budget on the lenses, not the camera. Even though I largely agree, that doesn&#;t mean you need to spend a fortune on lenses, either.
There is plenty of cheap, high-quality glass to be found if you accept some limitations. The classic example is a 50mm f/1.8 prime lens. There isn&#;t a bad 50mm f/1.8 from any major company right now, and there probably hasn&#;t been for about 50 years. These unassuming lenses can be found for about $100 on the used market, and they&#;re a great choice for portraiture and street photography. They also double as good macro lenses if you use inexpensive extension tubes.
If you&#;re not enamored with the 50mm focal length, inexpensive zooms are also better than they&#;ve ever been. For landscape photography, where you&#;ll tend to be using near-universally sharp apertures like f/8 or f/11, there isn&#;t a single kit lens on the market that I&#;d refuse to use. That includes even the cheapest 18-55mm variable aperture zooms, which I&#;ve used to take some of my favorite photos &#; photos with plenty of sharpness upon close inspection.
The issue with cheaping out on lenses occurs when you step outside the basic midrange of about 24mm to 85mm (full-frame equivalent). There are very few inexpensive ultra-wides with good image quality, for example, and fewer still if you intend to shoot demanding subjects like astrophotography.
Meanwhile, if you need a fast aperture beyond about the 85mm focal length, you&#;ll be paying through the roof. There&#;s just no way to get a 300mm f/2.8 for anything less than thousands of dollars, even used, unless you go with such an old generation of the lens that it no longer has autofocus.
I still think that cheaping out on lenses is possible with good results. But you need to be smart about how you use them. It&#;s easiest to get good image quality out of cheap lenses when you stick to midrange focal lengths and don&#;t try to use zooms at their widest apertures. The moment you step outside those requirements, you&#;ll be paying more for the privilege.
Tripods
Buy cheap, buy twice. That&#;s the truth behind tripods. The difference between a good and bad tripod (including the tripod head) can be bigger than that of almost any other equipment in photography.
As a landscape photographer, I guarantee that I would get sharper results on balance with a good tripod and a cheap camera setup than the other way around. I&#;d pick a Nikon D, 18-55mm kit lens, and high-end tripod over a Nikon Z9, 24-70mm f/2.8, and $50 plastic sticks any day.
Unfortunately, a high-end tripod is usually a $750- purchase, and this article is about cheaping out on your camera gear. I can&#;t just recommend a Gitzo or RRS willy-nilly.
So, here&#;s my suggestion instead. If you&#;re buying a tripod on a budget, go with something under $200 including the tripod head. Make sure to get a tripod with twist-locking legs rather than flip-locks. (Flip-lock tripods are usually flimsier, harder to use, and susceptible to sand and grit. High-end ones can be fine, but I&#;ve never seen a decent flip-lock tripod in this price range.)
A sub-$200 tripod is inevitably a compromise. The head will sag after you lock it, the tripod will shake in the wind when extended, and the whole setup may not be possible to disassemble and clean. But it gets your foot in the door. If you find yourself using the tripod all the time despite these issues, sell it after a couple of years, and bite the bullet on a Gitzo or RRS (used is fine to save money).
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On the other hand, if you realize that tripod-based photography isn&#;t for you, or is only something you do occasionally, you&#;ve just saved hundreds of dollars. Even a cheap tripod is fine on occasion. Portrait photographers, among others, may never need to upgrade it.
Other Accessories
There are countless other photography accessories. I&#;ll go through some of the biggest one-by-one.
This scratches the surface of the various photography accessories you may be considering. If you get into niches like astrophotography, macro photography, underwater photography, etc., the number of potential accessories might go way up. A lot of these products will improve your shots by marginal amounts at best, whereas practicing and learning more skills will make your photos better by leaps and bounds.
Next, let me turn my attention to the buying process itself. Not all retailers will sell the same equipment at the same prices, especially if you&#;re planning to buy used. There are also specific considerations when buying new, refurbished, or used, that may not be obvious at first glance. I&#;ll go through each of these in more detail and explain how to save money at each step.
Buying New
Some photographers choose to buy most of their equipment new, whether for reasons of warranty, peace of mind, or availability. Since most retailers sell new gear at identical prices to one another, you may not have as much room to save money here.
That said, I still recommend shopping around. Just because you see a lens at $ on one reputable website doesn&#;t mean you&#;re doomed to pay that much.
One seemingly obvious hint, but easy to forget, is that sales happen all the time on pretty much all photography equipment. They also happen year-round, with every major holiday sporting plenty of photography deals.
If you&#;re buying new on a budget, I&#;d go so far as to not recommend buying any big-ticket photography gear that isn&#;t on a seasonal sale. And I do mean a seasonal sale &#; plenty of gear is on a permanent &#;discount&#; that isn&#;t actually something special. If a $ camera has been on sale for $ for two years straight, it&#;s a $ camera.
The exception to my &#;only buy on sale&#; suggestion is for equipment that&#;s brand new to the market and still in very high demand. I&#;m not sure that a $ camera like the Nikon Z9 fits into this budget article, but nonetheless, I expect it to stay at $ for a long time without sales because the demand is so high.
If you&#;re after new, high-demand equipment like this, you won&#;t be able to save much money no matter where you buy. That said, you should still compare the options from various big-name retailers like B&H, Adorama, and Amazon. Often, one of them will offer better bundles of free accessories like memory cards and camera bags. It can be enough of a difference to pick one over the other.
There&#;s also the matter of rewards programs and credit cards from various companies. These are best handled with care, since the companies wouldn&#;t offer them if they lost money on the average consumer. Buying camera gear on credit is a quick way to spend far more on gear over time.
However, if you have autopay set up to the full balance each month, you can get some minor discounts on new gear this way. I get about 5% off anything I buy on Amazon and 7% off anything I buy at B&H by doing so, but it only works because I&#;m diligent about not missing each month&#;s full payment. Also, a few retailers like Adorama have rewards programs that give you a small percentage back per purchase.
On balance, though &#; even if you chase sales and rewards &#; you won&#;t have much flexibility in saving money when you buy new. That&#;s why, to pay less for camera gear overall, you should consider buying refurbished or used on occasion instead.
Buying Refurbished
The best way to get a &#;new-like&#; product for lower than MSRP is to go refurbished. Often, the condition of refurbished products will be indistinguishable from new, and even have a warranty in place (and practically always have a return policy). I&#;ve bought tons of refurbished gear over the years and never regretted it.
Most of what I said about new gear also applies to refurbished. Some retailers have better deals than others, and sales aren&#;t uncommon here, either. I won&#;t repeat what I&#;ve already said.
The only thing I&#;ll mention is that, unlike new gear, different retailers tend to sell refurbished equipment at different prices. I encourage you to do a quick Google search before buying any equipment, but especially refurbished gear, to ensure that you&#;ve found the best price from a reliable store.
Buying Used
It goes without saying that the best prices on camera equipment are almost always going to be found on the used market. I&#;ll go into detail in this section, because there are a lot of finer points that can save you significant money in the long run.
1. Buying Previous Generations
A not-so-secret secret in the photography world is that a lot of current products are very similar to those of previous generation. Nikon&#;s D, D, D, and D are almost interchangeable. Canon&#;s RF 400mm f/2.8 and RF 600mm f/4 are 99% the same as the EF versions of the lenses, just with a built-in EF-to-RF lens adapter. And so on.
Even when companies improve upon the previous generation in meaningful ways, it doesn&#;t mean the previous generation is bad. For instance, many of the G2 versions of Tamron&#;s lenses are optically similar to their previous G1 generation, but they have faster autofocus, newer coatings, and better build quality. I&#;d argue that these are meaningful upgrades &#; but they&#;re most likely not necessary for photographers on a tight budget.
That&#;s why, if you&#;re trying to pay less for camera gear, I not only suggest buying used, but also jumping back to previous generations. Instead of a used Nikon Z7 II, get a used Z7 &#; or, better yet, a used Nikon D810 or even D800. All of these are professional-level cameras, and all are capable of great results in the right hands.
2. Condition of the Item
I&#;ve bought some pretty beat-up used equipment over the years. My general policy is that if the item is in fully functional order, I don&#;t mind any cosmetic issues. However, if there are meaningful problems with performance &#; such as a big scratch on a lens, or a camera with 200,000+ shutter actuations &#; I will nearly always avoid it.
This means that from used gear companies like KEH, I don&#;t mind the &#;bargain&#; or even &#;ugly&#; rated camera equipment, depending on what exactly I&#;m buying. Likewise on eBay if the price is meaningfully lower (which it isn&#;t always). However, both KEH and eBay have good buyer protections and return policies. I&#;m always more stringent on condition when buying from an individual, especially if they live overseas where a return would be difficult.
3. Where to Buy Used Gear?
eBay
Everyone knows that eBay is home to a lot of used gear at cheap prices (and plenty of gear at unreasonably expensive prices, too).
There are other sites where I&#;d rather buy used gear, such as FredMiranda, since prices are usually higher on eBay. But some rare or unusual camera equipment is only found on eBay, so it pays to know how to get the lowest possible prices there.
Also, if you play your cards right, you can sometimes buy a product from big-name retailers like Adorama on their own eBay stores for less than the price on their website. I&#;ll explain how to do that in this section.
The most likely way to overpay for used gear is to purchase it at a seller&#;s &#;Buy It Now&#; price on eBay. Every once in a while, a good Buy It Now price pops up, but usually you&#;ll find the exact same item for cheaper on a different website or forum.
The exception is if you&#;re looking for rare equipment that shows up online no more than a few times a year. In that case, you&#;ll still probably be overpaying on Buy It Now, but it&#;s justifiable if that&#;s the only way to get the piece of equipment you need.
If there&#;s something you want on Buy It Now that you can&#;t find anywhere else for a lower price, I still don&#;t recommend clicking that button immediately! Instead, add the product to your eBay account&#;s Watchlist. In my experience, within a few days, about 30% of sellers will send a lower offer to everyone who has the product in their Watchlist, and not show it publicly. The discount they offer can be substantial.
eBay&#;s famous auction format is still the best way to get a low price on the platform. If the same product is offered on Buy It Now and Auction, you&#;ll usually save a good 10-20% by waiting a few days for the auction to conclude.
Auction Fever is a real thing, and eBay exploits it. Each time a bid is placed on an item, all the other bidders get an from eBay alerting them about it. This drives prices higher and higher.
Because of that, the best way to win an item on an eBay auction is to place your bid in the last 15-30 seconds so that there&#;s no time to alert the other interested parties and give them Auction Fever. (I&#;ve found that any later than about 15 seconds and my bid doesn&#;t always go through, even with a good internet connection.)
I&#;ve also found, to my dismay on an uncommon item that I missed, that you can&#;t leave the &#;place bid&#; screen open too long before placing your bid. It&#;s best to refresh the page about a minute before the bidding is done, then type your bid and hit submit in quick succession around the 20 second mark.
Make sure that your bid is the highest price you&#;d be willing to pay for the item. Not the highest price you&#;d like to pay &#; but the price at which, if it sells for even a dollar more, you&#;d say &#;that guy must be crazy, and I&#;m glad I didn&#;t win.&#; Thankfully, eBay automatically keeps your bid as low as possible &#; i.e., just a dollar higher than the highest bid from anyone else. So, 99% of the time, you won&#;t end up paying anywhere near your maximum. You&#;ll either pay substantially less, or you&#;ll be outbid by someone crazy who paid an unreasonable price.
You may laugh at how specific all this sounds, but following this method, I&#;ve rarely lost an auction, and when I&#;ve won, I&#;ve always paid much less than my maximum price.
The sneakiest way to save money on eBay is the &#;Make Offer&#; button. Not all listings have this button, since it depends upon the seller. Sellers can accept or reject your offer, and they can also make a counteroffer of their own (which they usually will).
Make Offer is exactly what it sounds like. Any time you see this button, do not pay the Buy It Now price. The seller wouldn&#;t have added the Make Offer button if they weren&#;t willing to give you some sort of discount.
I can&#;t say the Make Offer discount is always huge, but any lower price is welcome. I&#;ve found that most sellers tend to meet me halfway in their counteroffer; they average together my offer and their Buy It Now price. Do with that information what you will. Personally, if I see something for $600 on Buy It Now, I&#;ll offer $400 with the expectation that the final sale price will be $500.
My favorite part about Make Offer is that some big-name used gear retailers &#; like Adorama, Robert&#;s Camera, CatLabs, and more &#; will include this button on their used equipment on eBay, allowing you to spend less than the price on their official websites.
Case in point, I recently bought a rare filter from Robert&#;s Camera for $100 on eBay when it was $115 on their website. (It was $115 on their eBay store, too, but it had the Make Offer button.) Likewise for some used gear from Adorama that was $100, which I bought for $90 thanks to Make Offer.
You&#;re unlikely to get more than a 10-15% discount from these big stores with with Make Offer, but that&#;s much better than nothing. It also tends to apply only to used gear.
eBay Alternatives
Because eBay takes a fairly large cut of each sale, a lot of photographers choose to list their equipment elsewhere at lower prices. As a rule of thumb, when you&#;re dealing with individual photographers, you can usually find better prices and have more room to negotiate compared to eBay (especially if you&#;re buying multiple items from them at a time).
Facebook groups and FredMiranda are the two biggest forums for used photography gear, but depending on your niche, you can probably find even better prices elsewhere. For instance, the Luminous Landscape forum usually has the cheapest prices on medium format equipment, and the Large Format Photography Forum is my favorite place to buy inexpensive gear for my view cameras.
There are also some dedicated photography websites that sell used camera gear, with KEH being the biggest (and one of the better-priced). A quick Google search will usually show the used options from these retailers at a glance. But make sure to do this search each time you buy equipment, since it&#;s easy to get Buyer&#;s Fever and purchase something at a higher price without seeing all your options.
Four times out of five, the best price for used camera gear will be somewhere other than eBay. However, the private forums can be hard to find, since their buy/sell posts usually don&#;t appear on Google. If you don&#;t take the time to register for these groups in advance, whether on Facebook, FredMiranda, or elsewhere, you might not even know when the piece of equipment you&#;re after goes up for sale.
As a general rule, the longer you&#;re willing to wait, the lower price you&#;ll find. A particular camera may be abundant on eBay&#;s Buy It Now, uncommon on KEH or eBay&#;s Auction, and only up for sale once a month on FredMiranda. But each of these options is cheaper than the last. Good things come to those who wait.
Conclusion
That&#;s the sum total of what I&#;ve learned about saving money as a photographer. Part of the key is to pick your camera gear intelligently in the first place, and the rest is down to the buying process itself. The used market in particular can be anything from a great tool to a money-burning pit, depending on how you approach it. My hope is that the tips here will be useful next time you need to expand your kit! Let me know below if you have any questions or suggestions to photographers who may be in a similar boat.
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