Experts forecast trends for the optometric practice of the future

Issue: September 1996

ByMeryl Mandle

More and more optometrists are finding themselves squeezed between fixed fee managed care plans and the competition offered by optical service mass marketers. To offer advice on how to weather these challenges, Primary Care Optometry News asked three experts what role some ongoing trends will play in the optometric practice of the future.

Here's what Richard Kattouf, OD, a practice management consultant and owner of two consulting firms in Warren, Ohio; Jerome Hayes, OD, a practice management consultant and owner of Hayes Marketing, Ponte Vedra Beach, Fla., and Vicksburg, Miss.; and Theodore Gillette, OD, CEO of Vision 21, a large optometric/ophthalmological network, had to say.

TREND # 1 - Comanagement

Kattouf: The future will be bright as long as optometrists realize they hold the upper hand in comanagement. Ophthalmologists need our referrals. By the year 2000, 20% of ophthalmologists will perform 80% of all surgeries at a few big surgical centers. So the patient we refer is our patient, and we must dictate postsurgical care.

The only way the optometrist will earn maximum comanagement income is to receive the patient on the day after surgery. Comanagement of the postsurgical patient has a very high net to gross, approaching 50%. Compare that to contact lens fittings or general examinations under a contracted vision plan, which may net only 20%.

Hayes: Traditional optometric training doesn't really teach us how to work closely with other disciplines. But we are learning, and comanagement can be a won derful situation for appropriate cases.

A few ODs have created successful comanagement relationships, but many tend to take a back seat to the ophthalmologist. A situation that is beneficial to optometrists will not occur unless they are progressive in creating and defining the comanagement boundaries.

Gillette: Over the next 5 years, co-management will become very important in areas where it can reduce cost or increase access.

This is due to the overall macroeconomic trends leading to the aggregation of optometrists and ophthalmologists to form totally integrated eye care delivery systems.

This evolving structure will result in "team care" that seamlessly moves the patient to the professional most appropriate to provide the care. Forced comanagement that doesn't reduce cost or increase access will be viewed as fee-splitting or a kickback.

TREND # 2 - Optometric assistants

Kattouf: By the year 2000, two-thirds of the American population will have some kind of vision care plan. In contracting with these plans, the OD will accept at least a 20% reduction in fees. To maintain profits we will have to increase volume and efficiency. That requires a high level of delegation to technicians. Many computerized instruments are available, such as Marco's TRS (Total Refractive System), to facilitate delegation.

Hayes: Optometrists have made strides during the last decade in higher utilization of assistants, especially in delegating patient care. But we still lag behind medicine and dentistry. Optometrists who resist delegation tell me it's because they want to provide personal care.

What will force the issue of greater delegation to technicians is declining fees. We will need to see more patients in less time to maintain our incomes.

Gillette: The role of optometric technicians will become very important and their skill sets will become enhanced. Right now, the technician's sophistication is below the level needed. Technicians should perform routine refraction while the optometrists make the final prescription judgment. It is the most time-consuming and frequently performed data-gathering measurement of all the aspects of primary eye care. If optometrists are to be primary eye care providers, they should concentrate on case management diagnosis and treatment.

TREND # 3 - Information technology

Kattouf: More and more optometric offices are approaching the paperless workplace. The government is forcing electronic claims with new Medicare billing regulations that, when in effect, will deduct $7 or $8 from each paper bill.

Use of new technology for optic nerve disorder diagnosis will increase in response to new diagnostic laws, and ODs will not be excluded from that kind of reimbursement. Electronic transfer of records for consultation with specialists and use of the Internet to send topography reports for refractive surgery comanagement will also be important.

Hayes: It is difficult to manage the numbers side of a large practice without some level of computerization. But many processes are still more difficult to perform by computer than manually. Patient record storage is less cumbersome on computer and printouts look nicer, but in a busy day is it practical to enter that data on a computer? As software becomes more sophisticated and computers are easier to use, we will see a natural evolution toward electronic storage and transfer of data.

Gillette: Technology will be a key area in the future optometric practice. With the integration of optometrists and ophthalmologists, information management will become crucial, and the only efficient way to handle it will be electronically. All practices will have to invest in computer systems that capture, manage and exchange data efficiently. Although electronic medical records are cumbersome, they will be increasingly important for the optometric office of the future.

TREND # 4 - Practice structure

Kattouf: I believe that within the next 10-15 years, the solo practice will be a thing of the past. Consolidating several doctors in one building will lower overhead, increase hours of operations and expand the ability to specialize.

We will see an increased trend for managed care companies, such as Nova Med and Oxford, to buy the assets of a practice. The arrangement is contracted typically for 3-5 years and the company pays the salary of the optometrist and all employees at an office. All receipts go to the organization but, on the up side, the organization manages the practice.

Hayes: Some doctors will form multidoctor groups. But I am confident many will remain in small, one- and two-clinician practices. The more entrepreneurial practitioners will find a way to make more money out on their own than in a group setting.

On the other hand, I feel at least 20% of independents would be happier and make more money in a setting where they do not have to manage staff, worry about running an office or attract patients. The competitive environment could force those marginal managers, who lack the aptitude or interest for running a business but who may be excellent clinicians, into group settings.

Gillette: As health care becomes increasingly bought and sold in aggregate, optometrists will have to come together in group delivery systems. The dynamics of managed care will also demand tighter integration. Loosely held networks are not competitive enough to maintain market share and control quality and costs. Optometrists will consolidate with other optometrists (horizontal integration) and ophthalmologists (vertical integration) within their respective markets.

But such consolidation will ultimately have to be an equity integration so that the result is truly a group practice under one corporate umbrella with practitioners financially aligned.

TREND # 5 - Practice focus: Vision correction dispenser vs. primary eye care provider

Kattouf: Eventually, optometrists won't dispense standard contact lenses. Mail-order houses have caused replacement fees to plummet and forced ODs to slash mark-up by at least two-thirds.

Instead, ODs will perform only the examination, fitting and care of contact lens patients. Patients will use some sort of credit card validated by the optometrist for a 6-month to 1-year supply to purchase their lenses from a vending machine or pharmacy-like dispenser.

Spectacles will stay within the optometric practice. But with the increasing prevalence of fixed-fee vision plans, many patients enter the optical department wanting to purchase only what is covered. Opticians will need to encourage the purchase of multiple pairs or an upgrade in frame choices.

Hayes: Although optometrists have the right to diagnose and treat, many have been slow to use this everyday.

Established practitioners must alter their mode of practice from vision care to primary eye health care provider, and change the way they have done things for years. With each new class out of optometry school, this trend is accelerating. Recent graduates are already in the primary eye health care provider mode.

Gillette: Practices will be either vision correction dispensers or primary eye care providers, but not both. Most growth will occur in primary eye care. Optical services are a retail process and the skill sets required for providing good clinical eye care differ from those of retail business. Optometric practices will not be precluded from providing optical services, but the greatest opportunities will be in primary eye care for those who develop the necessary clinical skills. Some optometrists will undoubtedly join together to consolidate the optical side, possibly as a separate business.