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Collaboration key to meet patients’ needs
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The Ocular Surgery News editorial team has proven again that it is not afraid to cover stories on controversial topics. This issue’s cover story deals with one of the most controversial and divisive issues in our field, optometric scope of practice.
First, a brief thought about OSN’s editorial policy and philosophy, which is published in every issue. It states that: “Ocular Surgery News strives to be the global, definitive information source for ophthalmic professionals by delivering timely, accurate, authoritative and balanced reports on clinical issues, socioeconomic topics and ophthalmic industry developments.” Our editorial content is focused on the ophthalmic surgeon as the core reader along with members of the industry that supports the surgeon. For balance, we ask our reporters to interview a diverse group of sources for every cover story, with a commentary provided by myself, along with John Hovanesian, MD, in every issue. John and I do not share notes before publication, and we both look forward in every issue to reading each other’s commentary. We also include a point/counterpoint from two individuals with diverging points of view on every cover story topic to add balance. I do not provide any editorial oversight on the content of the point/counterpoint discussion. We are an ophthalmology newspaper, and our primary responsibility is to report the news accurately, but our readers also want us to provide editorial commentary and opinion.
To me, a good example of the challenges inherent in factual reporting and editorial commentary is the Wall Street Journal’s recent management of the Theranos and Elizabeth Holmes story. I just finished reading Bad Blood: Lies in a Silicon Valley Startup by John Carreyrou, an investigative reporter at the Wall Street Journal. It is a fascinating read, and I encourage you to get a copy. This story definitely challenged the editorial team at the Wall Street Journal, yet it was willing to report and provide editorial opinion on a controversial topic. Such is the case for OSN in choosing to publish a cover story and commentary on optometric scope of practice and its companion, co-management.
I am an advocate of both integrated eye care delivery with MDs and ODs working side by side collegially to provide quality patient care and what I call patient-centered co-management. (I have written a book, now out of print, on this topic and an editorial with this title in Ophthalmic Surgery and Lasers in 1998. You can still access the editorial if interested.) In my practice, cooperative, collaborative management — with my doctor of optometry and, to be inclusive, comprehensive ophthalmologist and primary care physician, colleagues both inside and outside the four walls of our practice — has worked extremely well and benefited our mutual patients. It has also worked well for my own family, closest friends and my personal eye care. For some of my fellow ophthalmologists, the “co” in co-management stands for collusion and is inappropriate and indefensible. I disagree.
When confronted with these difficult dilemmas, I always retreat to a “patients first” analysis. In my opinion, the integrated eye care delivery model and access to collegial patient-centered co-management is in the best interests of patients. I believe it is important to look not only at what we ophthalmologists think is in our patients’ best interests, but to also consider what the patients and their families prefer. That is, for me, the core principle of patient-centered care. Some authorities expand the concept and call it patient- and family-centered care.
Much has been written about this topic. One of my favorite sources describes eight principles of patient-centered care. Principle one is respect for the patients’ preferences. Patients in every survey prioritize choice of care provider highly. For one reason or another, in regard to their eye care, patients do not always choose an ophthalmologist. Principle two is coordination and integration of care. If more than one provider is engaged with a patient’s care, the engaged providers must work together in a cooperative, collaborative, collegial fashion with good communication. You can easily look up the other principles on the internet. They are another good read.
As I previously mentioned, I believe the best eye care is provided in what I call an integrated eye care delivery model, which includes an array of providers including surgical and medical ophthalmologists, optometrists, physicians assistants or nurse practitioners, certified ophthalmic technologists, technicians and assistants, medical record scribes, opticians, contact lens specialists, nurses, operating theater technicians, nurse anesthetists, experienced practice managers and others as needed. It takes a village to provide the highest-quality eye care, and doctors of optometry are part of that village. A big practice may have all the required resources under one roof. In other cases, they are available in a community but under separate roofs. Ideally, this village of eye care providers works together in the patients’ best interests.
When we see a new patient with a problem, they and their family want to know what they have, how do you treat it, who will treat it, where will it be treated, when will it be treated, what will it cost and who will pay for it. What, how, who, where, when and the cost. In the eight principles of patient-centered care, principle number three is information and education. Informed consent before any treatment today includes all the issues above, including who will prescribe, perform and monitor the treatment or procedure as well as who will pay for it and what will be the out-of-pocket cost to the patient and/or their family. This cost and payment issue takes an ever larger amount of my time in practice, as many patients cannot afford the treatment I would like to prescribe, but that is a topic for another commentary. Who will prescribe, perform and monitor the treatment or procedure is the primary topic for today.
While it is a given that scope of practice is an important issue, and every eye care provider must first be licensed to provide the optical, medical or surgical care they offer, the issue of who provides a given unit of care to a patient is far more complex than scope of practice. In the patient- and family-centered care model, it will be the patient and their family that ultimately select the caregiver. It will not be the state legislature or licensing board. In most cases, the main decider will be a woman who is the daughter, wife or mother of the patient. They will want to know much more than that the doctor is licensed to treat their loved one’s problem. In addition, the caregiver will require malpractice insurance, privileges at one or more institutions if inpatient care or a surgical procedure is involved, and during the informed consent process evidence will need to be shared with the patient and family that the potential caregiver has performed this treatment or procedure frequently enough to be competent. Finally, it will be critically important that the doctor is a preferred provider for the patient’s health care insurer if the cost of treatment is a factor, and it usually is not just a factor, but the core factor for the patient, their family, the potential provider of the treatment and the facility where it will be performed.
This is to me where the rubber really meets the road. This is where the real barriers for any practitioner to provide care to an individual patient reside. Scope of practice privileges and who the patient and family would prefer to diagnose and treat their condition is important, but who the third-party payer will pay to treat them and at what location often trump any and all patient and family personal preferences (most patients will change providers for a $10 per visit savings). Scope of practice means nothing if an insurer will not approve reimbursement for a given eye care provider to treat a condition or individual and/or no facility will give them privileges to perform the treatment or procedure.
For me, access to patients is the biggest challenge facing all eye care providers in the future. In confronting the challenge of ensuring broad patient access and choice of eye care provider, I believe ophthalmology’s and optometry’s interests are aligned, and we would be wise to join forces and collaborate.
Disclosure: Lindstrom reports he practices ophthalmology at Minnesota Eye Consultants and is an equity owner and on the board of directors of Unifeye Vision Partners.