Health care reform is currently being debated in the U.S. Congress, in state legislatures, and by nearly every element of the health care system. The reasons for change need little elaboration: Upward of 40 million Americans are without health insurance and facing restricted access to health care services, and health insurance premiums are reaching levels that neither employers nor low- and middle-income families can afford. Health care costs now represent 14% of the nation’s output of goods and services. The quality of care is inconsistent, and excessive health care resources, including training programs, are positioned in specialty areas, while major deficits exist in much needed primary care services and clinical training.
How must health care in America change? I believe that we must and will have universal entitlement – health care security for all Americans, but major changes are also required in all aspects of the current system. We must reach a proper relationship between the numbers of primary care health providers and specialists, improve access to health services, control costs, and assure quality of care, and any new health plan must support training of primary care providers, including optometrists. Ten states have recognized the need for change and already have some type of health reform legislation in place. As a health care administrator, I am frequently asked about President Clinton’s health care reform initiative. I believe that it is the right plan for the American people and the best plan for optometry. The President’s proposal explicitly provides eye/vision care benefits and recognizes optometry’s role in primary care.
In 1973, doctors of optometry were first granted the legal right and responsibility for administering pharmaceutical agents. Now, optometrists in 40 states are clinically privileged in the management of diseases and conditions of the eye. The progress of the optometric profession over the past 20 years has been dramatic. I attribute this success to a sincere desire on the part of practitioners nationwide to provide more accessible and cost-effective eye care to their patients and the expansion of the clinical practice of optometry to include the management of eye diseases and prescriptive authority that has been essential to optometry’s primary care role. As a result of this dramatic progress, I believe that optometry is now positioned to assume the role of primary eye care provider under national health reform.
Today’s optometrist is uniquely qualified to meet the challenge of national health care reform. Optometrists are the nation’s most accessible eye care providers, practicing in more than 6800 municipalities throughout the United States. In more than half of these communities, they are the only eye care providers available. Optometric clinicians are often the point of contact in the health care system for many people and their training qualifies them to serve in a role for patients with systematic health problems that manifest in the eye. This is particularly important in medically underserved areas.
Vision and eye health problems are among the nation’s most prevalent disorders affecting more than 140 million people. Vision problems inhibit the ability of children to learn, adults to work, and the elderly to live independent and productive lives. Regular eye examinations are also an essential preventive measure for the early diagnosis and prompt treatment of eye diseases, which, if undetected, result in individual suffering and added societal costs. A recent study by the Georgetown University Medical Center concluded that over 100,000 new cases of blindness yearly are preventable through timely detection and treatment and would result in an estimated annual savings to the federal budget of one billion dollars.
The demand for services of primary care providers in the United States continues to exceed the supply of manpower resources available. Health care reform provides an opportunity to restructure the delivery and health educational systems in ways that make better use of America’s available health care resources through the use of cooperative approaches to health delivery and training. Enhanced primary care training for optometrists is consistent with the current emphasis on primary care in federal health care policies.
Optometry and ophthalmology are complementary eye care professions in the Department of Veterans Affairs and nationwide. However, interprofessional controversy over certain issues persist. These issues include the extent of clinical privileges for optometrists, the role of the optometric clinician in pre- and postoperative patient management, and the use of laser technology by optometrists. Such sensitive issues are not easily resolved. However, there are many areas of mutual agreement, and I believe that the eye care professions can, and should, cooperate in patient care programs, education, training, and research. Cooperative programs already exist in some health care institutions in the nation, but on a limited basis.
The success of cooperative programs between optometry and ophthalmology is evidence that joint efforts can be advantageous to both medicine and optometry and that optometrists and physicians can work together as colleagues. In cooperation with affiliated health professions schools, I believe that properly constructed and thoroughly evaluated eye centers of excellence could serve as models that promote preventive care, while at the same time provide state-of-the-art treatment and rehabilitative services. These models could be emulated throughout the national health system.
The future can take us into a new era of accessible, affordable, and quality health care and lead optometry into an arena of greater responsibility for the eye care needs of all Americans.
I gratefully acknowledge the contributions of A. Norman Haffner, O.D., Ph.D., President, State College of Optometry, State University of New York, and James Holsinger, M.D., Ph.D., Chancellor, University of Kentucky Medical Center, to the preparation of this speech and the advancement of VA optometry. This editorial is taken from Dr. Mullen’s speech given June 2, 1994 at the graduation ceremonies at The Southern College of Optometry.
Clinical Eye and Vision Care.
Volume 6. Number 3. 1994.
Charles F. Mullen, O.D.
An unprecedented opportunity exists for the Department of Veterans Affairs (VA), the Association of Schools and Colleges of Optometry (ASCO), and the American Optometric Association (AOA) to develop jointly a large scale affiliated optometric educational system. Coordinated strategic action would establish and direct the dynamics of interaction among VA, ASCO member institutions and AOA, and could result in enhanced optometric patient care, education, and clinical research opportunities with the Department of Veterans Affairs.
Veterans Health Administration
The Department of Veterans Affairs includes three distinct organizations: Veterans Benefits Administration, National Cemetery System, and Veterans Health Administration (VHA).
The VHA administers the world’s largest comprehensive health care system for the nation’s 26.9 million veterans. It includes 172 medical centers, plus more than 700 outpatient clinics, nursing home care units, domiciliaries and vet centers throughout the United States and the Philippines. Operating with an annual budget of over $13.5 billion, VHA treats 1.1 million inpatients and records over 23 million outpatient visits annually.
In addition to its primary mission of providing health care to veterans of the U.S. armed forces, VHA has three other roles. First, in times of war or national emergency, VHA serves as the backup health care system to the Department of Defense. Second, VHA trains a broad range of health care providers, including optometrists. Third, VHA works to enhance patient outcomes through clinical research. Each year VHA appropriates over $200 million for medical and prosthetics research. Currently, nearly 6000 investigators are engaged in more than 10,500 research projects located at VA medical facilities.
In 1974 VHA recognized optometry’s contribution to veterans’ health care and named its first Director of Optometry to address the eye and vision care needs of veterans. Initially, the Director could not attract optometrists to service because of the outdated personnel system and salary schedule. There were just 8 full-time optometrists in the system and no residents.
In 1976 VHA designated optometry a Service and placed staff optometrists under title 38, in the same personnel pay system as physicians, dentists, and nurses. This provided more competitive salaries, created teaching programs, and increased optometric care for veterans. By 1980 there were over 70 full-time optometrists in the VA.
In the early 1970s, the VA also began establishing successful and innovative affiliations with schools and colleges of optometry. For instance, the nation’s first clinical education program for optometry students began at the Birmingham VA medical Center, in affiliation with the University of Alabama School of Optometry. Also, the nation’s first VA optometry residency program began at the Kansas City VA Medical Center. By 1980, 12 residency programs had been established.
Providing primary eye care by staff optometrists proved to be cost-effective and efficient, and veterans and veterans’ service organizations enthusiastically endorsed optometric care. This allowed VA Optometry Service to expand steadily and to begin to address the unmet need for primary eye care in the VA.
At present, 220 full- and part-time optometrists (150 FTEE) provide eye care services to veterans at 138 VA medical facilities. Optometrists manage over 300,000 patient visits annually and provide clinical training for 500 optometric students and 53 optometric residents at 79 academically affiliated VA facilities. Since many VA facilities have multiple affiliations, currently 121 affiliation agreements exist among schools and colleges of optometry and VA medical centers.
Included in Optometry Service’s responsibility is the provision of vision rehabilitation services at three Vision Impairment Centers to Optimize Remaining Sight (VICTORS), three Low Vision Clinics, and five Blind Rehabilitation Centers (BRCs).
The Field Advisory Group is an integral part of Optometry Service. Fifteen chairpersons, all optometrists practicing within the VA medical system, head special committees on areas critical to the development of the Service and the delivery of quality eye care, education, and research. They remain in constant contact with the Director and address issues ranging from total quality to improvement of public relations. The chairpersons, representing the dedicated work of their committees, provide invaluable assistance at biannual strategic planning meetings of the entire Field Advisory Group.
With regards to external relations, the Director of Optometry Service maintains liaisons with the AOA, ASCO, National Association of VA Optometrists (NAVAO), and the Special Medical Advisory Group (SMAG) Subcommittee on Eye Care. The Field Advisory Group and representatives from these organizations combine to form a significant network of advisors.
In the Armed Forces, Health Maintenance Organizations (HMOs), and the private practice sector, the ratio of optometrists to ophthalmologists is a little over two to one. This balance has evolved naturally in response to the need for a cost-effective, logical approach to primary eye care services, subspecialty eye care services, and surgery. In VA, the ratio is reversed; there are at least two ophthalmologists for every one optometrist. An opportunity exists to develop and implement a highly efficient and cost-effective national model for the provision of eye care, a model that minimizes duplication and overlapping of services among the eye care providers.
By the year 2000 the number of Veterans at visual risk will increase from 4.0 to 5.7 million impacting greatly on the total number of eye care visits to VA facilities. Optometry Service presents a cost-effective means of providing primary eye care.
The veteran population of 26.9 million is aging. It is a population with a high incidence of ocular and vision disorders. VA presents opportunities for eye care research in early diagnosis and management of eye disorders in the elderly. Significant clinical studies of age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma could be mounted.
Leaders within VA, ASCO, and AOA have a chance to dramatically shape the future of eye care delivery and optometric education. Opportunities within VA for enhancing patient care, clinical education, and research abound. The climate is right to jointly initiate constructive, strategic action.
VA has a history of support for sharing agreements and affiliations. VHA medical centers share extensively with academic health care centers demonstrating a history of commitment to clinical education and research. Thousands of sharing agreements exist between the VHA, the Department of Defense, and the Indian Health Service.
VA has an ongoing and active policy of cultivating new affiliations. Within the past two years 18 new academic affiliations have been developed among VA medical facilities and schools and colleges of optometry. Also, three existing programs have been expanded. More affiliations are possible and have been encouraged by various government organizations and VA advisory groups.
Related to this is VA’s high technology sharing program. This allows VA medical centers and its academic partners to purchase expensive equipment jointly and to share in the cost of operation. Technology sharing agreements with schools of optometry should be explored.
The quality and cost-effectiveness of health care delivery is of prime importance to VA. Optometry Service provides quality, cost-effective, and accessible care and is often used as an example of a model program in which high quality patient care is inextricably combined with the training of students and residents.
Funds were recently made available for 35 new optometric staff positions. In an effort to improve accessibility to primary eye care, additional funds for staff expansion are anticipated.
With its Field Advisory Group, Optometry Service already presents a highly qualified team ready for constructive interaction with ASCO, NAVAO, and AOA leaders. This extensive network of advisors covers every aspect of Optometry Service’s operation. Together we will be ready to address the issues. Together we will be ready to face the challenges ahead.
VHA is concerned with health services research and the structure of eye care services delivery in particular. Optometry Service, ASCO, and AOA, along with VA Offices of Quality Management, Health Services Research and Development, and Clinical Programs could respond to the challenge by creating Regional Centers for Eye Care Excellence. These Centers would involve the disciplines of optometry and ophthalmology and their respective academic affiliates in the collaborative provision of eye care, ophthalmic education, and research. They would serve as demonstration and evaluation sites for evolving eye care models.
Within the VA, as in the private sector, sensitive issues surround the respective roles of optometrists and ophthalmologists. A unique, coordinated health services research project which addresses the interaction between optometry and ophthalmology in the VA could be developed.
Such a demonstration project would examine reporting relationships for optometrists and ophthalmologists in VA medical centers. It would also study the extent of clinical privileges granted to ophthalmic clinicians. The project would address the issue of new and developing technologies and Clinical Practice Indicators for VA eye care.
Conclusions defining the practice of optometrists in relation to ophthalmologists and other health care providers could serve as guidance for the entire system.
VA, ASCO, and AOA should move forward in designing and implementing a comprehensive affiliation system. This would, however, present challenges in maintaining quality patient care and integration of educational programs. It is imperative that any system under consideration include guidelines for optometric faculty, resident, and student participation. Appointing all affiliated optometry school deans to VA Deans’ Committees and appointing selected optometry school faculty as consultants and attending optometrists at VA medical centers would assist in maintaining proper integration of patient care and clinical education.
Participants in the September 1991 ASCO Workshop on VA Optometric Academic Affiliations stated that in the development of large scale education initiatives there is a need for consultation by the AOA’s Council on Optometric Education (COE), which has been successful in accrediting and counseling optometric programs within the VA.
In cooperation with the schools and colleges of optometry the VA Optometry Service and Quality Management Office could review and update Optometry Service’s Quality Improvement Program. Further, quality could be insured by encouraging continued review of the VA Optometry Service patient care programs by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). However, optometric representation in JCAHO is essential to the success of the accreditation programs.
The greatest challenge faced by the VA, ASCO, and AOA will be interacting on a comprehensive scale; planning will require foresight and coordination. However the outcome – a newly acquired ability to mount large scale educational initiatives, to evaluate new technology, to test quality assurance mechanisms, and to develop innovative eye care programs – will be worth the effort.
VA, ASCO, and AOA could work to develop or enhance affiliation agreements between ASCO member institutions and key VA facilities. VA medical centers in New York, Philadelphia, Houston, Memphis, Indianapolis, and Boston present significant training opportunities not currently realized by ASCO members.
The time is right for VA, ASCO and AOA to take action. Cooperative strategic action by the health care system (VA), educational institutions (ASCO), and the professional association (AOA), could lead to the placement of hundreds of new optometric residents and externs in educationally cost-effective and clinically challenging environments.
If the initiative is consistent with the VA’s mission and addresses the challenges previously described, it will succeed. If the initiative creates improved models for optometric academic affiliations and includes discipline specific protocols for resident and extern placements, it will succeed. If the initiative includes innovative models for more accessible, cost-effective and efficient eye care delivery, it will succeed. And above all, if the initiative systematically addresses the eye care needs of our nation’s veterans, it will succeed.
Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 18, Number 2. Winter 1993.
Charles F. Mullen, O.D.
This article outlines the nature, describes the implementation process, and summarizes the status of operations to date of the affiliation between Hahnemann University (HU) and the Pennsylvania College of Optometry (PCO).
Health care financing and provision are issues that affect virtually every individual in the United States today. As health care costs continue to rise, providers, third-party payers, and patients alike actively seek more effective and efficient provision systems. If providers fail to provide quality and cost-effective health care, they will be left behind in the increasingly competitive market. Similarly, if patients and third-party payers do not use more effective and efficient systems, they will assume an even greater share of the rising health care expense.
Affiliation between professional institutions presents numerous opportunities for enhancing the educational and clinical training of students, residents, and practitioners. Institutions that are developing their respective professions can collaborate in many ways of mutual interest.
Two Philadelphia health care institutions, located within 9 miles of each other, HU and PCO, cognizant of the changing health care environment and the possible benefits of collaborative education, have begun to explore new approaches to patient care provision and ophthalmic education. On March 2, 1988, the two institutions signed an agreement for an affiliation. The agreement, effective July 1, 1988, proposes that the professions of medicine and optometry combine resources to develop unique approaches to ophthalmic education, eye care provision, and ophthalmic research.
The Context and the Decision to Affiliate
Ophthalmology and optometry have existed as separate, often antagonistic, professions since their inceptions, so why affiliate now? The impetus comes from outside parties – particularly third-party payers, health care policymakers, and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define these roles themselves. The ophthalmology community maintains that the diagnosis and treatment of eye disease should be restricted to physicians. The optometry community, on the other hand, proposes that optometrists should be the primary eye care providers and should offer an even greater range of eye care services than they do now. Interprofessional disputes involving the treatment of eye disease by optometrists, preoperative and postoperative management, and the use of laser technology in refractive treatment remain unresolved in many areas of the country. Debates in journals and in legislative chambers, however, may or may not produce satisfactory outcomes for either profession. In our opinion, the time has come for ophthalmologists and optometrists alike to acknowledge that through collaborative efforts the two professions can define a future for eye care provision that will satisfy their needs as well as those of patients and policymakers.
Pennsylvania College of Optometry, which graduates approximately 140 optometrists each year, and HU, comprising a medical school, graduate school of health sciences and humanities, and a teaching hospital, considered the potential benefits of a cooperative arrangement between the professions of medicine and optometry. In 1987, they began to explore the possibility of an affiliation. Such an affiliation was unprecedented and, given the political environment, highly controversial. Therefore, before agreeing to proceed with the affiliation discussions, representatives from both institutions considered the following issues:
- How will the professional communities respond to the affiliation?
- How will alumni and other constituencies respond?
- Should the services rendered under the affiliation be marketed? How will the professional communities react to joint marketing efforts? Will the managed health care systems accept a joint provision model?
- What are the roles of ophthalmology and optometry in primary care?
- How will patients be managed under the terms of the affiliation agreement?
- Will the model of patient care provision defined by the affiliation be in compliance with state and federal laws and regulations?
- Will the affiliation create competition between ophthalmology residents and optometry students for primary care encounters?
- How will the introduction of new technology, such as lasers, be administered under the terms of the affiliation?
- What is the proper and ethical role for each institution in the areas of patient management and financial agreements?
- What are the positive and negative consequences of such an affiliation?
Of these issues, those involving the reactions of health care communities were perhaps the most sensitive. Some ophthalmologists feared that the affiliation would undermine ophthalmology’s role in primary eye care. Locally, some ophthalmologists threatened to refer patients elsewhere if HU proceeded with the affiliation; in fact, a number of ophthalmologists did stop referring patients after the affiliation took effect. Nationally, some ophthalmologists voiced their disdain for a cooperative agreement between medicine and optometry (Argus. November 1988:8, June 1989:4, and December 1989:22). Optometrists nationwide questioned whether or not the affiliation would place their profession in a subordinate role to ophthalmology.
Alumni of HU voiced their disagreement with the affiliation through letters, telephone calls, and refusals to continue to support the school financially; PCO alumni, on the other hand, tended to view the affiliation positively.
Given the emotional nature of the affiliation, the marketing issue was all the more troublesome, and the planning stages proceeded with deliberation. The first efforts at marketing involved educational radio announcements, simply informing the public that the two institutions now offered joint services. These proved successful in piquing the interest of potential patients and third-party payers, such as health maintenance organizations. Marketing in the future will use both radio and newspaper media.
Issues regarding the provision of services and the roles of ophthalmologists, optometrists, students, and residents are addressed in a series of protocols, which will be discussed in greater detail below. Currently, these protocols are in draft form and are revised as necessary. However, they still constitute the backbone of the affiliation, and set the rules by which we operate. If care is not provided according to the terms of the protocols, the affiliation will fail, perhaps causing irreparable damage to the future of relationship between ophthalmology and optometry.
Recognizing a mutual desire to influence the future direction of the eye care professions, the two institutions decided to move ahead with the affiliation despite the risks and expected negative reactions. A primary goal of the affiliation is to define the role each profession will play in the changing environment before third-party payers and regulatory agencies mandate new policies. By engaging in curriculum discussions and in joint research efforts, the institutions hoped to enhance their own educational and research programs and, at the same time, design a health care provision system that would become a national model acceptable to all parties: ophthalmologists, optometrists, patients, and policymakers.
Philosophically committed to the affiliation, representatives of the two institutions began to define the elements of the agreement. It was decided that the firm foundation and base of the agreement would be education, on which other aspects of the agreement would be built. Many months of negotiations culminated in the written agreement to affiliate. Salient aspects of the agreement are summarized below:
- Each institution will retain autonomy over its operations and finances.
- An Affiliation Executive Committee will provide guidance, advice, and oversight on matters relating to the affiliation, including education, research, clinical, and administrative issues.
- The Chairman of the Department of Ophthalmology at HU and the Dean of Academic Advancement at PCO will be responsible for administering the affiliation.
- Appointments to the faculty or staff of either institution will be made in accordance with the policies and procedures of each institution.
- On request, the clinical faculty and house staff at HU will provide consultative subspecialty medical/surgical services to the patients of PCO in a location dedicated to subspecialty care. Consultative subspecialty services will be provided for a full spectrum of medical ophthalmic conditions, including, among others, cataracts, cornea and external disease, diseases of the ocular adnexae, diseases of the retina and vitreous, glaucoma, neuro-ophthalmic disease, ocular trauma, pediatric ophthalmic disease, and strabismus. In addition, HU will provide continuous emergency medical/surgical backup services to patients of PCO.
- Clinical faculty, residents, and other staff at PCO will provide consultative optometric, vision rehabilitative, and other services to patients of HU on request. Consultative optometric services will include contact lens evaluation and fitting, low-vision rehabilitation, eyeglass dispensing, orthoptics, and learning and disability evaluation and treatment.
- Patients will be referred to HU or to PCO, as appropriate, when such referrals are in the best interest of the patient, are agreed to by the patient, and are consistent with applicable laws and regulations, such as those mandated by the Medicare and Medicaid programs and by professional ethics.
- Students at HU, with approval from the dean of the School of Medicine, may take courses taught by PCO faculty. Likewise, PCO students, with the approval of their dean of Academic Advancement, may take courses taught by HU faculty.
- The faculties of both institutions will engage in joint educational programs, such as didactic and continuing education lectures, clinical preceptorships, seminars, electives, and grand rounds.
- The faculties of both institutions may participate in joint research efforts. Joint research programs will be approved and administered in accordance with the polices and procedures of each institution.
- The faculty and administration of both institutions will seek to develop new and innovative health care provision systems.
- All publicity, marketing, and fund-raising materials regarding the affiliation must be approved by the Affiliation Executive Committee.
- Neither institution will use the affiliation for its own or its profession’s political gain.
- All health care providers operating under the affiliation must have appropriate and adequate professional liability insurance as required by law.
- Each institution will make available to the other institution, on request, all pertinent information regarding legal, financial, contractual, managerial, and other issues relevant to the affiliation. All such information will be held strictly confidential.
An interim financial agreement was added as an addendum to the original agreement. A global financial agreement addressing the provision of clinical as well as educational services is still under negotiation. It will supersede the interim agreement as soon as it is finalized.
The faculty, medical staffs, and administrations of both institutions were informed of the affiliation discussions and most supported the initiative.
The Model and the Implementation Process
The model of eye care provision eventually agreed on assumes that ophthalmology and optometry are complementary, and it seeks to emphasize the strengths of each profession. It stipulates that primary eye care provided at PCO is delivered by optometric staff. Patients with conditions requiring subspecialty medical or surgical intervention are referred for consultation, management, or both to the HU ophthalmology staff. After the consultation and any necessary medical or surgical treatment are completed, the patient is referred back to the referring optometrist for ongoing care. Likewise, patients who receive their primary eye care by ophthalmologists at HU and who require contact lenses, low-vision rehabilitation, orthoptics, or learning disability services are referred to PCO optometric staff for treatment. Ongoing medical/surgical care is provided by ophthalmologists. In our opinion, therefore, ophthalmologists and optometrists work in tandem to provide appropriate, cost-effective, and high-quality care.
A fundamental goal of the affiliation is to develop joint education and research programs. Therefore, much effort has been spent in restructuring existing programs and creating new ones. Basic science and clinical faculty at HU currently offer courses in ocular microbiology/immunology, pharmacology, clinical medicine, and microanatomy at PCO. In the future, HU faculty will be offering courses designed for students of optometry in general and medical pathology and physical diagnosis.
Programs in clinical education also are being redefined. Ophthalmology residents accompany HU faculty on rotation in subspecialty care at PCO’s clinical facility, The Eye Institute. In addition, PCO’s faculty offers ophthalmology residents rotations in contact lens and low-vision rehabilitation services. Similarly, optometry residents and a few students are afforded the opportunity to rotate through ophthalmology subspecialties under the tutelage of the ophthalmology staff. Further, ophthalmology faculty participates in clinical conferences at PCO. Students and residents of both institutions are thus exposed to a broadened clinical base and an array of ophthalmic disorders. The hope is that such exposure will result in a more well-rounded clinical education.
Faculty of PCO have commented that the educational programs have enabled them to enhance their own clinical skills and knowledge base. However, educational programs are not limited to the faculty and students of the affiliated institutions; programs have been designed to benefit community providers as well. Faculty of HU have lectured at PCO grand rounds and have participated in the college’s continuing education seminars. Programs such as these encourage interaction between the professions and therefore, are consistent with the goals of the affiliation.
Before clinical services were actually provided under the terms of the affiliation, clinical faculty of both institutions worked together to draft patient care management and referral protocols, to outline the management process, and to establish quality assurance standards. To date, protocols have been approved for referral from PCO to HU regarding the following aspects of care: (1) cataracts, including preoperative and postoperative care; (2) cornea and external disease; (3) disease of the ocular adnexae; (4) disease of the retina and vitreous; (5) glaucoma; (6) neuro-ophthalmic disease; (7) ocular trauma; (8) strabismus; and (9) pediatric ophthalmic disease.
When a patient is referred to HU for management, the ophthalmologist assumes ultimate responsibility for treating the disorder. The referring optometrist may observe the operation and may assist in the preoperative and postoperative care. However, medical/surgical care is always rendered personally by the physician. Referrals from HU to PCO may include the following: (1) contact lens care; (2) eyeglass dispensing; (3) orthoptics; (4) low-vision and vision rehabilitation; and (5) learning disabilities.
The protocols define a “closed loop provision system” that enables providers to monitor more effectively the quality of care rendered. Under PCO’s previous program, patients were referred to independent consultant ophthalmologists for medical/surgical treatment. This system was open-ended, and methods of record keeping were informal. In the closed system model, providers are in regular communication, and referral information is compiled and reported on a monthly basis. Furthermore, independent computer systems currently being implemented at both HU and PCO will allow providers to monitor care more effectively and determine when patients miss appointments or leave the system so that appropriate follow-up communication can be initiated.
While the protocols were being finalized, administrative staff began to define the operation of the provision system. Issues such as scheduling, personnel, space requirements, equipment requirements, medical records management, and billing policies and procedures were addressed. Given the high volume of clinical activity at The Eye Institute, HU employs a full-time office manager at that facility to oversee the Department of Ophthalmology’s clinical and financial operations. This person is responsible for patient scheduling, registration, charge entry, and medical record preparation. Pennsylvania College of Optometry operates contact lens and low-vision services at HU one-half day each week. The Eyewear Center, located at HU, and also operated by PCO, is open 5 days each week and is staffed by PCO employees.
Joint clinical chiefs’ meetings are held regularly to monitor the progress of the affiliation in general and, in particular, to evaluate the protocols, discuss quality assurance issues, and to review clinical programs. These meetings help maintain open communication among the providers and facilitate patient care provision. To date, revisions have been made in the glaucoma and cataract protocols.
The affiliation agreement encourages joint research ventures and, indeed, opportunities for collaborative research are considerable. Approximately 75,000 outpatient visits are recorded each year at The Eye Institute. Likewise, 282,000 outpatient visits for medical problems, including eye disease, are scheduled at HU. As a result of the affiliation, investigators have a large base from which to draw patients for studies. Faculty at both institutions are currently working together on research projects, which include learning disabilities and macular degeneration. Protocols for excimer laser investigations also have been discussed. Should these be pursued, optometrists will engage in basic research while ophthalmologists and other physicians will conduct clinical trials.
Of special note is the fact that research areas have not been limited to eye disorders and disease. Faculty at HU’s Department of Neurology and Psychiatry have joined faculty at the PCO’s Learning (Disabilities) Center in research investigating learning disabilities.
Recent Developments and Future Directions
Over the past year, many of the goals of the affiliation have been realized, and the future looks very bright to us. As participants of the PCO externship program, a few selected optometry students soon will have the opportunity to share in patient care in the Department of Ophthalmology at HU. New projects under discussion include a joint prison eye care program and the establishment of satellite clinics and faculty private offices, which will be structured according to the provision model previously described. Satellite clinics would be geographically located in the Philadelphia area to serve areas populated by the “underinsured” – the working poor who do not have adequate health care coverage. The faculty private offices would be strategically located to enhance the marketing potential of the affiliation.
Marketing initiatives already are underway; efforts will be directed to optometrists in private practice, primary-care physicians, managed-care systems, commercial insurers, and the general population. The opportunities for marketing are perhaps greatest in the managed-care sector. The model of eye care provision developed under the eye care affiliation is consistent with that used by many managed-care systems, i.e., optometrists provide primary eye care, while ophthalmologists provide medical and subspecialty care. The vehicle for marketing services to managed-care systems will be EyePA Ltd, Philadelphia, a for-profit subsidiary of PCO. On a contractual basis, EyePA Ltd provides eye care services to managed-care systems, self-insured corporations, and other insuring entities. EyePA Ltd is a multifunctional specialty organization that (1) manages utilization of eye care services; (2) provides, on a capitated or fee-for-service basis, a full range of professional eye care services through a network of contracted professionals; and (3) credentials specialty eye care providers and institutions.
Many individuals maintained that doctors of medicine and doctors of optometry could not work together as colleagues sharing the same goals and aspirations.
Looking back over the past 17 months, we believe that the skeptics were wrong. The affiliation has exceeded our expectations and has progressed much more quickly than any of the planners had imagined. Events to date suggest that joint educational, clinical, and research programs have been advantageous to both medicine and optometry, and that teams of medical doctors and optometrists can work together as colleagues in one eye care provision system.
Archives of Ophthalmology
Controversies in Ophthalmology
Volume 109, Number 2. February 1991.
Charles F. Mullen, O.D.
Myron Yanoff, MD
Laura A. Wilson, MS