January 2011

 

COVER FEATURE

 

Ophthalmology and optometry: working together


by Michelle Dalton, EyeWorld Contributing Editor
 

 

With the current state of healthcare reforms, most optometrists think working with ophthalmologists provides the best patient care model

A decreasing number of ophthalmologists, coupled with an increasing patient base, has led numerous physicians to embrace an integrated eye care modelwhere optometrists, ophthalmic technicians, and ophthalmologists all work under the same roof to provide efficient and effective patient care.

Others prefer co-managementwhere different practices refer patients across boundaries and leave the optometrist as the primary care physician to handle a majority of eye care complaints. In the majority of states, optometrists can diagnose and treat glaucoma, refractive errors, numerous anterior segment diseases (such as dry eye), and can prescribe oral and topical drugs. With the current healthcare reforms, it's likely that "co-management will take on a greater role, as will integrated eye care," said Michael Fu, OD, in private practice at D'Ambrosio Eye Care, Inc., Lancaster, Mass. "Primary care providers are going to provide more care to more people," and with some major insurance companies no longer accepting consultation codes, integrated practices may be more efficient, he said. Noting that "integrated eye care can have nothing to do with co-management," the former is likened to a vertical integration in the same practice, and co-management comprises different practices where both jointly manage the patient, said Jimmy Jackson, OD, president of InSight LASIK, Lafayette, Colo.

The pressures of healthcare reformas it currently stands"will favor practices with multiple practitioners in them, whether it's large optometry practices with consulting ophthalmologists on staff or vice versa," Dominick M Maino, OD, MEd, FAAO, FCOVD-A, a professor of pediatrics/binocular vision at the Illinois Eye Institute/Illinois College of Optometry, Chicago, and an adjunct professor of pediatrics at the Centro de Optometria, Madrid, Spain, and is in private practice in Harwood Heights, Ill. He believes an area that has not yet fully embraced the idea of integrationbut should is pediatric ophthalmology and optometry. When executed well, both optometrists and ophthalmologists benefit, experts say. The primary care physician (usually the optometrist) probably knows the patient "better than anyone else, and is a fully engaged member of the team," Dr. Jackson said. The surgery centers win in this scenario, he said, because each member of the team has access to the most complete patient records and ophthalmic surgeons can spend more time on surgery and less time on routine care and post-op care. Optometric practices benefit as well"the best way to retain patients in the long-term is to facilitate the best secondary and tertiary care and be an integral member of the post-op team," Dr. Jackson said. Dr. Fu agreed, saying co-management/integrated eye care is a "more efficient way of treating patients. The specialists are busy perfecting their surgical techniques, and we can easily handle the primary care aspects. In this model, we see numerous potential surgical candidates, not just those who have no problems in their post-op or those who don't have a need for surgery."

Of concern to the American Medical Association and the American College of Surgeons is that the most appropriate trained professional be responsible for post-op care and that co-management is not approved by those societies when based on economic decisions to transfer care of patients after surgery, and in fact, may be illegal.

Keys to success

As with most business plans, integrated eye care can only succeed if there is mutual respect between the ophthalmologists and optometrists. "There's no magic formula or true secrets that someone knows that will magically make your practice a successful one," Dr. Jackson said. "There's no secret beyond having a solid business plan, working really hard and paying attention to details." His practice follows three tenets: high-touch (meaning every team member pays attention to every detail of patient care), high-tech (continuous investment in new technology and education for all staff members), and high respect of all team members in co-managing all patients. Some practices have continued to thrive simply by putting patient care first, said George Rickard, OD, in private practice at Laurel Eye Clinic, Brookville, Pa. "We've continued to prosper over the years because of our model. We support area ODs and our commitment to integrated eye care. When new surgeons join our practice, they have to share the company philosophy and show they're committed to the model we've created or they wouldn't fit in," he said. Laurel Eye Clinic has three main offices and several smaller offshoots, and each team member is committed to the founder's philosophy, he said. At Illinois Eye Institute, "we have 'advanced care area' with incredible ophthalmologists who work with us. It is a very good working relationship. In that sense, it's an integrated environment," Dr. Maino said. In that case, there's a three-physician office with a full referral list of ophthalmologists "whom we know we work well with and with whom we've built a long history."

As a practice, Dr. Fu said the group has "a mission statement to deliver the best possible eye care. You have to have a mission statement inn mind to focus on what you want to do. We have to continually train and motivate staff. We close our office once a month to discuss the mission statement with everyone on staff," he said. "The goal is to consistently ensure patient care is the first and foremost topic in our minds. It's imperative to the success of a practice to listen to the patient, follow-through, etc. It doesn't have to mean spending a lot more time on the patient care. Our staff meetings include updating each other on the latest research and treatment, what's new in the journals, etc."

Pros and cons

For some optometrists, the advantages of an integrated eye care practice are numerous. For one, optometrists have readily available access to specialty care for their patients, Dr. Fu said. "The patient already knows the practice and doesn't have to travel further to go see a specialist, or worry about not being familiar with the practice," he said. Additionally, he believes that for optometrists who are so inclined, working in an integrated practice can be a "great learning experience." Further, since everyone on staff has access to all the charts, there's an immediacy co-managed practices cannot offer. "Immediately after someone's been referred to the ophthalmologists, we can see what the diagnosis was, or how patient care proceeded with their specialist. We're never caught waiting for referral letters back from another office," he said. Dr. Rickard noted one advantage of an integrated model is the ability to control the quality of care because everyone is under the same roof. "There's nothing wrong with the quality of care of an independent doctor, but an integrated model might be more attractive to groups of surgeons in terms of oversight and control whereas the traditional model of a single 'storefront' might be more applicable to a surgeon who's by himself because of logistics," Dr. Rickard said. "For instance, if you're the sole eye care provider in a small town, you might better serve your patients if you've got a network of specialists you can use." If surgeons prefer to maximize their time performing surgery, "then the integrated model is good because the surgeon is using his skills and training to the maximum," Dr. Rickard said. "If you're the type of surgeon who enjoys handholding and spending a lot of time with patients without necessarily doing a high volume of surgery, or you enjoy the interaction with patients after surgery, then co-management might be for you."

The advantages of an integrated eye care practice are "significant if there is, indeed, mutual respect for the skills of each profession," Dr. Maino said. "What I find in the day-to-day interaction for most practitioners is that the mutual respect is there. Optometrists find the ophthalmologists who value our abilities. Integrated eye care can only work when both professions have a god understanding of what each other does and allows each to do what we do best for the patient."

Optometrists interviewed for this article could not name many disadvantages to an integrated eye care practice. For the most part, the only down side remains a somewhat territorial attitude about patients, where once referred to the practice's ophthalmologist, patients are not "handed back" to the optometrist until it's time for the annual vision exam. One disadvantage to a co-managed approach is a potential for poor communication between the two practices which could inadvertently lead to complications with insurance paperwork or even patient records if practices are on different electronic health records systems.

Politics

In most states, optometrists are not allowed to perform intraocular surgery or use lasers. Beyond that, however, most optometrists believe their role as the primary eye care provider should place them in a leadership position, working in cooperation with a specialist. "Despite what the ophthalmic community might say, an appropriate healthcare system should be under the leadership of the primary eyecare provider, which is usually the optometrist," Dr. Maino said. "In most states, optometrists practice medical ophthalmology at the highest level, diagnosing and treating glaucoma and anterior segment problems. When something goes beyond our scope of expertise, we'll make an initial diagnosis and refer out to an ophthalmologist. What benefits everyone in that situation is that it frees up the ophthalmologist to do what he or she does best, which is more surgery. The more surgery they perform, the better they become, the better the patient outcomes. Conversely, the more optometrists are managing the patient as a primary care practitioner, that individual also becomes more skilled at a much higher level."

In Massachusetts, optometrists are allowed to place punctal plugs and perform punctal occlusion, but "we can't prescribe oral medications. We can prescribe topical, but not oral," Dr. Fu said. The state legislature has been debating the issue "for years and years," Dr. Fu said, but Massachusetts remains the sole state that makes it illegal for an optometrist to prescribe glaucoma medications. "Overall, optometrists have shown across the country they are well-trained to diagnose and treat glaucoma and are very willing to refer for those cases they can't handle or when patients are progressing even with treatment." At the core of the issue, Dr. Jackson said, is that optometry is a regulated profession, yet there's no universal agreement among the states as to what an optometrist can and cannot do. "Because I have lived and practiced in different states, I've seen the legislative battles in all of them, and I'm a little cynical on the process," Dr. Jackson said. "Optometry as a profession is continually going back to the legislature to deal with advancements and how to allow the physicians to change and grow." He adds that legislative battles are only about patient care and not monetarily based "is complete baloney. There are scores of practitioners who get along wonderfully well, but in the hierarchy there are some fundamental differences."

On the other hand, continuing to define optometry "as a non-surgical profession and I don't have a problem with that," Dr. Rickard said. "Some optometrists out there don't feel we should be that limited, but the vast majority are okay with the laws the way they are. Of course, there are some ophthalmologists who begrudge optometrists for what we're allowed to do. Some, not most, but some."

Moving forward

Dr. Fu believes integrated eye care will continue to gain in popularity, mainly because optometrists "can learn quite a bit by being that much closer to the specialist, and can become more comfortable with patient care because of that relationship. The ophthalmologists in our practice have helped make us all better diagnosticians." Overall, he said optometrists are not trying to "steal" anyone's patients; they're comfortable "treating what we treat and we know when we need a second opinion or something is out of our comfort zone."

Co-managing patient care is "the most cost-efficient care model for the patient," Dr. Jackson said, based on the greater geographic distribution of ODs in general. "There's going to be a greater interest in co-management because it makes fiscal sense for the overall healthcare system," he said. "There's always going to be patients who need to be referred out. No matter how good an individual state law is, and no matter how comfortable an optometrist is performing various procedures, there are patients who are going to need secondary and tertiary care." With patient loyalty dictated more by insurance company coverage than actual quality of care these days, "if you tell a patient they've been diagnosed with X, 'here are some practices I work with for you to go see,' the patient isn't going to feel you're involved in their disease management. You're not helping them navigate the surgical aspects of their disease. If, however, you refer the patient to an individual doctor, or tell them you've created a lists of people who can provide the best care for their diagnosis but you will be the point person and provide all the pre- and post-op care, you're in essence doing what you can to foster some sort of patient loyalty."

Any business model that can "improve efficiencies in the delivery of care is going to succeed," Dr. Rickard said. In the future, he envisions practices vying or bidding for government contracts and integrated eye care groups will be better positioned to compete in that scenario than a typical co-managed practice. Saying a colleague of his noted optometry "is no longer just on the menu, we're on the table," Dr. Maino said, "our associations have spoken to lawmakers. Because optometry has taken such an approach to our involvement of healthcare at state and national levels, I hope our ophthalmic colleagues will realize working together is the only way to achieve good patient care."

He firmly believes that if the two professions do not work together to provide patient care, "lawmakers will gobble us up. They'll dictate to us what system they want for eye care delivery and they'll determine who's the least expensive to provide it."

Dr. Jackson agreed, "To be true partners with ophthalmologists is the ultimate. That being said, a lot of optometrists and ophthalmologists go into practice because of the autonomy. You will give up some of that when you join an integrated practice. One of the beauties of our profession is that it's so broad and there are so many options available to us, we do have the best of all worlds."

Editor's note: No one had a financial interest to disclose aside from a vested interest in his practice.

Contact information:

Fu: (978) 537-3900; michael.fu@dambrosioeyecare.com
Jackson: (303) 665-7577; jimmy@insightlasik.com
Maino: (312) 949-7280; dmaino@ico.edu
Rickard: (814) 849-8344; gsr849@aol.com

Ophthalmology and optometry: working together Ophthalmology and optometry: working together
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