Relationship between MDs, ODs changing as integrated eye care gains in popularity

With the aging population significantly increasing in the coming years and the medical field facing a shortage of physicians, optometrists and ophthalmologists may need to combine forces to deliver adequate care.

There are indications that closer optometrist and ophthalmologist ties are gaining in popularity to meet those needs: An estimated 47% of U.S. ophthalmologists employ optometrists in their practices, a 2007 member survey by the American Academy of Ophthalmology found.

That number appears to be growing, according to Michael W. Brennan, MD, president of the AAO.

“It hasn’t peaked – it’s probably plateaued a bit, but it’s on the rise,” he said.

Michael L. Nordlund, MD, PhD, is medical director of Cincinnati Eye Institute, where an integrated practice model of ophthalmologists and optometrists has been successfully treating patients for more than 20 years.

“The benefit of this model is that you can care for a larger group of people with the same number of surgeons as long as you have the help of primary care eye specialists — the optometrists,” Dr. Nordlund said. “It allows for us to absorb the increase in patient volume as the population ages and develops eye problems, and still provide excellent quality of care.”

Michael L. Nordlund, MD, PhD, is director of Cincinnati Eye Institute where they have employed an integrated practice model for more than 20 years. Image: Nordlund ML

Scope of practice

Integrated and co-managed eye care might also ease another key issue facing ophthalmology and optometry: the controversy over scope of practice. Historically, the two professions have been at odds over the boundary between ophthalmic and optometric practices. Although the professions have worked together on some issues, including contact lens distribution and the Prevent Blindness America program, friction is brewing over optometric legislation calling for a wider scope of practice.

Dr. Brennan said that friction might be reduced if more optometrists and ophthalmologists work together.

“I am certainly in favor of optometrists on the integrated eye care team,” he said. “We need to be more accessible, we need to communicate better between the professions, and we need to build more unified eye care teams.”

He compared the scope of practice controversy to similar situations in other medical professions when limited license providers have sought privileges that have been traditionally held by physicians with plenary licenses.

“The personal relationship and the professional relationship and the interrelationship with patients between the two professions are not the issue. There are organizational differences when it comes to state legislation and occasionally at the federal level,” Dr. Brennan said.

Optometric representatives have sought wider scope of services for optometry throughout the United States, most recently in Texas, Florida and Oklahoma. In 2008, a California bill, SB 1406, sought to allow optometrists to perform surgical procedures not requiring general anesthesia and to administer eye injections. The bill’s provisions did not stand.

Cynthia A. Bradford, MD, secretary for state affairs for the AAO, works with state ophthalmic societies on various subjects, including legislative issues. She said people get caught up in reasons why optometrists would want to expand their scope of practice. There are many reasons why they would like to expand, and ophthalmologists like to discuss these reasons on a scientific basis.

However, the legislative battle has nothing to do with science.

“It’s about politics. It’s not science,” she said.

Dr. Bradford, who teaches and practices alongside optometrists at the Dean McGee Eye Institute, said ophthalmologists and optometrists should administer patient care within the strict boundaries of their respective professions.

“You can’t work in a vacuum – you do have to work with others – but you need to be sure that you’re trained to do what you’re asked to do,” she said.

To address the scope of practice challenges, the AAO has established a “surgery by surgeons” policy that states: “The American Academy of Ophthalmology believes surgery should be performed by physicians with a medical or osteopathic education and training.” Members can make confidential donations to the Academy’s Surgical Scope Fund for activities supporting surgery by surgeons causes, including lobbying, education and political strategy.

The American Society of Cataract and Refractive Surgery supports the AAO policy.

“We, too, draw a line in the sand, essentially in terms of who should perform surgery. Like the AAO, we feel very strongly that surgeons, ophthalmologists, MDs should be the only ones who do surgery,” said Stephen S. Lane, MD, a past president of ASCRS.

He discussed the two basic eye care models that are currently in use promoting surgery by surgeons: co-management, when ophthalmologists and optometrists work in separate practices, and integrated eye care delivery, when ophthalmologists and optometrists work in the same practice or institution.

Co-management

Alan E. Reider

Co-management models typically work by having ophthalmologists and optometrists practicing independently while maintaining a referral relationship. Alan E. Reider, JD, said that among the many legal issues

regarding the proper relationship between ophthalmologists and optometrists in co-management models, the most important is that agreements should never exist between the two. Ophthalmologists and optometrists can agree to care for a patient who wants to seek care from one or the other, but neither should make a specific, binding agreement on the matter, he said.

Patients must know they are allowed to go to either an ophthalmologist or optometrist for care, he said, as per Medicare requirements. Documenting patient choice is as important as ensuring that patients are allowed that choice.

Refractive co-management issues are also important, especially in matters of optometrists’ fees, Mr. Reider said.

“The key is to follow the basic parameters that … there can be no agreement to refer, the OD must receive fair market value for the services that he or she performs, and the patient must have choice,” he said.

“My personal belief is that if [co-management] is done ethically and correctly, it’s not abusive. But you’ve got to follow the rules, and if you don’t, you’re going to create potential problems,” Mr. Reider said. “I think the big driver at the end of the day is the legal question as to how to do this correctly.”

Integrated management

Integrated eye care delivery models typically work by having ophthalmologists and optometrists together in the same practice or institution, where either can see patients at any time. Integrated models, do not raise the same legal issues involving referral and postoperative care as there may be in co-management models, Mr. Reider said.

The integrated model also allows for ophthalmic oversight of optometry on a practice-by-practice basis, with ophthalmologists often controlling what tasks optometric employees perform. However, some medical centers in the model can be co-owned by optometrists.

Elizabeth A. Davis

Dr. Lane said the daily operations of integrated eye care delivery models differ by practice. The state that the practice is located in dictates what optometrists can do by law, while the size of the medical facility often dictates what optometrists do within their privileges.

At Minnesota Eye Consultants, based in Bloomington, Minn., the ratio of ophthalmologists to optometrists is 1-to-1. The integrated system there works by having both ophthalmologists and optometrists see patients for regular exams, consultations, preoperative evaluations and postoperative care. Optometrists at Minnesota Eye Consultants also perform contact lens fittings, Elizabeth A. Davis MD, FACS, who works at the practice, said.

“The surgical MDs spend a good portion of their time in the operating room or laser suite. Furthermore, many of the surgeons travel between several different offices,” Dr. Davis said. “This is only possible because we have a great team of ODs and medical ophthalmologists seeing our patients in clinic when we are not available.”

Dr. Nordlund said the integrated eye care delivery model works differently at Cincinnati Eye Institute. There, the ratio of ophthalmologists to optometrists is 5-to-1. Because Cincinnati Eye Institute is a specialty provider, it employs more specialist ophthalmologists than general ophthalmologists, and so the optometrists are also specialized, he said. The practice also does not have a dispensary or perform routine eye exams.

Optometrists at Cincinnati Eye Institute receive specialty training for glaucoma, retina, cornea, anterior segment or refractive services, Dr. Nordlund said.

“Clinics get busy, and so by having specialty-trained optometrists that are capable of performing most of the routine exams and routine care, it allows the surgeon to focus our attention on those patients who need more intervention,” he said.

He described the working relationship between optometrists and ophthalmologists at Cincinnati Eye Institute as synergistic. The practice has established criteria for patient care, with cases seen in an orderly and timely fashion by either an optometrist or ophthalmologist, depending on the complexity of the case, he said.

“As far as the relationship between the OD and MD themselves, it’s very collegial. We certainly respect what each has to offer and what each brings to the table,” Dr. Nordlund said. “There’s a very cohesive feeling. We don’t spend a lot of time delineating between an optometrist and ophthalmologist within the practice, but rather on providing quality patient care, and we’re providing that care. It’s only when we need to transfer care for one reason or another that that distinction is made.”

Benefits of integrated model

There are many benefits to co-management and integrated eye care models for not only the ophthalmologist and the optometrist, but also for the patient. For instance, the Cincinnati Eye Institute has co-management links to primary care optometrists outside the practice who attend to the primary care needs of patients, Dr. Nordlund said. Office visits are more streamlined as a result, with shorter wait times.

There is also a financial benefit to both the practice and the patients. According to Dr. Brennan, optometry routine exams are typically less expensive. With the current economic outlook and possible cuts to Medicare, those savings could be a great financial benefit for patients and practitioners.

Dr. Nordlund said surgeons and optometrists in these models experience benefits, especially in a specialty practice situation, such as where he works.

“Specialists typically like seeing those patients with complex problems within their own specialty. That way, they get to focus on those [problems] they are most qualified to treat,” he said. “There’s not just efficiency, but it’s gratifying. There’s an emotional and personal satisfaction that we gain by being able to focus on what we do best.”

Another benefit is accessibility, Dr. Brennan said. By having ophthalmologists and optometrists in the same location, patients do not have to go as far to visit either and can receive the best care possible from both professions. The shared proximity of services could also help reduce case backlogs in ophthalmologic practices.

In addition, ophthalmology practices can expand their internal services, with such offerings as contact lenses and low vision, Dr. Brennan said.

“It would add an enhancement to the schedule and add an enhancement to the full dimension of the practice. It would also add an enhancement because some people have known optometric eye care for getting their glasses, and they want to have their refraction with an optometrist,” he said.

Other efforts

To help disseminate information about integrated care to Academy members, the AAO has developed the Eye on Efficiency Initiative, Dr. Brennan said. It was designed to encourage ophthalmologists to work together with allied health professionals, including optometrists, orthoptists, opticians, ophthalmic technicians and ophthalmic executives, for the most streamlined and quality patient care. The initiative will focus on exchanging information through a benchmarking project, block scheduling concepts, training and certification of technicians, Dr. Brennan said.

The initiative will also examine optometry employment options, including affiliate status for optometrists who do not want to become employees of ophthalmologic practices but still want to be involved, and partnership options for optometrists in ophthalmic practices.

“Eye on Efficiency will be Web-based, media-driven and focused on engaging optometry in our practices and how to do it,” Dr. Brennan said.

The ASCRS has also looked at ways of including optometry in the ophthalmic practice model. ASCRS officials allowed optometrists who are employed by an ophthalmologic practice or an academic medical facility or who are co-owners of a medical facility to attend its annual meeting. Optometrists who have a PhD and work at an academic medical facility could also attend the meeting.

Dr. Lane said the meeting was opened to those optometrists so they could gain information and insight for use in integrated care models. However, the optometrists in attendance are not allowed to participate in any skills transfer course in which surgical skills were taught, he said.

At its last two annual meetings, the ASCRS has also featured a symposium on integrated eye care. Dr. Lane is the task force chair for the ASCRS integrated eye care delivery team committee and has assisted in organizing the symposia. He said they have brought together optometrists and ophthalmologists for an open dialogue about integrating services.

“We’ll have another symposium with ODs and MDs [this] year, discussing certain aspects of how patients are dealt with in the integrated eye care delivery model,” Dr. Lane said. “We’ll basically have ODs and MDs explain to audiences what it is that they do and how they do it.”

Future of integration

While the growing number of integrated services shows the success of the models, their future will be determined by the willingness of all players involved to put aside differences and work together to address the need for quality patient care, Dr. Brennan said.

Other medical professions with scope of practice disagreements have received regulation. Dr. Brennan said optometrists and ophthalmologists should continue to work together without negotiators or mediators, despite differences on some issues.

“This is where it takes personalities to engage; it takes people willing to be open-minded,” he said. “We aren’t going to relent on surgery by surgeons and the practice of medicine and surgery, but at the same time, we have to be open-minded right now. I would rather do it one-on-one, face-to-face with [optometrists] than have a regulator, a legislator or [an insurance company] make these judgments.”

Dr. Lane said combining the services of ophthalmology and optometry might be the most effective way to deliver quality patient care.

“If people look at this as a mechanism in which we can take care of patients very well and more efficiently and effectively, I think they will see the beauty in how this can work,” he said. “The time to define and refine this is at hand now. Those practices that embrace this will have a very bright future.” – by Erin L. Boyle

What advice would you offer ophthalmologists who are working in an integrated eye care model?

• Cynthia A. Bradford, MD, can be reached at Dean McGee Eye Institute, 680 Stanton L. Young Blvd., Oklahoma City, OK 73104; 405-271-1819; e-mail: cynthia-bradford@dmei.org.
• Michael W. Brennan, MD, can be reached at Alamance Eye Center, 1016 Kirkpatrick Road, Burlington, NC 27215; 336-228-0254; e-mail: mbrennan1@triad.rr.com.
• Elizabeth A. Davis MD, FACS, can be reached at 9801 Dupont Ave. S, Suite 200, Bloomington, MN 55431; 952-567-6067; e-mail: eadavis@mneye.com.
• Stephen S. Lane, MD, can be reached at 2950 Curve Crest Blvd., Stillwater, MN 55082; 651-275-3000; e-mail: sslane@associatedeyecare.com.
• Michael L. Nordlund, MD, PhD, can be reached at Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242; 513-984-5133; e-mail: mnordlund@cincinnatieye.com.
• Alan E. Reider, JD, can be reached at Arnold & Porter LLP, 555 12th St. NW, Washington, DC 20004-1206; 202-942-6496; e-mail: alan.reider@aporter.com.