Medical Homes are the Best Source of Reimbursement for Optometrists

By Mark A. Ridenour

This could very well be a headline in the future given the direction of changes in the healthcare industry today.  Many Primary Care Physician (PCP) practices have converted to the Patient-Centered Medical Home (PCMH) practice model.  There are now more the 7000 accredited Medical Home practices nationwide with 535 in Ohio.  PCPs have embraced this model because it allows them more practice freedom, offers the opportunity for increased reimbursement, improves their patient’s outcomes, and increases their patient satisfaction; not necessarily in that order.  PCP practices must meet numerous criteria to be considered a Medical Home, including 24-hour remote patient access, next day appointments, coordination of patient’s care with other providers, and team-based provider care with specific expertise around nutrition and behavioral change.  Physicians who have successful migrated to this model report greater job satisfaction themselves, because they are put into more of a CEO role, where the more complicated cases and decisions come to them and more routine care is seen by mid-level staff.  Patient response to this transformation has been mixed, but many insurers are now incentivizing their members to use Medical Homes via reduced co-pays and benefit design.

Payers (insurance companies, employers, and government) have discovered PCPs operating as Medical Homes lowers their costs.  Reducing emergency room admission rates and eliminating duplication of diagnostic tests are examples of quick payoffs.  Typically, they will pay these practices extra for care coordination and case management and/or pay bonuses for improved patient population health outcomes.  Many payers have shifted their risk to the Medical Home; i.e., they have given the Medical Home a percentage of the employer/employee premium to manage the patient.  The Medical Home, in turn, must manage the expenses of the patients, leading them to become more discerning about referrals.  Insurers will supplement this because a parallel objective they have is to reduce the most expensive care they pay for – hospital and specialty care.  This is one of these reasons the OOA continues to stress the importance of your relationship to your PCP referral sources.  Medical Homes will likely establish criteria for referrals to Optometrists.  Which practices supply me with the best and timely information about my patients?  Do I consistently receive exam results on my diabetic patients?  Are they encouraging them to maintain healthy behaviors?  Are they accessible for eye care emergencies?

This movement in the provider payment landscape is part of the reason the OOA continues to promote the Optometrist as the primary eye care provider.  Along with dental and behavioral care, optometric services are generally perceived as essential preventive care.  As long as fee-for-service reimbursement dominates, it is beneficial to be aligned as a primary care provider.  Payers are favoring reimbursement codes for these services over specialty care codes.  Plus, any alternative payment models will be based on the premise of investing in preventive care to avoid greater catastrophic costs.

So you may not be getting reimbursement checks from PCPs yet,….. but it may not be far down the road.  Now is the time to recognize this shift and solidify our relationships via active interactions and demonstrations of value.  Are PCPs likely to value Optometrists more than the insurance companies?  Now is the time to start influencing the answer.

For more information on the Medical Home model and specific information on those in Ohio go to the Ohio Department of Health website at http://www.odh.ohio.gov/pcmh.

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To Grow or Not to Grow – That Is the Question

By Dr. David Anderson,

In 2011 we were faced with this question.  I had been in my practice for seven years and was really busy.  My wife had joined our office three years prior and was also becoming quite busy.  My partner, Dr. Keith Basinger, had been seeing patients at our office for over 13 years, and his schedule was packed.  We were faced with a choice — get busier or risk being out of business.  Neither sounded attractive.  I felt I was working hard as it was, and I didn’t want my seven years of hard work to be lost as decreasing payment for services and pressures all around were taking hold.  We had seen a dramatic increase in the number of patients with managed care plans; therefore, fewer patients were paying full price for our services and products. We had not seen an increase in reimbursement for services since I joined the practice. Expenses were going up, but our fees for service were not rising accordingly.  So we had to find a way to increase revenue to overcome a potential decrease in overall net profit.

Simply adding more patients to our schedule was not the answer.  I did not want to compromise patient care by having to hurry through a patient visit in an effort to stay reasonably on time.  Besides, with the layout of our office, there seemed to be a daily bottleneck at the pre-test room.  Often people would be worked up and ready to see the doctor but then had to spend time waiting in the reception area because all the exam rooms were full.

We had not yet implemented EHRs into our practice.  The wheels were in motion, but we really did not know how we could do this with our current patient flow.  We thought we would have to see fewer patients or stay later to finish records because of the extra time to input the information in the EHR.  

At a business meeting, the speaker raved about incorporating scribes in the exam room.  He discussed benefits, including improved patient care and a better experience for the patient.  This resonated loud and clear – “better experience, better care.”  We saw a way incorporate scribes when we switched to EHR and possibly grow our practice by getting busier.  If I could perform an eye exam and trust a scribe to record the visit in the EHR, it would free up some of my time.  If I became more efficient, I could see more patients in the same amount of time.

After two months we realized the concept worked.  We had enough patient flow to get busier by seeing more patients per day.  We saw more medical patients, such as glaucoma follow-ups or eye emergencies throughout the day.  There was more time to add a contact lens fit into the schedule.  We did not use specific time slots for these items but simply worked these patients in throughout the day between scheduled exams.

Our staff costs went up, but our revenue went up to more than compensate.  Soon after we made this change, we realized our office was too small, our parking lot was too full and our patients had no room in our office.  We needed more space to accommodate this change.  Again, the question arose – “To grow or not to grow?”

We chose to grow and built a new office, expanding from 3800 square feet to 7400 square feet.  Most importantly, we now have ten patient care rooms and two pre-testing rooms.  The up-front cost was a challenge, similar to adding one additional staff per doctor to be their scribe.  However, there are many days during the week when all patient rooms are full and two other patients are being pre-tested.  Having each patient already in the exam room and ready for the doctor increases our efficiency and helps keep us on time.  We no longer have to waste time waiting for a patient to be pre-tested or moved into an exam room from the reception area.

To grow or not to grow – we chose to grow.  We currently have enough space for patient care with room for future growth.  We have 16 full-time and three part-time employees.  Our schedules are booked ahead for over one month.  We are seeing over 700 patients a month without adding any doctor hours compared to four years ago.  We have maximized our schedule, delegated to our highly trained staff and added space to handle the work load.

We have grown because we chose to grow.  With the assistance of our scribes, we easily managed the more difficult requirements for Meaningful Use 2.  When the ACA went into effect, more patients with medical coverage were seeking care.  This had a positive effect as we were ready to increase our patient volume.  In the foreseeable future, as diabetic patients and an aging population need medical care, we will be poised to meet these challenges.

Make a Difference in Children’s Lives

By Dr. Ann Rea Miller

Children’s vision has always been something I’ve actively participated in since graduating optometry school. Presenting RealEyes to children in schools and seeing babies 6-12 months through the InfantSEE program just seemed like something I needed to be involved in. It seemed natural to me that optometrists should focus on kids vision with our knowledge that 80% of what we learn is through our eyes. Having poor vision while children are in school can lead to poor grades, children who become disruptive because they can’t see what is being taught, get bored and may be unable to verbalize their problems. Kids may even be misdiagnosed with ADHD or unnecessary IEPs may be issued which could potentially cause unnecessary emotional turmoil for children and/or their families.

So many times after I examine a child and tell their parent(s) about the problem I’m finding with the child’s eyes, the parent(s) are shocked because their child did not tell them they were having problems. Parents feel guilty and beat themselves up about why they didn’t take their child to see me sooner. We all know that some people tolerate all kinds of blur without complaining, especially children who do not have expectations of what their vision should be. I love that we, as optometrists, are able to have a positive impact on these children’s lives and allow them clarity through contact lenses or glasses to function at a higher level.

I have done many RealEyes presentations since graduating. Some go better than others and just when you feel like the students may not have gotten the message as well as I was intending, I get clarity to my own perceptions of what the children really got out of my presentations.

Recently I presented to a school and really was concerned that the children may not have gotten the messages I was trying to teach them about their eyes, vision, and getting their eyes checked yearly to keep their eyes healthy. After my presentations that day, I really started to question whether I should have spent my time that day versus seeing patients and making money, or spending time with my son. My questioning was put to a halt when I received over 20 thank you letters from kids who wrote to me about what they enjoyed when I was in their classroom and the favorite thing they learned about their eyes…they really had paid attention! We need to remember that kids’ brains are like sponges and they soak in so much knowledge. We need to remember that kids are our future.

We need to take the time to educate them on the importance of their vision and eye health. It amazes me how often I have a child who comes into the office because they have told their parent(s) about what they learned through my presentation and the child was made aware of what blurry vision was and they realized they were experiencing it. Our goal should be to examine all young children and treat vision problems when needed, therefore allowing children the ability to learn more easily by having clear vision. I urge everyone to take the time to impact young kids’ lives through RealEyes and InfantSEE to provide the knowledge and expertise we are able to provide. As a bonus, remember that one day the children you impact (and the rest of their family) may become your patients in the process.

The Practicality of the Medical Model

By: Jason R. Miller, OD, MBA

The medical model…the medical model…the medical model is a term that is frequently used within optometry and the question is why?  Why do we as practitioners need to be involved and what impact does it have on our practice?  Traditionally, optometry is known as the primary eye care provider who provides not only vision care, but medical eye care as well.  We are all highly trained in the diagnosis and management of ocular disease, yet only 17% of practice revenue is derived from medical eye care.1  The question is why is this number so low?  The medical model can have a positive impact on our patients and our practice.

For Survival

There are numerous threats to our profession that will have an impact on our practice survival.  Online retailers (both glasses and contact lenses) will continue to offer affordable options to our patients.   We know that many patients who make purchases online are less frequently coming into our practices for their routine care.  Insurance plans, both vision and medical, will continue to find ways to attract their customer base while providing less reimbursement for our services.  Get involved and support your local, state and national associations either physically or financially.  These are the groups that help fight and secure your ability to practice medical optometry.

You are the Expert!

We are the experts and it’s important to establish that perspective of ourselves in such a manner.  Although we all have different comfort levels in ocular disease management, there are numerous educational resources available to help us along including continuing education and webinars.  In those cases outside of our comfort level, we have colleagues that we can refer to for secondary and tertiary referral.  Nonetheless, the majority of ocular disease can be managed within any optometric practice.  Our role is to educate our patients on what we do and our role within medical eye care.

Technology Integration

Although advanced technology isn’t necessary for all ocular disease cases, evaluate your current patient base to see what types of patients are already within your practice.  For complex diseases such as glaucoma and macular degeneration, state-of-the-art technology will be a must.  There are numerous technologies that we all have on our “practice wish list” however we know that the decision needs to make economic sense before any purchase.  Determining what percentage of your patients comes to your practice for medical eye care is important.  Utilize your EMR system to data mine common diagnoses or patient segments that may benefit from specific services.  One example would be determining whether or not to purchase a fundus camera.  The first step would be to look at the number of patients within your practice who have diabetes or glaucoma.  Next, evaluate the current trends and prevalence of the various disease states to see how you compare.  Is your practice prevalence pattern higher or lower than these averages?  If it’s lower, there may be numerous patients that may have been potentially overlooked in the past or just wasn’t followed since the technology wasn’t available.  Lastly, perform a breakeven analysis (projected gross income minus projected annual expense) to see how long it will take for you to pay off the technology.  If it all adds up, then purchase the equipment.  If not, there are other ways to provide these services such as co-ownership of technologies where the cost is shared or comanaging with our optometric colleagues for special testing services only.

Write the Rx

One last note on developing yourself as an expert in medical eye care is practice of prescribing versus sampling.  Although samples are available for us to offer our patients, we must use them wisely.  In our practices, we use samples for our patients who may not be able to afford them or to determine efficacy for chronic conditions such as glaucoma.  By having patients purchase their medications, they will have to take ownership in their condition which will also help with patient compliance.  Since they have made in investment in their care, they will understand the value in their treatment and more likely follow the prescribe regimen.

In Conclusion

From the initial phone call to schedule an appointment to the examination to the checkout process, everything that we say, do and not do (non-verbal communication) contributes to the overall patient experience.  Technology is constantly changing the way that we practice optometry and contributes to the “WOW Experience”.   Whatever your passion is in medical eye care from ocular surface disease to glaucoma to retina, there are numerous technologies that have impacted the way that we care for our patients today.  Each time we perform testing, we need to maximize the opportunity to discuss the reason for doing each test. Invest in adopting the medical model and the practice will win.

References

  1. Management and Business Academy. Key Metrics: Assessing Optometric Practice Performance.  2013.  Accessed from http://www.mba-ce.com/data/sites/1/paa_keymetrics_0813.pdf on March 23, 2014.

Patient Portals and Direct Messaging, how do they affect me?

By Dr. Rod Snow,

The OOA has been receiving questions concerning “practice portals” of Electronic Medical Records versus “patient portals”, along with some confusion around direct messaging.  Is there a difference with these things and how do they affect me?  There may be some minor differences between each EMR, but here is some information on these terms that may be helpful:

There is a difference between the “practice portal” and the “patient portal”.

  1. The practice portal is the practice’s command center. It is where many of the essential functions of the EMR are set-up.  It is also where employees can message each other.  It has the “inbox” messages received from patients and from other doctor’s offices (called DIRECT messaging) because they are located on an encrypted server.
  2. The patient portal is a “subset” of the practice portal. This is where patients can log in and see some of their exam information. They will see the clinical summaries (CCD’s) that the doctor has created for that patient.  The patient can use this portal to send a message to the doctor and possibly schedule appointments through this portal.

“DIRECT” messaging is different than typical email.  Doctor to doctor communications via email should always be through “DIRECT”.  That is because DIRECT is associated with the doctor’s practice portal and will then be encrypted.

Important:  If a doctor uses private email to discuss health concerns, that is a HIPAA privacy violation as that information is not encrypted!

Doctors can exchange patient information through the DIRECT messaging account, which goes directly to the practice portal which is automatically encrypted for privacy.  Additionally, patients can email through the patient portal, which will connect to the practice portal where it will be viewed by the doctor.  It also is automatically encrypted.

Rick Cornett’s Retirement

On Sunday March 29 OOA members and friends celebrated the retirement of Rick Cornett.

OOA President Dr. Gossard, Dr. Augsburger, Dean Zadnik and Dr. Roark spoke.

OOA Past Presidents conducted the “passing of the gavel” ceremony concluding with Rick who gave the closing remarks.

Congratulations, Rick! Thank you for your outstanding years of service to the OOA.