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Don't compromise your role in patient care when choosing a PRK delivery model
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The coming years will see not only an evolution of new technologies in refractive surgery care, but also entirely new methods and models through which to deliver patient care. The high costs of lasers, rapid obsolescence, mass media advertising and the likelihood of large numbers of optometrists and ophthalmologists participating in such care will require eye care professionals and business entities to create or select maximally efficient and effective modes of delivery.
It is essential that all eye care professionals examine certain critical elements when considering developing or selecting a delivery model. Of the four categories of elements—professional issues, business plans, investment opportunities and operational strategies and options—we'll review professional issues.
The long history of strained professional relations between optometry and ophthalmology has the potential of being either assuaged or aggravated by refractive laser care and its evolving delivery models. Models that suggest bias or domination of one profession over the other will obviously continue to inflame OD-MD relations, whereas balanced partnerships may create increased cooperation and harmony.
Optometry-oriented models
Some models claim to be optometry-controlled through ownership, executive, advisory and management dominance and resultant authority over ophthalmology. Such models play very well on the emotions of optometrists who have long been subjugated in the OD-MD professional relationships but now perceive an opportunity for control through their historical and apparently strong influence over the refractive patient market.
Some analysts believe optometry-oriented models could prove to be successful if properly managed and well funded during initial development. Indeed, optometry does care for 70%-80% of the ideal candidates for refractive laser care. Other analysts, however, contend that patients will be far more influenced by mass media advertising than by preexisting relationships with any given eye care practitioner.
In either case, the greatest weakness of an optometry-oriented model is the certainty that it will generate a strong competitive response from ophthalmological practitioners excluded from a specific system or forced to participate in an actual or perceived subjugated relationship with optometry. Such reality or perception could lead to competitive systems that would create expensive, aggressive marketing efforts on both sides and resultant dilution—not to mention pollution—of the potential vision care market.
Ophthalmology-oriented models
These models are usually developed by individual ophthalmologists, groups of ophthalmologists or hospital and university medical centers oriented towards servicing their attending ophthalmological staff. Often such models will invite optometric participation, but more as "feeders" for referrals to their dominant ophthalmological counterparts in such a system.
Fee structures in such models generally offer the participating ophthalmologists higher fees than optometrists for similar services (pre- and post-procedure care) and generally don't provide any equity investment opportunities for the optometrists. These perceived inequities to the optometrists jeopardize their potential referrals and are apt to force the optometric community to look for alternatives in the form of a national optometrically oriented system or a system offering a more equitable arrangement.
The ophthalmology-oriented model tends to support the concept that the refractive patient will primarily be generated from direct mass media advertising and word of mouth. Thus, referrals from optometrists would not be critical in that optometric patients would abandon relationships out of impulsive response to advertising, convenience and, eventually, perhaps pricing.
Corporate models
These models treat the delivery of refractive laser care strictly as a business that emphasizes generating a high volume of referrals through aggressive strategies aimed at the professional market (eye care professionals) and the consumer market (refractive care patients). Such systems are developed and run not by optometrists or ophthalmologists as much as by corporate entities that may be unrelated to the field of refractive surgery.
The market approach to eye care professionals (generally more MD- than OD-oriented) by involved corporate entities is primarily through highly competitive financial inducements (usually high professional fees) to join and refer to a corporately owned and operated laser center. Such a center may be freestanding or affiliated with a preexisting health care facility (e.g., clinic, ambulatory surgical center, hospital or hospital chain) to which the corporate entity has some ownership or financial relationship.
For the consumer market, the corporate model relies on referrals from participating doctors as well as strong mass media advertising to stimulate interest and drive patients directly into their center. Such non-referred patients would then be managed directly by center staff (usually employed or contracted ophthalmologists) or referred to a participating doctor.
Limitations to the corporate model include, but are not limited to, a general reduced interest in education and quality control in favor of patient volume; absence of or diminished opportunity for doctors to vest in a delivery system driven by their patient referrals or their patients going directly to a heavily advertised center; and lack of any professional control in the management of patient care. Such weaknesses could suggest questionable early and long-term professional support for corporate models and, certainly, the likelihood of strong competitive responses from community ophthalmologists and optometrists.
Combination partnership models
An obvious solution to the weaknesses of the OD-oriented, MD-oriented or corporate models would be a balanced model of OD, MD and corporate/business participation. Such an obvious solution sometimes is easier said than done given the long history of interprofessional rivalries; political, economic and turf battles between optometry and ophthalmology; and the inherent distrust by both professions toward corporate entities.
Nonetheless, a true partnership of optometry, ophthalmology and business could prove to be the most effective professional delivery model and the most successful business model, if attainable.
Hope for such a model requires the participating ODs and MDs to accept actual and perceived concessions in the form of professional and economic sharing and some corporate control. This level of sharing and control requires candid understanding and acceptance by the ODs and MDs and a corporate entity with recognized fairness, integrity and objectivity toward both the OD and the MD community.
The best way to achieve a partnership of ODs, MDs and business will be with an open-access, equitable and balanced system for every qualified community OD and MD interested in participating.
Such a system could best be implemented among ODs and MDs who already work together (to some degree) in a local community relationship. This professional relationship would provide the essential high quality clinical, educational and quality assurance/outcome assessment programs for the delivery system.
Parity in reimbursement and an equal and equitable investment opportunity (as permissible under prevailing laws), all managed by a trustworthy business partner, might be just what the doctor ordered for the delivery of refractive laser care.
Don't compromise patient care
The coming months and years will require new and challenging professional and business decisions regarding the delivery of refractive laser care. One of the most difficult of these decisions will be selecting the most appropriate and effective delivery model for your needs as well as your patients' and practice's needs.
When deciding on a delivery model, you must assess the immediate and long-term effects of the professional and business position with which it will provide. An appropriate professional model that recognizes your role in your patient's care and interest should not be negotiated.
Beyond that, however, accessibility, community, interprofessional relations, professional fees, vesting opportunities, corporate/business entities, controls and concessions all become variables that every eye care professional will wrestle with as individuals and, perhaps, as partners.