Providing value will ensure optometry’s continued role in comanagement

Issue: March 2001

ByJerome A. Legerton, OD, MS, MBA, FAAO

Thirty-five years of immersion in the ophthalmic industry as an OD with an MBA and a Masters in Counseling has equipped me with a few skills to analyze events as they occur. The following is, I hope, a fresh perspective regarding the past year’s volleys on the subject of comanagement.

For some time, I have enjoyed the study of semantics and ethics. I find that both are useful when discussing the interaction of optometry and ophthalmology in the field of treating eye and vision disorders within the scope of the respective licensure of each profession.

Semantic considerations

Most agree that the use of the term “fee-splitting” will result in the inference that some impropriety has taken place. The term contains no meaning regarding the work that was conducted by either party or the basis for the split. Fees could be split to compensate a “bird-dog” or someone providing a protection service.

Comanagement continues to carry the implication of “joint” involvement, as does “split,” and has the added value of defining an act, “management.” Semantically, the term is fair in describing an event where two or more individuals manage patient care.

I prefer the term “complementary care.” Complementary must be differentiated from complimentary. They are a vowel and a world apart in meaning. In the latter, we pay a compliment (flattery) to each other, while in the former, we complete each other. Complementary is the correct descriptor. Together, we deliver complete care to the patient.

Optometry is a primary eye and vision care profession. The mission of optometry to be the guardians of the visual welfare of the public is taken very seriously by nearly all doctors of optometry. Optometrists have historically demonstrated success in clinical refraction and prescription for refractive disorders.

Optometrists, on average, spend more time per patient in case history and consultation than their ophthalmology counterparts. Optometrists have more broad geographic access than their ophthalmology counterparts. Optometrists in every state are trained and licensed to manage pre- and postoperative care of cataract and refractive surgery patients.

Satisfied patients

At the end of the day, the valuable final product is an enthusiastic, satisfied patient with a good clinical outcome.

For the past 5 years, I have served as a consultant for the clinical regulatory, research and development activities of a major refractive surgery laser company. I have participated in the biostatistical analysis of clinical data and their presentation to the Food and Drug Administration Ophthalmic Devices Panel. I authored the psychometric questionnaire used during the clinical trials for the company and participated in the analysis and presentation of the visual performance and psychometric results.

In the course of that work, I found that patients with excellent clinical outcome could have lower satisfaction and patients with lower clinical outcome could be very satisfied. I have read numerous articles regarding “quality of life” assessment and postsurgical management. I actively practiced low vision care for 17 of my 26 years in practice. I am an inventor and researcher in the field of presbyopic contact lenses and surgical treatment. These experiences support my understanding of the value of expectation formation and satisfaction management.

Doctors of optometry have historically fit the majority of bifocal spectacle lenses and managed millions of patients to satisfaction. They made progressive lenses the widespread success they are today by managing patients to satisfaction. Optometrists are primarily responsible for the penetration of contact lenses in the United States from PMMA to disposable. All of these modalities had significant limitations that optometric care overcame to the ultimate benefit of patient satisfaction.

Cataract and refractive surgery care starts and ends outside of the surgical suite. It starts with case history and presurgical evaluation. It continues with consultation and expectation management. It continues with a surgical plan that is enriched by input from doctors of optometry.

I respect a desire on the part of the surgeon to conduct a second refraction, but I strongly disagree with those who hold that the refraction and analog refinement of the refraction by the attending optometrist has no value. Optometrists combine digital clinical measures with analog input to support millions of patient-centered clinical decisions every year that result in safety, efficacy and enthusiastic satisfaction.

Four ethical foundations of health care

Above all else, do no harm. With all the finger pointing and power play aside, there are very few blind eyes from the primary activities of the practice of optometry. Combining PMMA lenses, extended wear and optometry’s introduction to the use of diagnostic pharmaceutical agents and therapeutic pharmaceutical agents, blind eyes are as rare as hen’s teeth. It is highly likely that more eyes were blinded by radial keratotomy (RK) alone than all eyes blinded by all activities of optometry in its history. Loss of lines of best spectacle-corrected visual acuity by RK may far surpass that by all activities of optometry. Optometry as a whole was validated in its pessimism of RK. Optometry continues to be vigilant regarding surgical refractive procedures. Through networks with surgeons and surgical center systems, optometrists provide valuable input in outcome analysis systems to refine the procedures and provide information access to determine the appropriate nature of procedures for their patients. Optometry as a profession has performed in an admirable fashion to do no harm. If there is any question on this issue, check into comparative malpractice claims and rates. Optometry serves an excellent purpose in guarding the visual welfare of the public.
Prescribe in the best interest of the patient. Two of the most powerful tools of health care are case history and consultation. Doctors of optometry have historically gained rapport with their patients and thoroughly explored patients’ needs, wants and preferences. Optometrists are repeatedly trained to offer treatment plans that are patient centered along with the advantages and disadvantages. Optometrists offer equal fulfillment on the full continuum of treatment alternatives to provide the patient with freedom to access the patient’s best interest.
There is healing in knowing. A critical component of “satisfaction management” is imparting knowledge. I have been consistently impressed with the acceptance of the “doctor equals teacher” role by optometrists. To be forewarned is to be forearmed. Optometrists have executed an excellent job of engendering realistic expectations in their patients and in helping them — through knowledge — to accept surgically related complications. Simply, the optometrist has the time and takes the time to offer this component of complementary care.
There is healing in caring. Today, optometrists must attend to more patients in less time. They live out the notion: “Don’t tell me how much you know until I know how much you care.” Optometrists, for the most part, live with their patients. They live with them for a lifetime and often serve families for several generations. A practitioner who is present with his or her patient pre-treatment adds value by being present post-treatment. If the outcome is good, they rejoice with them. If it is complicated, they support them and help them to move on. Either way, value is added.

Ethical considerations

As I read the American Society of Cataract and Refractive Surgery and American Academy of Ophthalmology joint position statement, I had several concerns.

It was unilateral. I am concerned, in a pluralistic society, when one faction sits down to formulate a value statement and perpetuate the imposition of that value without having fair and equal representation of the other parties involved. Where at the table were the representatives of optometry and consumers?

The decree was clear in stating that the surgeon should inform patients of their right and freedom to choose if they want comanagement. No statement was made of the optometrist’s right to inform the patient of the right and freedom to choose if they want comanagement. It seems that both professionals are capable of informing a patient of the benefits of accessing or not accessing comanagement. All parties should be concerned about bias when informing patients of their rights.

Three choices

As the baby boomers turn gray, they will enjoy the fruits of their degenerative processes, and cataract surgery demand will grow. The era of anatomic alteration for the correction of ametropia is still in its early stages. With the growth of both modalities, the health practitioner resources will be stretched to provide patient-centered care. If the intention of some surgeons is to retain the fees that are garnered by the complementary care of optometry, they will have three choices: do the work (key word) themselves that optometry currently executes in complementary care; streamline and eliminate elements of care that optometry executes; or hire an army of para-professionals to do the work of optometry.

I am confident that an ophthalmologist can do the pre- and postsurgical care alone and that he or she can do an equivalent job in an equivalent time compared to an optometrist. Given increased demand and increased volume, the MBA side of my brain asks, “Why”? I see a strong potential for the “I’ll do it all myself” MD to drown in the pre- and postop evaluations and, in the end, lose efficiency and opportunity to do more of what he or she does best.

The second choice bothers me the most. With the advent of cost containment in health care, most of us only do things now that are instrumental. There’s not much to leave out. My concern is that streamlining may result in a loss in case history and consultation that is preventive and a loss in analog satisfaction management that has therapeutic potential in postsurgical care.

The third choice is the most probable outcome and brings the issue to a head. If the surgeon begins to drown in the pre- and postoperative visits and resists comanaging with optometry, he or she will simply hire technicians to do the work “in house.” The public then suffers a delivery system that has eliminated highly trained and licensed professionals with access, experience and fiduciary responsibility. Since optometrists care for 60% to 65% of the public needing refractive corrections, the “new system” under the supervision of the surgeon offers patients their habitual optometric care by a non-optometrist. Will this outcome be clearly detailed in the informed consent that is intended to limit comanagement?

The role of value

Over time, the distribution channel of nearly every product or service compresses to eliminate any component that has a cost or takes profit without adding value. This is an efficiency-seeking, natural law of business. It is market driven. The market ultimately defines the price; the provider can only control the cost. It was clear to most involved that laser vision correction was priced high initially and that it would reduce as demand increased. At the same time, high price could decrease demand as the elective procedure did demonstrate elasticity of demand.

The issue of the existence of comanagement 5 years from now will be much less a function of lofty biased decrees and pressured legal intervention as a function of economics and the contribution of “value” by each party.

I have made a number of theoretical and espoused value statements about the role and potential of optometry in complementary care. At the end of the day, the question to be answered is whether there is real or perceived value in the service component of optometry in the distribution channel. Both the surgeon and the patient must appreciate this value. If there is perceived value, then comanagement will potentially exist.

Price vs. value

The final issue will be the remuneration level for the service. If the price-to-value curve for laser vision correction is crushed by market forces (too much supply or too little demand at a given price), the portion of the fee available to optometry may be too small to interest providers. If the price-to-value curve holds and the volume grows, the ability of a total fee for the procedure to be great enough to compensate those that add value will be present.

The pivotal issue is value. If optometrists truly add value, they will be included in the distribution channel in spite of lofty decrees. If there is little or no perceived value added by optometrists, they will not be included. We come full circle to the differentiation from fee splitting. If all you have been is a bird-dog, a chicken farm doesn’t need a bird-dog. If you provide complementary care that has perceived value, you will ultimately be compensated for the perceived value of that care in proportion to the perceived value of the total care.

Given a complementary care delivery system or one without optometry, I’ll bet on the value of optometry in the valuable final product — an enthusiastic, satisfied patient.

For Your Information:

Jerome Legerton, OD, MS, MBA, FAAO, is president of the EPIC Group, specializing in product development consultation in the ophthalmic industry. He is also a member of the Editorial Board of Primary Care Optometry News. He can be reached at 874 Harbor View Place; San Diego, CA 92106; (619) 758-9140; fax: (619) 758-9141; e-mail: jlegerton@aol.com.