Currently, there is an ophthalmologist-only eye care delivery model, as well as an MD/OD cooperation model. Now what is gaining more attention is what is referred to as an integrated eye-care delivery type model.
By Stephanie Skernivitz
Stillwater, MN-As the U.S. population continues to age, the demand for more eye care for older patients is ever increasing. Yet, the supply of ophthalmologist time is shrinking, leading to a shortage of available eye-care professionals.
“How will we provide the integrated eye care that this group needs?” asked Stephen S. Lane, MD, adjunct clinical professor, University of Minnesota, and medical director, Associated Eye Care, Stillwater, MN.
In an impromptu poll of an audience at a recent ophthalmic meeting, he asked: “Do you currently employ optometrists in your office?” Sixty-four percent answered “yes.” When asked how optometrists were used in the practice, 22% said as physician extenders, 55% said as independent comprehensive practice within the practice, 18% reported their use as a technician, and 5% had “other” reasons.
For those who answered “no” to employing optometrists in practice, they were asked: “Why not?” The answers: too expensive (5%); opposed to the concept (10%); would not fit current practice style (33%); may interfere with co-management already in place (10%); or planned to employ one in future (43%). No doubt, there is an ever-expanding number of Baby Boomers who are reaching a retirement age of 65 years every day-to the tune of 10,000 per day for the next 17 years.
“We better figure out how it is that we’re going to take care of all these patients in our practice,” Dr. Lane said. Commercially, in the 16- to 65-years age groups-about 74 cents is being spent per person on care. For seniors over 65 years of age that number jumps to $6.52-8.8 times as much money.
What role should optometry play in this increasing need for eye care? he asked. Currently, there is an ophthalmologist-only eye-care delivery model, as well as an ophthalmologist/optometrist cooperation model. Now what is gaining more attention is what is referred to as an integrated eye-care delivery model.
In these above-mentioned optometric relationship models, the question is how do ophthalmologists perceive optometrists?
“Some perceive them internally as a super-tech/screener, some as a colleague,” Dr. Lane said. “From an external standpoint, that is, optometrists outside your practice, (some perceive) these folks as interlopers, referral sources, and colleagues.”
As Dr. Lane explained, internally, for internal optometry models, the super-tech/screener is essentially one who works up patients for the ophthalmologist to finish, such as fitting contact lenses, and providing some postoperative exams, but few exams on their own.
“This is a fairly expensive model for the [ophthalmologist] practice to take on compared with using techs only for work up,” Dr. Lane said.
In the internal models where optometrists are treated essentially as a colleague, it is often typical, according to Dr. Lane, for the optometrist to see patients with routine needs; the optometrist practices to the limit of licensure and training, and the optometrist refers medical and surgical patients to the ophthalmologist. In reverse, the ophthalmologist refers patients to the optometrist for routine, postoperative care, contact lenses, and other exams, which optimizes the time spent for the ophthalmologist and optometrist and allows the existing ophthalmologist to do more surgery as opposed to adding another ophthalmologist.
“This model can be more cost effective,” Dr. Lane said.
In delegation models, this is where some elements of exams and most ancillary testing are delegated to employees. Most clinical employees are not licensed, though some are certified.
“But there is shortage of trained techs, which forces many practices to train their own,” Dr. Lane said.
Overall, Dr. Lane said there is minimal use of physician assistants and nurse practitioners.
At present, the average comprehensive ophthalmologist sees about 44 patients per day; retina specialists may see about 29 patients a day; pediatric ophthalmologists may see 30; optometrists may have 20. But, according to Dr. Lane, ophthalmologists see many more patients than these numbers show.
“How do some doctors see so many patients? They have excellent systems and processes, well-trained staff, efficient office space to do similar type of exams, and the overall physician pace is quick,” Dr. Lane said.
Delegation to physician extenders can make the difference in seeing more patients and finding more career fulfillment, he said.
“With a physician-only delegation, the theoretical number of exams that can be done in a day is 19,” Dr. Lane said. “As you add the number of physician extenders to carry on various functions of portions of exam-where you have optometrists, physicians extenders, technicians-you can certainly see the amount of time taken to see these patients decreases with extenders and significantly increases number of patients you can see.
“The number of patients obviously increases with an ophthalmologist and technician to 20 regular patients and 2 surgical patients. By adding an optometrist, you can increase the number of surgical patients because of referrals that come from the optometrist,” Dr. Lane said.
To make this theory work in practice takes some initiative on the part of the physician.
How can practices evaluate themselves and determine whether to change models?
Stephen S. Lane, MD suggests that physicians truly ask some probing questions:
1) Is the demand for your services greater than the supply of time? Determine whether the lead time to get an appointment is greater than 2 weeks and growing. Are there long patient waiting times? Are you working beyond scheduled hours? Is the ophthalmologist performing a high volume of routine exams? “If extra help is added, but patient flow doesn’t increase, the cost of extra help is simply a drain on practice resources. But on the other hand, if you maximize the use of these folks, the profitability of the practice increases,” Dr. Lane said.
2) When deciding whether to change models, you have to ask: is there enough patient demand to increase the patient flow enough to pay for increased costs?
3) What is the long-term plan of the practice?
4) At what pace does the ophthalmologist work? Will that pace be compatible with a new model?
5) Is the practice capable of handling additional management?
“It’s an opportunity to provide education to optometrists and physician extenders to improve quality of care and efficiency available,” Dr. Lane said.
“If he or she truly delegates some of the tasks, the doctor will have time to examine more patients,” Dr. Lane said. “From observation, a doctor can complete more exams if they’re using techs and optometrists. Adding such staff can help optimize use of the ophthalmologist’s time so that everyone can each practice within their scope. Everyone then feels fulfilled as a result of this because they feel they are doing what they are trained to do.
“Whether their enjoyment of practice is higher with additional staff is an additional consideration,” Dr. Lane added.
“At the end of the day you will feel a whole lot better-even after seeing 60 to 70 patients-when you have all these extenders helping you,” he concluded.
Stephen S. Lane, MD
This article was adapted from Dr. Lane’s presentation at the 2014 meeting of the American Society of Cataract and Refractive Surgery. Dr. Lane has no disclosures.