DEA License Is Important to ODs

By Dr. Elizabeth Muckley

While it is not mandatory, I encourage Ohio ODs to obtain a DEA license.  This national identification number issued by the U.S. Department of Justice Drug Enforcement Administration Office of Diversion Control is used by drug companies to track OD prescribing habits, It is especially important to these companies when allocating funds to optometry for research or support of CE meetings.  Insurance companies and pharmacies also use DEA numbers to track optometry’s prescribing habits.

Ohio optometrists receive a TPA (therapeutic pharmaceutical agent) number from the Ohio State Board of Optometry at the time of licensure; however, TPA numbers are unique to Ohio and many national entities and certifying boards are not familiar with them. OOA members worked hard during the last scope update to obtain the privilege for ODs to receive a DEA license and prescribe narcotics when appropriate.

Please go to https://ohioeyes.org/2015/11/20/scheduled-narcotics/ for information on how to obtain your DEA license.

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November Legislative Update

Written by: Executive Director Keith Kerns, Esq.

HB 213

This month, the Ohio House Commerce and Labor Committee began deliberations on House Bill 213, a measure that would require that all professional licenses be renewed on a biennial basis.  HB 213 was introduced by State Representative Tom Brinkman (R-Cincinnati) last spring.

The bill would impact several regulated professions, including: auctioneers, pawn brokers, real estate agents and appraisers, sanitarians, hearing aide dealers, private investigators, nursing home administrators, contractors, dieticians, pharmacists and opticians and optometrists.  Physicians, dentists and other health professionals currently renew on a biennial basis and are not included in the bill.

The OOA has serious concerns with the legislation and has requested to have optometry removed from HB 213.  This week, I submitted testimony to the House Commerce and Labor Committee on behalf of the OOA on this issue.  To view the testimony, click here.  Be sure to visit www.ooa.org to view the latest updates this and other important legislative issues.

Sales Tax Repeal Bill Pending In Ohio Senate

Recently, State Senators Dave Burke (R-Marysville) and Randy Gardner (R-Bowling Green) introduced Senate Bill 216 into the Ohio legislature.  SB 216 would exempt the first $500 of the sale of a prescriptive optical aide or component from the state sales tax. The Ohio Optometric Association strongly supports the legislation.  The bill has been assigned to the Ohio Senate Ways and Means Committee for deliberations.

Ohio currently requires retailers of prescriptive eyewear to collect and remit sales tax on prescriptive eyewear and other optical aids which creates an unnecessary barrier for patients and places Ohio-based retailers at a competitive disadvantage. 42 states exempt these products from sales tax.

To learn more about SB 216 and to get involved, Read More about SB 216 

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Scheduled Narcotics

Written by: Dr. Elizabeth Muckley

As you should be aware of by now, the FDA rescheduled hydrocodone from a Schedule III controlled substance to Schedule II controlled substance.  Our law was amended to address this issue and became law on March 23, 2015 (see below), so you didn’t lose any prescribing rights that you previously had before the change. YOU MUST NOW UPDATE YOUR DEA CERTIFICATE.

If you go to DEA’s website, www.DEAdiversion.usdoj.gov and review the mid-level practitioner chart (see below) you will find that DEA has already identified O.D.s in Ohio as having schedule II, III and IV authority.

Since the law has now been amended and you have authority to handle schedule II narcotic controlled substances (if you have a valid DEA certificate), then you can use the following web link to add schedule II to your DEA registration.  You should also add Schedule IV because Tramadol was rescheduled also by the FDA.

You will need information obtained from your DEA certificate in order to log on.

https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/updateLogin.jsp

If you need assistance with the log on, please call 1-800-882-9539.

If you don’t complete the update, your scripts may get denied by the pharmacy. 

Everything else regarding your prescribing authority remains the same as before the change.

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House Bill 213

By Executive Director Keith Kerns, Esq.

State Representative Tom Brinkman (R-Cincinnati) recently introduced House Bill 213 into the Ohio General Assembly.  HB 213 would require that all professional licenses be renewed on a biennial basis.

The bill would impact several regulated professions, including: auctioneers, pawn brokers, real estate agents and appraisers, sanitarians, hearing aid dealers, private investigators, nursing home administrators, contractors, dieticians, pharmacists and opticians and optometrists.  Physicians, dentists and other health professionals currently renew on a biennial basis and are not included in the bill.

The bill would essentially bring all professions into alignment with a two-year renewal process, yet the benefit behind such a change appears unclear.  In fact, the change could prove to be detrimental for licensees.  A long gap between renewal periods carries several logistical challenges.  Changes in practice location that are not properly recorded with the appropriate licensing agency may result in licensees failing to receive renewal notices.  Additionally, licensees may simply forget when a license is to be renewed because of the amount of time between renewals.

Failing to renew a license can be a significant problem in some professions.  For example, in the dental industry, which maintains a biennial renewal process, several hundred dentists would fail to renew their licenses every two years resulting in an automatic suspension from practice.  Not only did this result in the dentists experiencing licensure discipline, it also caused some dentists to be canceled from insurance contracts because they did not maintain a license free from encumbrances.  The problem was so significant that the legislature stepped in to create a grace period for renewals in dentistry.

In contrast, the annual licensure renewal process that exists for optometrists is a system that works.  OOA members and others within the profession understand and comply with the current renewal process.  In fact, the State Board of Optometry reports no significant problem with optometrists failing to renew licenses in a timely manner.

The State Board of Optometry operates at a high professional level within their operating budget and is well-equipped to perform the licensure renewal process on an annual basis.  While there might be other professions and licensing boards for which biennial licensure may be helpful, in optometry there is no known benefit to the public, the licensees or the state.

The OOA has requested to have optometry removed from HB 213 and will continue to monitor the bill as it is debated in the legislature.   Be sure to visit www.ooa.org to view the latest updates on HB 213 and other important legislative issues.

ICD-10; Transition Tips from inside the Trenches

OOA President-Elect Dr. Jason Miller will be the featured speaker at each of the Zone President’s Nights in the fall. In addition, new OOA Executive Director Keith Kerns will provide a legislative update and looks forward to meeting the members in each Zone.

Dr. Miller will speak about ICD-10. A summary (one hour practice management ce)

ICD-10; Transition Tips from inside the Trenches

The conversion to ICD-10 will change many aspects of Optometric practice. It requires improved record documentation and plays a larger role in the delivery of health care. This course will discuss steps to help make the conversion a success. From the front office to the examination room to the billing office, it will uncover tips to help with that transition leading up to October 1, 2015 and into the future.

Mark your calendar and plan to attend your Zone’s President’s Night.

President’s Night Zone meeting dates are as follows:

Zone 1 (Mansfield) – September 14

Zone 2 (Cleveland) – September 9

Zone 3 (Canton-Akron)- September 2

Zone 4 (Youngstown)- August 24

Zone 5 (Zanesville)- September 24 

Zone 6 (Athens)- September 21

Zone 7 (Portsmouth)- September 3

Zone 8 (Cincinnati)- August 26

Zone 9 (Dayton)- August 27

Zone 10 (Lima)- September 16

Zone 11 (Toledo)- October 14

Zone 12 (Worthington)- September 23

 

 

 

Referral Programs

By Keith Kerns, Esq.

In an effort to increase patient visits, many offices offer incentives to current patients who refer friends and family to the office.  Optometry offices which engage in this practice should be aware of a key provision in Ohio law before instituting such an incentive program.

Ohio has maintained an anti-kickback law for many years.  The law is intended to help protect patients and healthcare payers against fraud and abuse and to prevent financial incentives from influencing health care providers treatment recommendations and decisions.  Though the focus of the law is seemingly meant to address provider-to-provider and agent/broker-to-provider referral corruption, the law is written broadly and actually applies to everyone.  Therefore, offices that are considering establishing a referral incentive program for current and new patients must be familiar with this law in order to avoid pitfalls.

Ohio Revised Code section 3999.22 makes it illegal for anyone to “knowingly solicit, offer, pay, or receive any kickback, bribe, or rebate … in cash or in-kind, in return for referring an individual for the furnishing of healthcare services…for which whole or partial reimbursement…may be made by a healthcare insurer.”  Any violations of this section are considered felonies under the law.

Despite this broad prohibition against any kind of payments – gift cards, cash, gifts, etc. – in exchange for referrals, there are several important exceptions outlined in the law which may still allow offices to pursue a patient referral program.  First, the law excepts those referral payments that are authorized by an health insurance contract and does not apply to deductibles or copayments.  The law also does not apply to a health care practitioner who provides services that are not covered by the patient’s health insurance plan.

Finally, and most importantly, the restriction does not apply to the offering of discounts or reductions in prices.  This exception provides a simple avenue for optometrists to offer incentives to patients who refer their friends and family into the practice.  A discount off of future services, or new pricing structures for certain procedures can be offered in exchange for the referral of new patients under Ohio law.

Optometrists seeking to step up their marketing campaign and attract new patients are strongly encouraged to seek advice from legal counsel prior to instituting a referral incentive program or an advertising campaign to discuss these issues and avoid any difficulties which may arise.

A Follow- up on Direct Messaging

**A follow up to an earlier Blog post by Dr. Snow (Patient-portals-and-direct-messaging-how-do-they-affect-me) 

By Dr. Jay Henry,

Q: How would direct email messaging assist optometrists?   Explain why it’s important for ODs to talk directly with the primary care physician (PCP) through  Direct protocols.    What could optometrists share that would be mutually beneficial to other physicians?

A: Direct messaging would allow optometrists, the primary eye care providers, to discuss results and information of shared patients with PCPs and other specialists.   Every diabetic patient gets a report sent to the PCP with results of the eye exam.   Many times it is the Optometrist who makes the first diagnosis of Hypertension, Thyroid disease, Diabetes, MS, high cholesterol, strokes, and  other systemic conditions.   When these situations occur, Optometrists need to be able to reach out to the patient’s PCP to coordinate care.

Optometrists also see many patients who need to be sent to a specialist or ophthalmologist.   ODs refer patients to a specialist / sub specialist and need to send  the testing results from the patient’s office visit or a clinical summary from their office visit.   A great example is when a patient is sent to a cataract surgeon for cataract surgery.   ODs do the majority of the patient’s pre-op testing and the post-op care from day 1 after the surgery.   ODs need to share this information back and forth with the surgeon.

For a patient with a retinal concern the OD may need to send clinical notes, photos, images, visual field results, OCT results and other information to the retinal specialist so the patient may receive further treatment or surgical intervention.     

All of these could be done via direct messaging.

Q: My eye doctor will be examining my eyes next week, and my neurologist wants him to test me because I’ve had an increase in migraines recently. He said he wanted to know about my “pressures.” Can you explain what this means?

A: This scenario would be the same for an Optometrist or Ophthalmologist.   Often a specialist or PCP wants  further testing done on a patient that the specialist or PCP may not do.   In this case the neurologist is concerned that  intraocular pressure is high and causing headaches to be worse or that preventative medicine you are taking is causing your eye pressure to be high and this can cause vision loss which is the disease of glaucoma.

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.

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.

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.