BLOG: Disease management programs for eye care

ByScott A. Edmonds, OD, FAAO

The fundamental unit of eye care for optometrists has traditionally been the eye examination. This speaks to the roots of our profession of measuring the refractive status of each eye and providing vision correction in the form of glasses or contact lenses.

We started out as a profession that provided the refraction as our primary service. Many of the optometrists of my dad’s generation did not even use the term “eye examination,” but rather just referred to their encounters with patients as “refractions.” Any testing other than the refraction or testing of binocular vision was considered just an eye health screening and provided as a courtesy.

The slit lamp biomicroscope was not part of the process, as this implied that the optometrist was actually examining the eye rather than just refracting and screening for eye pathology. Times have changed. We have evolved.

Today, the fundamental unit of eye care for many optometrists is not the eye examination, but rather the medical office visit. This is often provided as a follow-up to manage ocular pathology. There are a few medical eye conditions that require multiple office encounters as well as testing, and these problems fall into the category of chronic medical eye problems. Some of these conditions also have surgical options and require collaboration between the optometrist and ophthalmologist for appropriate management.

Depending on the mission and scope of your practice, there are a number of broad eye conditions that can be considered chronic:

general practice
glaucoma
ocular surface disease
diabetic eye disease
specialty practice
macular degeneration
keratoconus

Patients with these diagnostic states require frequent follow-up, testing and/or collaboration with other providers.

In the current fee-for-service payment system, encounters related to these problems are largely unregulated. Therefore, these eye problems represent a significant source of income to the optometrist and, by the same token, a significant cost to the health care system. In an era of health care reform, these eye problems are going to be among the first candidates for the new payment systems.

Optometrists and ophthalmologists that are involved in integrated networks or regional eye care delivery systems need to look at how the providers in their organization manage these conditions and get a good handle on the annual cost of the eye care for these problems. Beyond the unmanaged cost, the organization needs to look at designing protocols and standards for this type of care that will improve outcomes and increase efficiently and cost effectiveness. At the very least, regional eye care delivery systems will need to manage the global risk of these problems in an overall capitation payment to their system.

Looking at how other chronic disease is managed by accountable care organizations and other new health care delivery models, there is a good chance that these problems will be reimbursed on a flat annual fee-per-diagnosis. This model is similar to the diagnosis related group (DRG) programs that were used to control hospital admissions in the 1990s.

Programs to manage patients with a particular disease are often termed “disease management programs” and are a fundamental element in health care reform. Although they have not been widely used in eye care, their principles apply to the management of chronic eye disease. Preparing for these new programs is part of the mission of the American Optometric Association’s Measures and Outcomes Registry for Eyecare new program. There are also private eye care registry companies and other eye care informatics and analytic services available.

We will see the beginning of this with the conversion to ICD-10 this fall. For those of you who have looked at the new system (and I truly hope that this is most of you), you will note that chronic eye diseases like glaucoma have much more details, including the severity of the disease, that need to be coded. This will pave the way for different annual payments for a diagnosis when a case is more severe.

And so the tools of health care reform such as electronic health records (EHRs), meaningful use, electronic secure transfer of protected health information and now ICD-10 are all leading the way to reformed payment vehicles. Eye doctors that have a functional EHR, are ready for ICD-10 and are providing primary health care as part of the comprehensive eye examination, are in a good position for the future. However, those of you who are organized into an integrated network or regional eye care delivery system are in the best position, as you stand to gain the most in the transition. You are already well poised to win the new contracts and move forward with a strong contracted patient base.

Although health care reform has been on a very slow pace since the 1960s, it is now accelerating rapidly, and optometrists need to be informed and ready for the changes that lie ahead.