Ophthalmologists who invest in physician assistants reap valuable rewards

Among the various physician extenders for an ophthalmic practice, a physician assistant may very well be the most valuable for patient care, patient convenience and the practice’s financial well-being due to the wide scope of services that a physician assistant can perform. However, practices must be willing to commit the time and resources necessary to properly train such a medical professional.

“Having a physician assistant (PA) is a critical part of the eye care team, but not necessarily more or less valuable than having an optometric provider,” Michael L. Gilbert, MD, medical and surgical director at Northwest Vision Institute in Bellevue, Washington, said. His practice hired a PA for the first time 2 years ago. “The advantage of a PA is that he or she is going to be better at handling the predominately medical aspect of the practice. The training and scope of practice for a PA is more closely aligned with that of the supervising MD.”

Likewise, Gilbert said a PA has the potential to be more advantageous than a nurse practitioner (NP) for this same reason.

Initially, the PA at Northwest Vision Institute was trained in-office, similar to orienting a certified ophthalmic assistant, but was already able to conduct all preoperative health and physical examinations (H&Ps). “This certainly streamlined the preoperative process because preop H&Ps can be a challenge to coordinate,” Gilbert said.

With training, PAs gradually grow substantially in what they are able to contribute, according to Gilbert. At 6 months, the PA at his institute, with a contractual commitment, was sent to a 1-month training program in basic science at the University of Texas Health Science Center at Houston, where the classmates were mostly ophthalmology residents.

Upon her return to the practice, the PA started to triage and manage emergency patients within her area of comfort and supervision. Gradually, the administration of steroid injections and supervised removal of chalazia, along with lid margin debridement and similar patient services, have been added. “These minor procedures are technically and clearly outside the scope of practice of an optometric provider or nurse, but well within the capability of a supervised PA,” Gilbert said.

Image: Preston L

After being with the practice 1 full year, the PA was added to the call schedule. “I am not sure I would as easily do that with an NP,” Gilbert said. “Having an additional staff member on the call schedule is certainly beneficial to the ophthalmology-led team.”

Before employing a PA, the institute reaped no revenue from preop H&Ps. “That has now changed, though, by creating efficiencies and a supportive revenue stream,” Gilbert said. “The availability of the PA to see walk-in patients also allows for the same revenue as if the physician saw that patient. Such an arrangement makes the practice much more efficient and responsive to last-minute needs than the average ophthalmologist may be able to easily fit in his or her schedule.”

Furthermore, Gilbert knows of other practices that use PAs more aggressively in surgery alongside the ophthalmologist or the ophthalmic surgeon, and they may be primarily responsible for Botox (onabotulinumtoxinA, Allergan) and fillers.

Surgeon mentality

“A PA or NP may provide services that traditionally have been reserved to physicians, such as physical exams, minor surgery and interpreting diagnostic tests. By virtue of their training, a PA or NP can help triage diabetic patients and conduct H&Ps prior to major surgery,” according to OSN Practice Management Board Member Kevin J. Corcoran, COE, CPC, CPMA, FNAO, president of Corcoran Consulting Group, which specializes in reimbursement and compliance issues for ophthalmic and optometric practices. However, a practice needs to have a certain patient volume to justify a physician extender.

The mentality of the surgeon plays a role. “For instance, is the surgeon willing to delegate some parts of patient care?” Corcoran asked. “There is also a learning curve for a new PA or NP to acquire postgraduate education about ophthalmic anatomy, physiology, pathophysiology and treatment options. Within 3 months, a physician extender will have a modicum of proficiency. After 12 months, you can expect they will be very useful and pay their own way.”

At present, PAs are rarely used in eye care. In fact, “there are fewer than 50 PAs in the entire country employed by ophthalmologists and even fewer NPs,” Corcoran said.

Corcoran said that state law governs the scope of practice of PAs, and it varies. “As a general rule, the scope of practice of the PA is only limited by the extent of delegation that the supervising physician is willing to make,” he said. “It might include eye exams, intravenous injections, triage and assess emergencies, minor procedures, chronic disease management and postop care. In one case, a PA serves as executive director of a large ophthalmic ASC and assists with oculoplastic surgery.”

PAs are paid either 100% or 85% of the Medicare Physician Fee Schedule (MPFS), depending on whether they provide services “incident to” a physician’s professional services of not. When the PA is closely supervised, as is the case with direct supervision, reimbursement is 100% of the MPFS. Reimbursement is lower (85%) when the PA does not provide services “incident to” a physician; it is not reduced for NPs who have greater independence. Corcoran acknowledged that the Medicare rules regarding reimbursement for physician extenders are subtle and not easily understood with just one reading, so his firm offers educational material on this topic.

The Eye Institute of West Florida hired its first PA about 10 years ago and added a second PA position in 2012. The institute hired the PAs in part to assist surgeons in complicated surgeries such as glaucoma, retina and plastic procedures.

“PAs are also able to help us with H&Ps prior to surgical procedures because we wanted to make sure that we did not miss anything general healthwise,” OSN Technology Board Member Robert J. Weinstock, MD, director of cataract and refractive surgery at the institute, said. “This is a more streamlined, efficient process than having patients schedule a separate appointment with their primary provider.”

Over the past 5 years, the institute has delegated to its PAs more primary care eye services, such as mild to moderate ocular surface disease management and cosmetic and functional procedures related to the skin and ocular surface, in addition to some routine postop care visits.

“Our two PAs are a vital component to our practice,” Weinstock said. For example, after patients are consulted for cataract surgery, they return for a second visit, at which time an H&P and all biometry are administered by a PA, “so it is one streamlined process to fully prepare the patient for cataract surgery. This moves patients toward cataract surgery faster than if they had to schedule with their primary care doctor and wait for clearance from the doctor.” The protocol also allows the PAs to detect conditions through meaningful diagnoses “that help save people’s lives and improve their health unrelated to the eye,” Weinstock said.

Letting a PA handle postop day 1 visits and routine checkups “saves me a lot of time and allows me to see a more urgent care patient or have another cataract consult,” Weinstock said. “It is rare for the PA to need me for postop day 1 visits or routine checkups.”

Establishing a PA

From a financial prospective, PAs bring in income from H&Ps and assist in surgery, thus reducing overhead, according to Weinstock.

“There is a financial value in having PAs in your practice, even after deducting for their financial compensation,” he said.

Weinstock acknowledged, however, that a PA in an ophthalmic practice is a “very unique and rare situation. In my experience when talking to people, it is not the norm at all to have a PA. It is more the larger, more progressive practices that need physician extenders because the physicians themselves are so busy and things have become so subspecialized that physicians need PAs to handle some of the routine care and help streamline practice operations.”

Christine A. Crevello, PA-C, a PA at The Eye Institute of West Florida, completed a 28-month PA program at Barry University in Miami Shores, Florida, in December 2007.

“The amount of time dedicated to the eye was very, very limited,” she said. “This is not a criticism of Barry. The course load is condensed into such a short amount of time that ophthalmology is not covered in depth.”

Crevello was employed by Orthopedics of West Florida from January 2008 to June 2008.

“I was a physical therapist assistant in my first career, so I had experience with bones,” she said. Then, in July 2008, Crevello began working for Bay Area Emergency Physicians at Morton Plant Hospital in Clearwater, Florida, where she remained until starting at the eye institute in May 2012.

“I was looking for a change of pace,” Crevello said. “The emergency room was a wonderful experience, but the stress and hours away from my family were starting to take its toll on me.” While working in the ER, Crevello would speak with Neel R. Desai, MD, of the Eye Institute. “It was refreshing to speak with a specialist who was so willing to help patients, even meeting them in the office on weekends.”

When Crevello learned that a PA position might be available, she emailed her resume to the practice. “I was contacted by phone that day, and an interview was set up,” she said. However, Crevello shadowed Weinstock on many occasions over several months before accepting the position “to see if it was going to be a good fit. I was nervous because the eye was new to me, and it was a little intimidating seeing all the diagnostic equipment for testing and all the specialists.”

Still, when Crevello began, she possessed basic knowledge of the cornea, retina and cataracts. Then, like technicians starting out in ophthalmology, she became proficient in using the slit lamp, checking visual acuity, measuring IOP and learning how to operate all of the different diagnostic equipment. “As I was learning the basics, I was also rotating through the various clinics — working patients up, observing physicians with patients and watching the patient through the entire visit,” Crevello said.

In addition, Crevello spent many months with each specialist — a “residency type” specialty training — and a lot of time in the OR observing different surgeries for more than 1 year. “The entire staff was so gracious with their time and energy that they devoted to me,” she said.

Finding PAs

To recruit PAs, “create an effective recruitment ad and place it with local resources,” Candace S. Simerson, COE, CMPE, CAHCM, said. Simerson is president of Minnesota Eye Consultants, which has three PAs on staff. Another strategy is to contact local or state universities that have PA programs, “or perhaps participate in their programs to help groom candidates.”

But even before starting the hiring process, “take time to prepare a business plan and identify space/equipment needs,” Simerson said. It is also important to review documentation and coding requirements and design chart templates, as well as to establish a script for educating patients about the services and options they will have with a PA. “Also, educate payers about the fact that the practice will be offering these services, so that the claims are processed when the practice is ready to offer them,” Simerson said.

In addition, the PA will need to go through the typical credentialing process for all payers; hence, allow enough lead time to undergo submission and approval. Simerson also recommended that during the PA’s first 30 days of employment, time should be spent with surgeons and other staff who are involved with surgery patients. “This will help the PA understand the process and how he or she fits in,” Simerson said.

At Minnesota Eye Consultants, which has four surgery centers, the primary role of the PAs is to perform the preoperative H&P for surgery patients.

“By having this resource in-house, it is much more convenient and easy for the patients, as they can schedule their H&P at the same time we are scheduling surgery,” Simerson said. “This ensures that we manage appropriate timelines within the 30-day window.”

For patients who are having bilateral cataract surgery or other bilateral procedures typically performed within a 2-week period, “it is more complicated to manage this timeline if a patient needs to schedule an H&P on their own with another practice,” Simerson said. “It is also more efficient for the practice because we can internally submit the H&P forms to our surgery center on a timely basis. This eliminates last-minute chasing for the patient who is having surgery in the next day or so, but still waiting on an outside provider to submit the form.”

Corcoran said he believes there is a bright future for physician extenders in ophthalmology.

“In 1970, there were about 20,000 ophthalmologists in the U.S., the same number as today,” he said. “However, the number of elderly patients will double over the next 10 years, with no additional ophthalmologists.” Plus, it is unlikely that proportionally more money will be earmarked to care for these patients. In the future, health care spending will increase, but at a much slower rate. Corcoran said it is unrealistic to expect optometrists to completely fill this void created by a physician shortage, but that PAs and NPs could help.

The challenge, though, is that PAs and NPs graduate from school with essentially no knowledge of ophthalmology.

“Ophthalmologists need to be willing to spend the money on training,” Corcoran said. “At that point, PAs become exceptionally valuable.”

Weinstock does not believe there is reluctance among ophthalmologists to employ PAs, “but the practice needs to have a certain volume and need that justify the expense.”

Ophthalmic practices also have to be motivated to find a PA.

“Typically, PAs and NPs think they will do primary care medicine, not subspecialized medicine,” Weinstock said. “You then have to train that person, almost as if you were training a resident, starting with the basics.”

Despite the investment, Weinstock estimated there are hundreds of ophthalmic practices in the U.S. that have reached a size at which physician expertise warrants delegating, for which employing a PA makes good business sense. He also noted that PAs and NPs are able to do things that some optometrists cannot, such as assist in surgery, do minor procedures and prescribe medications.

Continuity of care

Because Crevello assists in glaucoma, retina and oculoplastic surgeries, she provides continuity of care to patients and is informed about specific medical needs. “If a question or emergency develops, I am able to fast-track the patient to the appropriate provider,” she said.

Similarly, because patients have seen Crevello working in conjunction with their doctor, “they are already familiar with me, which enhances the patient experience,” she said. “I am also able to spend valuable chair time with patients in the dry eye clinic. I frequently hear from these patients that no one seems to take their condition seriously or has the time to explain dry eye and what to expect regarding treatment options and benefits. I can explain in detail to the patient the diagnosis, treatment options and what to anticipate in surgery and recovery, which puts the patient at ease.”

For those considering a career as a PA in an ophthalmic practice, Crevello said one should not be afraid of the eye.

“It is a tiny organ, but there is so much to it. I have learned so much, and the patients are so grateful for your services and time that you spend with them,” she said. “It is very gratifying to be part of restoring someone’s vision, and for dry eye patients, letting them know there is light at the end of the tunnel.”

From a patient’s perspective, the patient usually incurs fewer out-of-pocket health care costs, according to Simerson, because the PAs know what tests, if any, are indicated for any of the specific procedures. “This reduces the risk of complications or unexpected outcomes,” she said.

Moreover, specialty-trained PAs can help identify issues needing further evaluation or follow-up by a physician. “They can also facilitate communication and coordination of care with the patient’s own primary care physician,” Simerson said. “Many of our senior-age patients have not seen their primary care doctor in some time or may not even have one, so the PA can educate and encourage them to see a primary provider to take care of their routine preventive care needs.”

The PAs at Minnesota Eye Consultants also provide urgent care services for the 300 employees.

“We have a self-insured health plan that helps keep our costs down and employees productive by having these services available in-house,” Simerson said. “For example, if an employee believes he or she might have strep throat or an ear infection, that individual can see one of our PAs to evaluate and treat, if needed.”

Gilbert believes there are many ophthalmic practices that could benefit from employing a PA to complement existing staff.

“However, because PAs and NPs do not have any significant ophthalmic experience or training in their basic education, any ophthalmologist considering the opportunity must realize that the in-house training or the commitment to outsourced training is going to be the biggest initial hurdle to make that individual valuable to the practice. I think this is the reason there is general hesitation and uncertainty on how to proceed and what model to adopt,” he said.

Despite this barrier, Gilbert is acutely aware of the national interest in physician extenders and potentially adding a PA to an ophthalmic practice, as he has fielded inquiries from ophthalmologists across the state of Washington. In addition, his own institute expects to add a second PA position within the next year.

“The patient demographics, the increase in demand for services and the reimbursement challenges faced by ophthalmic practices are requiring that we adeptly use PAs in a complementary provider mix to make the eye care delivery team as efficient and cost-effective as possible,” Gilbert said. – by Bob Kronemyer

• For more information:
• Kevin J. Corcoran, COE, CPC, CPMA, FNAO, can be reached at Corcoran Consulting Group, 560 E. Hospitality Lane, Suite 360, San Bernardino, CA 92408; email: kcorcoran@corcoranccg.com.
• Christine A. Crevello, PA-C, can be reached at The Eye Institute of West Florida, 1225 W. Bay Drive, Largo, FL 33770; email: tina.crevello@eyespecialist.com.
• Michael L. Gilbert, MD, can be reached at Northwest Vision Institute, 12301 NE 10th Place, Suite 200, Bellevue, WA 98005; email: mgilbertmd@gmail.com.
• Candace S. Simerson, COE, CMPE, CAHCM, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S., Bloomington, MN 55431; email: cssimerson@mneye.com.
• Robert J. Weinstock, MD, can be reached at The Eye Institute of West Florida, 1225 W. Bay Drive, Largo, FL 33770; email: rjweinstock@yahoo.com.

Disclosures: Corcoran, Crevello, Gilbert, Simerson and Weinstock report no relevant financial disclosures.

What are the pros and cons of relying on a scribe in your practice?

Scribes responsible for many duties

At Minnesota Eye Consultants, we employ close to 40 scribes. Probably the greatest benefit is that I am able to focus on the patient-physician interaction by listening to and interacting with the patient, rather than looking at a computer screen and making entries. A scribe also facilitates retrieving information from the patient chart and provides a witness in the room for secondary documentation of what was stated and what the patient stated in return. At the conclusion of a visit, the scribe is another person who can obtain additional testing, escort the patient to the surgical scheduler or checkout, send prescriptions to the pharmacy and help fill out paperwork. In essence, the scribe is a great asset in handling housekeeping items for the patient.

A scribe also helps with the continuity of care, including if the patient makes a call-back. Physicians are not usually readily available to return all phone calls, so a scribe can function as a physician extender by speaking to the patient from a knowledgeable viewpoint because the scribe was in the room with the patient. The scribe knows what transpired and the patient’s history. The scribe can explain to the patient what the plan is. Frequently, the scribe can fully answer the patient’s questions and concerns on the doctor’s behalf.

We use our scribes to a much greater extent than simply data entry. They are part of each physician’s team, so they may help with lens selection, power calculations, and scheduling and flow of patients. Scribes sort of play air traffic control by directing physicians where to go next, explaining which patients have been waiting the longest, and working with the staff to generate a schedule that is ideal for both the patient and doctor. Scribes also help me with coding. My brain power is best directed toward medicine and not government regulations, updates and changes.

Having a scribe is definitely worth the financial investment. The scribe can provide comprehensive patient care, enhance personal interaction and communication, and handle administrative practice issues. The scribe is easily able to multitask.

Elizabeth A. Davis, MD, FACS, is an OSN Cataract Surgery Board Member. Disclosure: Davis reports no relevant financial disclosures.

Scribes useful but there may be challenges

We use two scribes at our practice at Siepser Laser Eye Care. I use electronic health records, which have all but necessitated a need for a scribe. In fact, documentation takes longer than examination. I also believe the leading problem for everyone with EHRs is autofill, which is a trap for the scribe because he or she does not understand fully the medical and technical side. The scribe is basically a note-taker. By concentrating on the patient, I am no longer really looking at the chart. I may not check the optic nerve at a particular patient visit or the IOP is different from last time. The scribe autofills the chart, for which it will indicate I performed a fundus exam, when in reality I did not. Similarly, the autofill might show the patient still has a cataract when the patient has already undergone cataract surgery. Therefore, it is important that the clinician review the filled-out chart.

I use the “one-touch” technique for mail and medical records, among other tasks. I try to touch one thing once, make a decision and I am done. The challenge is that the scribe may still be in the patient room securing additional medical history or adding some materials to the chart. If I wait for the final chart in our particular system, I do not get to see it because it takes about 10 to 15 seconds. That is OK in about 99% of cases. But the malpractice attorneys have been making a lot of hay about chart inconsistencies. You have no control as to what the scribe does once you leave the room. The scribe may assume something or add something without checking with you. Our charts are also signed electronically, mostly by our technical team.

The cost of employing a scribe is significant. It is not quite obvious to the doctor until the end of the month, when you realize that your profit is not as great as it might be. These little costs and the loss of efficiencies due to EHRs have a significant impact on the bottom line. Even though the doctor’s time is probably 10 times more costly than a scribe’s, it still causes both of us to lose precious seconds while examining patients.

Furthermore, when a scribe misses a day of work, I am forced to fill out the charts myself and must cancel a few patients and rearrange my schedule. On those days, I can only operate at a 30% to 40% capacity.

Steven B. Siepser, MD, FACS, is an OSN Cataract Surgery Board Member. Disclosure: Siepser reports no relevant financial disclosures.