ODs must provide services to cover technology costs

Issue: August 1996

--- Richard Clompus, OD

Richard Clompus, OD, completed his Family Practice Residency at the Medical Center/University of Alabama at Birmingham before establishing a new group practice specializing in primary care and contact lenses in West Chester, Pa. An adjunct faculty member at the Pennsylvania College of Optometry, Clompus lectures nationally and internationally and has published numerous optometric articles. Recognized as an innovator of new procedures for optometry, Clompus discusses with Primary Care Optometry News how optometrists can successfully incorporate today's new technologies into their practices.

Primary Care Optometry News: In this age of cost containment and managed care, how do you justify bringing new technology into your practice?

Richard Clompus, OD: There are two categories to consider. One category is technology used to increase efficiency, but not charged to the patient. Under that category I put the autorefractor/autolensometer and the office computer. These permit us to increase our efficiency and see more patients per day while still providing a high level of care.

--- Clompus feels auto-lensometers increase efficiency while helping ODs maintain high quality care.

The second category of equipment is diagnostic, such as visual field instruments, retinal camera, ultrasound and, most importantly, corneal topography. These instruments help diagnose and manage patients, but you charge the patient each time you use them.

Each piece of equipment prompts different decisions. If you only have three patients a day, then maybe you don't need an autorefractor. However, as time goes on, you'll see that you need to increase efficiency; therefore, you need to gather a number of automated instruments to increase efficiency, and then others to help you diagnose and manage your patients. Otherwise, when those services are needed, you have to refer the patients elsewhere and you won't have the opportunity of charging for the service.

PCON: Can you give a quick rundown of the equipment in your office?

Clompus: In pretest, we have the Humphrey autorefractor/autokeratometer as a combination unit and the Humphrey autolensometer. In each of our four exam rooms we have a Zeiss slit lamp and binocular indirects. In one room we have a video digital capture system, which captures a video image of the patient's anterior segment through the microscope.

We have a Humphrey visual field instrument and the Atlas corneal topography instrument. We have a computer system in each exam room and we now have 10 terminals throughout the office.

We have the Nidek 3DX retinal camera. We also have an A-scan ultrasound instrument that we use to comanage cataract patients.

We also use a laser disc of optometric and medical programs to update and educate patients. For patients who develop a condition such as glaucoma or cataract, we have a laser disc we play for them to bring them up to date on treatment. We have a patient education room, and that's where we put all the pretest equipment.

At our practice we have about 10,000 patients. We have four optometrists and three consulting ophthalmologists.

PCON: In a busy practice, how do you incorporate these technologies and tests: on the first visit or on re-appointment?

Clompus: Again, you have to look at the type of instrument. When patients come in for a comprehensive exam they are tested with the autorefractor and the autolensometer, and then they proceed to the exam room where a technician will work up their history and perform the external exam, the refraction and applanating tonometry, and then dilate the patient. The patient then goes to optical to look at glasses while they're dilating, if they need glasses, or they can be fit with contact lenses.

When patients come back from being dilated, I see them. I review their history and sometimes recheck the refraction, if necessary, and fine-tune it further or evaluate contact lenses again. Then I do a biomicroscopic or slit lamp exam and then a binocular indirect ophthalmoscopic exam of the fundus.

PCON: Can an optometrist exist today without these technologies? And is technology setting standards of care?

Clompus: No, it's not that. It really comes down to what managed care is directing us to do. Managed care wants high-quality care at low cost. As an optometrist I can provide high-quality care; the twist comes in at what cost. Right now, with the managed care plans that we have, my office is only about 40% managed care, third party.

--- Managed care plans today expect, if not require, ODs to have basic equipment, such as this slit lamp.

At the prices we've contracted to accept, the majority of managed care programs do not cover our overhead to provide the necessary tests and the comprehensive exam. That's an important statement. The more automated we get and the more efficient we become, the closer we get to breaking even.

The only way you can make a profit in managed care is to provide a product along with the service, such as prescribing and fitting contact lenses or selling a pair of glasses. If optometric practices did not have glasses or contact lenses to provide and collect fees for, we'd all go bankrupt; no question about it. Most ODs haven't realized this yet.

PCON: Do optometrists need these instruments to be on a managed care panel?

Clompus: No, you don't need them yet; that will be the next step. Currently, you need basic examination equipment, such as a biomicroscope and a binocular indirect ophthalmoscope, and standard equipment such as a hand-held ophthalmoscope and applanating tonometer. The difficulty is that without the automation your efficiency is so low you can lose even more money.

When you sign a managed care contract, you're agreeing to provide a certain number of minimal services. Some panels will require that you have an automated visual field instrument, although many do not. However, if you have a patient who needs a visual field to diagnose a disease, and you don't have the instrument, then you have to refer that patient somewhere else and another doctor or office will collect the fees for it.

My philosophy for the last few years has been that the best referral is no referral. When you have a patient who requires surgical care, why don't you arrange to have the ophthalmologist come to your office and examine your patient?

Three ophthalmologists come to our office. They perform fluorescein angiograms and they bring a portable laser with them and do laser surgery in our office. Those services you can provide in the office keep patients coming back, whether it be for routine eye care, specialty ophthalmological services or surgical care.

It's a given that I participate with the follow-up care. If, for some reason, we can't provide the care, we'll refer them elsewhere. But, if we can provide care in our office, why send them anywhere else?

PCON: So you're saying that a clinician can exist without some of these technologies, but not for long?

Clompus: Right, not for long. The reason is that single-office practices with very little technology will eventually realize—and this is unfortunate—that the fees for services will be so low that it may not be worth it to practice optometry. Right now, it's almost as if by accepting managed care you accept a loss with the hope that you can make it up by prescribing contact lenses or by dispensing and selling glasses.

Without these additional services, you can't make a profit, because the third-party plans are not covering your overhead. This is one of the difficult choices for optometrists: do you sign up with the third-party service or do you say, "No, I won't do it?" The difficulty is that your practice in your area could be dominated by a certain third-party plan; therefore, if you want to remain in practice you don't have a choice.

Some might think their office is protected from all this, that it will never happen to them. Then, a year later, they realize that 80% of their patients are on a specific plan. If they're not on the plan's list, their patients may not come back, no matter how good they are. The whole concept of patient loyalty is changing dramatically, because when patients get an eye care plan, they often feel compelled to use it.

It leads me to believe that the future of eye care will be more consolidation. Smaller offices may join to become a larger office. The individual office out there with one doctor, one employee and one optician will have a tough time generating income with third-party plans.

I don't think I'm the only one out there noticing this, but my conclusion has been that if you lose money on each eye exam because a third party doesn't cover your overhead, you can't make up for it by doing more exams. The only way you make up for it is to prescribe contact lenses or sell a high-quality pair of glasses.

PCON: Are managed care and technology working hand-in-hand now? One isn't necessarily driving the other, but it's getting close?

Clompus: Right. We have never been turned down by a panel that said if we didn't have this instrument we're out, but I can see it may get to that.

They will require that you have certain minimum instrumentation so you don't have to refer patients.

They want you to do the service and they want to pay you to do it.

The easiest instrument to cost-justify is a visual field instrument, because you have to have it. If you do one or two fields a week, then you can cost-justify having it.

The newest instrument we are enjoying is the corneal topographer. We separate topography into screening maps and threshold maps. Screening maps are quick power maps of each eye. It takes only a few minutes to get both images and print out one sheet of paper with both of them on it. We do this once a year for our contact lens patients and we charge a minimal fee.

In a threshold map, we do more analysis and multiple printouts. That's reserved for patients with keratoconus and corneal dystrophies or patients having photorefractive keratectomy or other refractive surgery.

However, what makes the instrument cost-justifiable is the fact that we do lots of screening maps on all our contact lens patients once a year to verify that the corneas are healthy and the contact lens is not inducing a change. We do this for a minimal fee. It's not covered by insurance, but most patients are happy to pay for it.

The fact that we can now put a corneal topographer in pretest next to the autorefractor makes it that much easier to use. Corneal topography really belongs in pretest. It should not be considered to be like a retinal camera or a visual field instrument that's put in a separate room as a special kind of high-tech diagnostic test. Although it's high tech, it should be part of the pretest sequence.

PCON: Cost-justification, then, is key when considering one of the new technologies for your practice?

Clompus: Yes. The hard part with any instrumentation you're going to purchase is how you can cost-justify it. You can cost-justify visual fields and retinal cameras pretty well just by the nature of your reimbursement for doing it.

The same thing occurs for corneal topography when you think about the fact that we like to screen contact lens patients once a year.

If you're looking at Medicare reimbursement for corneal dystrophies or keratoconus, that's probably not sufficient to justify it on a monthly basis. But you can easily justify it if you use it as a screening instrument for the majority of your contact lens patients.

In fact, as time goes on, it makes even more sense that it will become as common as the autorefractor and autolensometer in a pretest area.