Patients, hospitals, ODs can benefit from hospital staff privileges

Serving on the staff of a hospital affords several benefits to optometrists, including the ability to order laboratory and imaging tests, the opportunity for networking and referrals, and the chance to play a more complete and integrated role in a patient’s ocular and systemic care.

In addition, according to the American Optometric Association Hospital Privileges Manual, optometrists have the potential to become increasingly valuable to hospital systems. As third-party payers continue to emphasize outpatient services and primary care, optometrists are poised to play a greater role in generating hospital income.

But, ultimately, patients may reap the greatest benefit from optometrists on hospital staff. The use of ODs in emergency situations may allow patients to receive care in a faster and more efficient manner.

Source: American Optometric Association Scope of Practice Surveys

“I certainly think every optometrist should make an attempt to get hospital privileges,” John A. McCall Jr., OD, a practitioner in Crockett, Texas, a Primary Care Optometry News Editorial Board member and a former AOA president, said in an interview. “It allows you to practice at a higher level. It’s good for patients and it’s good for the profession.”

Types of privileges

Most hospitals have four levels of staff privileges, Dr. McCall said. They include active staff, which entails full voting privileges and the ability to admit patients and hold office; consulting, which includes co-admitting privileges and the ability to attend medical staff meetings as a nonvoting member; courtesy, which is a temporary designation based on need; and allied health, which is the most limited level. Some hospitals may have additional or interchangeable titles, such as affiliate, associate or honorary staff, he said. All levels permit optometrists to order lab or imaging tests.

Dr. McCall, who serves as active staff at his local hospital, said his privileges require him to attend at least 51% of medical staff meetings per year. According to his hospital’s bylaws, he is also required to live within 30 miles of the hospital.

“If you’re active staff, you have to pull your load; if they need you at the hospital or the ER, they need to be able to call you,” said Dr. McCall, who currently serves as secretary-treasurer on his hospital’s medical staff. “If you live further than 30 miles, you can be on consulting staff, but that’s the highest level you can achieve.”

Dr. McCall said he considers allied health privileges – which are generally conferred upon nurse practitioners, physicians’ assistants and similar staff – to be an inadequate category for optometrists.

“I believe allied health is an inappropriate place for optometry on a medical staff,” he said. “Optometrists are independent practitioners and should be on a level with other independent practitioners.”

Exceptions and opportunities

Despite what might seem to be limited hospital privileges, some optometrists manage to harness interesting opportunities as a result of their hospital affiliations.

Andrew J. Sacco, OD, a practitioner from Vestal, N.Y., has allied health privileges at his hospital. He also serves as a clinical instructor for a residency program where he teaches family physicians about eye health.

“I’m in a unique situation, because I’m a clinical instructor and, according to the bylaws of my hospital, I can’t do that without hospital privileges,” he told PCON. “This teaching appointment came about, in part, due to the hospital privileges, and I enjoy it quite a bit.”

Kerry Beebe, OD, a practitioner located in Brainerd, Minn., is a member of the affiliate staff at his local hospital. At a second hospital, Dr. Beebe runs a full-scope primary care optometry practice – including cataract surgery comanagement – within the hospital system.

“We do eye exams, we arrange for surgeons to do cataract surgery in the hospital and then we do the 1-day postop,” he said in an interview. “It’s pretty much the full gamut.”

Legislative limitations

The level of hospital privileges an optometrist can attain is, in some cases, determined by location. According to Dr. Sacco, his state’s laws and his hospital’s bylaws limit his level of privileges.

“According to my hospital’s bylaws, the only way I could be full medical staff is if I were able to admit patients,” he said. “And when you look under ‘admitting,’ it says you must be able to administer oral or injectable medications. In New York, we don’t have that legislation.”

Ami C. Ranani, OD, of Somers, N.Y., currently does not have hospital privileges. “New York State is one of the only states that doesn’t have oral legislation,” he said. “It’s such a big battle for us; it’s so important for us to achieve that.”

Dr. Ranani said he hopes that, in general, hospital affiliation will become more attainable for optometrists.

“I think that both on a national level and state level, our organizations need to help us make the process of getting on staff easier for ODs,” he said. “It took such a long time for podiatry to achieve this, and now it’s common for podiatrists to be on staff.”

Dr. Ranani added that he also thinks it’s important for the AOA to work on uniformity across state lines. “Optometric students are trained the same coming out of school,” he said. “Why should they practice differently?”

Rural vs. urban

Even in areas that are not constrained by state laws or hospital bylaws, optometrists may face obstacles in gaining privileges simply due to competition. Dr. McCall, who practices in a rural area, acknowledged that in urban environments, competition from ophthalmologists can make the attainment of hospital privileges more challenging.

“For example, Houston has one of the largest medical centers in the world; whatever hospital you go to, there will be two or three ophthalmologists on staff,” he said. “So if an optometrist were to apply for staff privileges there, with three ophthalmologists already on staff, they would most likely nix it. There has to be a need.”

He said such needs-based decisions, made at the hospital’s discretion, would not be considered discriminatory.

“You can have anti-discrimination laws, but it still comes down to a vote by the hospital staff,” he said. “And, usually, that’s based on need.”

Dr. Beebe said according to a study he authored in 2001, there is still plenty of hope for optometrists to gain privileges in urban areas. His study, titled “Optometric, podiatric and chiropractic services in Minnesota hospitals,” had surprising findings regarding the distribution of optometrists in Minnesota.

“Our study found that there were as many optometrists with hospital privileges in metropolitan areas as in rural ones,” he said.

Thirty-three percent of all Minnesota hospitals had optometrists on staff, he said. Eighty-four percent had optometry or ophthalmology and, of these, 90% had both.

Emergency services

Another potential opportunity for optometrists within the hospital systems is that of urgent care. According to Dr. Ranani, optometrists could easily provide on-call services to patients who would otherwise be waiting in the hospital’s emergency room.

“It is such a waste of manpower that ODs aren’t used for on-call by hospitals; we should look at the number of people who come to the ER for emergencies that could have been taken care of by ODs.”

Dr. Ranani said he has experienced weekends in which he has seen three or four eye emergencies in his office, treating cases of conjunctival hemorrhage, abrasions, eye pain due to iritis, high IOP, herpetic infections and trauma as a result of patients calling his emergency number.

He said that optometrists could help bear the burden of on-call.

“Many ophthalmologists hate the on-call schedule,” he said. “It makes so much sense for optometrists to share it. Think of the number of people who present to the ER. It’s more efficient and, in these days of cost control, it’s needed.”

Dr. Ranani added that the use of electronic medical records connects optometrists more firmly to the medical community.

“With meaningful use, we take height and weight and ask many of the same history questions of patients that other health care providers ask,” he said. “When I e-prescribe I see what medications the patient is on. This ties us more than ever to all physicians and makes ODs part of the health care team at their local hospitals.”

Lab testing

The ability to order important lab work for patients is another key motivator for seeking hospital privileges, according to Dr. Beebe.

“I just ordered a sed rate and a C-reactive protein test for a patient I saw in the office yesterday, to rule out temporal arteritis,” he said. “Because I have hospital privileges, I was able to order the test and have the results back ASAP.”

Dr. McCall said he regularly orders numerous lab tests and cultures, including carotid Dopplers, sed rates, inflammatory blood profile tests, MRIs, cultures and even occasional echocardiograms.

“I can’t even imagine practicing the way I do if I weren’t able to order lab tests,” he said.

Dr. McCall emphasized that optometrists should not be afraid to order tests for their patients.

“They may think, ‘I’m not an MD, I don’t know how to read a carotid Doppler or an echocardiogram,” he said. “But that’s why we have radiologists. At a rural hospital like mine, radiologists read all diagnostic tests and interpret the results for me.”

Seeking privileges

Dr. McCall said when seeking hospital privileges, an optometrist should research the members of the hospital medical staff and prepare to approach each of them individually. He suggested first talking with any ophthalmologists on staff, then the hospital administrator and, finally, the hospital chief of staff.

“Find out who might be most likely to vote against you, and explain your value to them,” he said. “I would first go to the ophthalmologist. I would say, ‘The more tests I order, the more referrals I can accurately make to you.’”

Dr. McCall next advised explaining your skills and services to the hospital administrator, and finally, to the chief of staff.

“I would say, ‘We see a lot of conditions that need further testing, and for me to even make the proper referral to an MD, I have to run some tests,’” he said. “Explain how this is going to be revenue-generating for the hospital.”

Know your objectives

Dr. Beebe said an optometrist should also carefully study the hospital’s bylaws, to understand the parameters of privileges available to them.

“You need to find out how the bylaws are currently written, making sure they will actually allow an optometrist on staff,” he said. “Then you need to determine what appointment you’re going to request.”

Dr. Sacco added that it is important to be able to communicate what you hope to achieve by gaining privileges.

“You have to know what you want and how you’ll use the privileges,” he said. “There has to be a clear benefit to the hospital, because it’s going to cost them time and money to credential you and reappoint you every year.”

Dr. Sacco said while he doesn’t consider it imperative for optometrists to serve on a hospital staff, he believes it is beneficial.

“I don’t subscribe to the ‘sky is falling’ theory that if you don’t get on a hospital staff, you’re going to be shut out,” he said. “But I do think that in light of health care reform, it’s valuable to be plugged into the medical system and be aware of what’s going on.”

• Kerry L. Beebe, OD, FAAO, is a member of the American Optometric Association’s Clinical Care Group and a private practitioner. He can be reached at Brainerd Eyecare Center, 506 Laurel, Box 803, Brainerd, MN 56401; (218) 829-0946; fax: (218) 829-1279; klbeebe@charter.net.
• John A. McCall Jr., OD, is a Primary Care Optometry News Editorial Board member, a private practitioner and senior vice president of vendor relations for Vision Source. He can be reached at 711 East Goliad Ave., Crockett, TX 75835; (936) 544-3763; fax: (936) 544-7894; jmccall@visionsource.com.
• Ami C. Ranani, OD, is a practitioner at Somers Eye Center in Somers, N.Y. He can be reached at 380 Route 202, Somers, NY 10589; (914) 277-5550; fax: (914) 277-5735; ACRSEC@aol.com.
• Andrew J. Sacco, OD, practices at Sacco Eye Group in Vestal, N.Y. He can be reached at 400 Plaza Drive, Suite B, Vestal, NY 13850; (607) 798-1987; asacco@stny.rr.com.