ODs will need to conduct business differently in the near future, experts say

Primary Care Optometry News Editor Michael D. DePaolis, OD, FAAO, moderated a discussion among members of the PCON Industry Council during the American Academy of Optometry meeting on issues facing optometrists today.

Our January 2014 issue featured part one of the proceedings, where the participants discussed the Affordable Care Act, technology, performing refractions, prescribing to and advising patients, and the future practice of optometry.

In this second part, our experts in the areas of contact lenses, therapeutics, technology and spectacle lenses tackle the topics of dry eye, staff delegation and training, private label and generics, and recommending and prescribing.

Dry eye

Michael D. DePaolis, OD, FAAO: What conversation should practitioners be having with their patients, especially contact lens wearers, regarding dry eye? Is it a message of hope?

Cristina M. Schnider, OD: I like the bank account conversation. You put money in and you take money out – at some point you have to look at the investment. If you are putting contact lenses on, wearing them forever and sleeping in them, maybe you are using up more of your account. At some point you need to include a better look at what else is going on in the system. It may be part-time wear and wearing your glasses more. It may be supplementing with some ocular surface drop. It could be a systemic medication. But it’s probably really bits of all of the above.

Sean Clark: To have a successful wearing experience in contact lenses you might need to go beyond just the lens. What solution are you using? Are you using a drop with it if you need to? That’s the conversation that needs to evolve. It’s not a single variable conversation but a multivariable conversation.

DePaolis: So, the take-home here is we keep coming back to embracing technology and delegating. As a patient gets older, the conversations in the exam room are tremendously diverse. They evolve from discussions about contact lenses and solutions to discussions including diabetes, dry eye and cataract, among others. You want to give them advice on nutritional supplementation and on diet and lifestyle and you also want to address their contact lens needs. But a lot of clinicians just run out of time. That’s where the delegation comes in.

Schnider: I like the transfer of trust. I remember going to a physician some years ago, and the way he did that was magical. He said, “Cristina, I’m going to have you see Beth, who is my expert in women’s health.” I don’t know what she was. She could have been a nurse. She could have been a physician’s assistant. But he told me that I could trust her to deal with the rest of my exam. So I had his full attention for those moments of the intake, and then I was gracefully handed off to this woman. I thought it was a fantastic experience. It can be done.

Rod Tahran, OD: Dave’s 90/10 rule applies to that. The 10 are those who are magical with that transfer of trust.

Carey Reynolds: There’s also a lot of trepidation on the reimbursement side of the equation when you get to that point in the exam and figure out it’s not just a contact lens issue. We’re in an increasingly complex managed medical environment, so we have a lot of work ahead of us to instill confidence in optometrists to medically manage patients and be reimbursed for the services they perform.

DePaolis: Part of the message we want to give them is that information, technology and products continue improving to help meet those needs.

Steve Jeffords: But to that point, more than one-third of the contact lens care market now is technology developed over 20 years ago.

DePaolis: Private label.

Jeffords: Mostly private label.

Private label, generics

DePaolis: Let’s talk a bit about that, because patients have come to accept private label solutions and generic pharmaceuticals and believe they’re interchangeable. How do we address that?

Michael Pier, OD: I don’t think you can magically produce the same experience in a branded product vs. a nonbranded product and expect people to believe the branded product is better. I think you can make a noticeable difference through technology that allows the contact lens wearer to have a better experience than there’s justification for. We can help that along by recommending what that might be, and for that patient to look for that. We don’t do a good enough job of that. You need to make a noticeable difference for the patient, whether that be vision, comfort, wearability, usability, however you want to couch it. But there has to be a difference, whether that be in contact lenses or generic pharmaceuticals, for the patient to really understand it’s worthwhile, because otherwise they won’t.

DePaolis: There are tremendous pressures in the marketplace, from insurers, for example, to transfer costs over to patients through high-deductible plans. As a result, patients are becoming more frugal consumers of health care. You’ve got to make the difference and make it more compelling for them to do what you ask.

Schnider: That’s the accountable part.

Pier: I also believe that it has to do with what we were talking about before, that the technology will continue to progress and give us the opportunity to make new options available for those patients who are having trouble with what they currently have. As a practitioner, we have to introduce them to those, advise on those and give them that opportunity. It’s not just about making do with what you have, but perhaps taking it up to the next level. It’s sad that one-third of contact lens technology is 20 years old.

DePaolis: Cristina, you made a comment about accountability. That’s a message that we should be very clear about when we’re talking about the power of the pen. That’s how you differentiate yourself and that’s how you’ll thrive in an otherwise challenging marketplace. We shouldn’t make our decision to prescribe based on whether it is or is not covered by insurance, but because it’s the prudent thing to do. And patients need to know that.

Schnider: That was Mike’s point about being the doctor. You still have to be the doctor.

Tahran: It helps raise the level of the image of the entire profession. I am around a lot of elderly people who are frustrated with trying to find an over-the-counter eye drop. They want the doctor to tell them which one to buy.

It’s the same thing with spectacles. If the doctor prescribes it, the patient travels a whole different route, and it’s generally much better for both the patient and the practice. There are fewer problems, fewer follow-ups. It raises the bar for everybody in the profession.

Schnider: It’s just not in optometry. There was a Consumers’ Reports article recently that said that the number-one gripe of patients generally is that their doctors don’t tell them enough. Being accountable involves manufacturers, insurers and payors, and doctors or prescribers to their patients. You have to tell them why, and your power is still enormous as the physician.

DePaolis: Tell me something good about dry eye.

Tahran: We have the ultimate solution.

Dave Hansen, OD: I believe the industry, including clinicians, is focused with the wrong data involving “signs and symptoms.” New technology is available that assists with diagnosis and management of the ocular surface for optimizing clinical success.

Reynolds: We would argue that the therapeutic technologies are here today. But, yet, an awful lot of patients are walking into practices clearly demonstrating signs or symptoms of chronic dry eye and walking out with only a bottle of artificial tears.

The doctor’s recommendation

DePaolis: We talk about the power of prescribing, but you truly need to give the patient good, sound, clinical rationale for your recommendation, so they just don’t default to the lowest common denominator.

I read in a Gallup survey about a year ago that the average patient with dry eyes tried at least three drops before they saw their eye doctor. My guess is that most of those eye doctors don’t know what those drops are. And maybe you’re just repeating what has already failed.

Jeffords: We surveyed doctors and patients about lens care recommendations, and the ODs said they recommended lens care approximately 70% of the time. Patients said they received a recommendation 30% of the time.

DePaolis: Do you think it really is that only 30% are recommending it? Or, do you think 70% are recommending it and patients are leaving the office having forgotten the conversation?

Clark: It goes back to what we were just saying. What is perceived to be a recommendation at times by the doctor isn’t necessarily what the patient would say is a recommendation, because it’s not accompanied with that “why.” So I may throw a sample in a bag and consider that a recommendation vs. saying, “Based on your condition, the contact lens you’re wearing or whatever your situation is, this is the right product for you. And here’s why.” That’s the recommendation. That’s the magic.

DePaolis: We have a one-page sheet in our office that explains the nature of the dry eye, whether it’s evaporative or otherwise. It explains proper eyelid hygiene, the level of omega-3s we recommend, including how much EPA and DHA. We specify the drop and circle the dosing.

Hansen: Practitioners need to have formal tools to educate their staff, and especially their patients, to enhance comanagement.

Schnider: Compliance is the worst word in the world for what we’re talking about. It starts with concordance. Do we speak the same language? We almost never do. Consider contact lenses; patients think things that sting are unhealthy or unsafe, and we know it’s just a pH problem. We don’t start at the same level of understanding, and even with your nice forms, they probably don’t know or care what those letters mean.

Then you go to the next state, compliance, where your form really will help. Are they instructed to do what you want them to do? And then adherence – do they keep doing it?

It starts with concordance. We don’t often speak the same language. And we often don’t have time to figure out that same language. Compliance is probably the easy part. Show one, do one, tell one. But then adherence is horrendous, and it is because we’re humans. I don’t know how we fix all of those things, but I think the concordance part is something we need to pay a little bit more attention to, because we think we told them, and we probably did, but they hear, “Blah, blah, blah.”

John Hawley: If you’ve got a patient with glaucoma, a sight-threatening disease, and they won’t take their drops, how are you going to help someone with dry eye? They just don’t listen unless you educate them and really hit home with the long-term effects of dry eye.

Schnider: With diseases that can kill them, they don’t take their meds.

DePaolis: I think the take-home here is that our message must be understandable and ongoing.

Staff training, delegation

Clark: It’s interesting. Other industries have done a better job training the culture around wellness and preventive activity, right? Everybody brushes their teeth twice a day. People exercise more than they used to because they know it’s good for their heart as they get older. Dermatologists recommend skin care regimens, and there seems to be better adherence with some of those. I’m not sure what they’re doing differently, but there are models out there to follow.

Hawley: Do they get different training?

DePaolis: I don’t think so. If anything, they are most likely lower touch than optometry in terms of spending time with the patient.

Schnider: Who helps them?

DePaolis: It has to start with the doctor and it has to start with the chair, and, again, that would be a strong message to come out of this. But it also has to involve the staff, because you just physically don’t have the time.

Hawley: If 100% of your patients see your staff, what kind of training do they get? There’s no organized training, so is it serendipitous that you happen to get a good staff member? And how many doctors will let a good one go because she might want $1 raise? There’s a certain rationale to having good, confident staff and training them.

DePaolis: Staff will be more important going forward.

Hawley: Absolutely, because you have to delegate these things. You buy a $50,000 piece of equipment, and the person that’s using it has never seen the back of an eye before. They couldn’t spell glaucoma or retina. And, yet, you’re leaving important aspects of this patient’s diagnosis in their hands. If doctors are going to move in this direction, they have to make a full commitment to the practice and to the staff. The staff members do all the ancillary testing, as you know. And patients are used to it. That’s the only way you’re going to see all those patients that you’re going to need to be successful.

Pier: This is just one more reason why the existence of the solo practitioner as an individual is in jeopardy. Having a well-trained staff to help with the influx of more patients is a high burden for a small business. But will you be able to compete if you don’t have that?

Hawley: Not effectively. Unless you are happy bridging for another 5 to 10 years maximum as a retail person because you’re going to retire. Then, will your practice be worth anything because it doesn’t have what these younger doctors need to get involved?

Steve Reiman: We see a real disconnect between OD and staff in many cases. OD recommends one thing and staff says, “Patient, do you really know how much that’s going to cost you?” I think it’s a problem in a lot of offices. There’s no concordance.

The other thing about the office, in general – would we say the office is any more efficient today than it was 20 years ago? You walk into many private practitioners’ offices and fit sets are stacked all over the place and it’s a retail establishment not making the best use of every square foot of space.

DePaolis: That’s a great point because, going forward, you have to be so much more efficient in everything that you do, from every aspect of the patient encounter to the office’s space allocations. That’s true not just of optometry, but also ophthalmology. In most medical practices, historically there’s been enough leeway in the system so you didn’t have to run a lean, mean ship. Now you really have to.

Comanaging ocular disease

Let’s talk a little bit about IOLs and how the optometrist should participate in that decision making. Do we simply refer the patient for surgery? Or do we make a recommendation regarding the type of IOL?

Hawley: I’m probably over the top; 78.2% of all primary care comes through optometry now. They should be the leaders in knowing types of phacoemulsification, types of procedures, types of diagnostic and therapeutic instruments. They need to know that technology to choose the surgeon who will give them the best outcomes. I believe the Affordable Care Act will be outcomes-based over a period of time, and those surgeons will be in that 10% who do 30 of them a day and do them well. We’ve done a poor job in the optometry schools in that area. Some of us companies have tried to educate, yet there doesn’t seem to be an interest. Doing it as continuing education seems inadequate. I think it’s our purview and responsibility to do that.

If you own that patient, then you care about their future and their happiness from a vision standpoint, and you’re their primary care physician from a vision standpoint. You have to be cognizant of all that’s going on and what is right for that patient. Consider what will make them happy with their future. If you don’t manage the dream, you live the nightmare.

Pier: A referral without an integrated following is going to lose you a patient. There are two ways to approach it. One of them is the appropriate way if you really care about that patient and you want to follow through. With the other way, send the patient out, and he or she will not come back.

Schnider: It’s comanagement, not referral.

Pier: Exactly.

Schnider: And to Dave’s point, you need to comanage. You need to know the surgeon’s ability, you need to know the state-of-the-art procedures and you need to know that patient’s lifestyle.

DePaolis: In surgical comanagement, you really do it because it’s the right thing to do for the patient.

Let’s shift gears a bit. What about age-related macular degeneration?

Schnider: The statistics show that it’s growing faster than diabetic retinopathy and glaucoma together, which is a scary thought. We have to do everything we can early. UV is a huge risk factor early in life that I think most of us have not paid enough attention to. UV protection early, supplements early … we can’t wait until it’s a crisis, because we may not be able to fix it.

Tahran: Also, we’ve been working with an institute in Paris where they’re just starting to see the effects of small bands of blue light. This is just the tip of it. In fact, they’ve released their first product for it, which may be part of the treatment as well.

DePaolis: Again, prevention and early diagnosis is very diverse. Good cardiovascular care, the right supplements, the right eye wear and careful monitoring including OCTs are all critical.

Hawley: It’s a lifestyle issue. And if these patients are coming to see you for that type of care, when they need glasses, do you think they’re going to run down to the corner shop? They are coming for you. Again, it’s building the practice. And you have to do that as a partnership with the patient.

Schnider: And they have families as well. So you are building your practice in more ways than one.

Hawley: Absolutely.

Tahran: Do you think it makes an impact when patients with AMD come in with their son or daughter? Do they listen to the message of preventive care?

Schnider: It makes it real. And I’ve never overheard lay people talking about AMD until recently. The more the conversation happens, the more people hear it. And when it’s personal, when it’s a relative, it’s much more real than if it’s something you see on a billboard or read in magazine.

DePaolis: It is frightening for a son or daughter driving their parent to the appointment. They are fearful for their parent’s safety and they are fearful for themselves. Conditions such as AMD and glaucoma, more than anything else, will motivate children to start making changes earlier.

Clark: I saw a survey recently that said people believe the fear of going blind is twice as scary as the fear of early death.

Helpful apps

DePaolis: What app would you suggest that a practitioner have at his or her disposal?

Hawley: If doctors are going to treat more diseases where the patient needs information or the office needs something right now, doctors have to be able to access that information from a cloud and on an iPad. They need to get information instantly and be able to comment on it. You can be anywhere and look at an image and say, “Send him to the retina specialist.” They’ve just done a test and they’re not in the office. That’s going to happen more and more where ancillary testing is being done and the doctor is not there at the time.

Schnider: I just heard today about one called pingmd, and it’s Health Insurance Portability and Accountability Act-compliant, where you can speak with patients about their condition. And you can, in a compliant way, ping other health care professionals to consult. It’s something optometry needs to learn to do. Somehow the Internet makes things a little bit less intimidating, less personal, less embarrassing.

DePaolis: To remain viable, practitioners need to be more adept at shifting gears while moving through their daily schedules. Long gone are the days where your patient mix is pretty homogenous, a mix of refractive and contact lenses. Today’s optometrist experiences a much more diverse and challenging day.

Hawley: If companies conducted business the way we did 5 years or 10 years ago, we wouldn’t be in business. If we’ve got to shift gears as companies, then the practitioner has to shift gears to keep up. We’re doing it because we want to run successful businesses in the future, and they’ve got to look at it in the same way.