Would an O.D. Complete the Picture?

Puzzled by the potential role for an optometrist in your practice? Here's a look at many possible combinations.

BY JERRY HELZNER, SENIOR EDITOR

Anyone who takes the time to scan the archives of this publication over the past decade will find numerous news articles describing scope-of-practice "turf" battles between interests representing optometry and organizations that speak for the ophthalmology community. A reader of these articles might naturally assume that the relationship between optometrists and ophthalmologists is decidedly confrontational.

That might be somewhat true at the organizational level, but Ophthalmology Management has found that at the grassroots level, where ophthalmology practices routinely employ — and depend on — optometrists to carry a major share of the practice workload, relationships between M.D.s and O.D.s tend to be complementary and cooperative. This article will focus on those relationships while offering insights into the best and most cost-effective ways to employ optometrists in a comprehensive eyecare practice.

Using O.D.s in Practice

Especially in smaller practices, ophthalmologists use words such as "partner" to describe the optometrists they employ. Some M.D.s even describe their employed O.D.s as the equivalent of "medical ophthalmologists."

Of course, even those ophthalmologists who delegate a great deal of responsibility to their employed O.D.s are quick to point out that none of these duties go beyond the scope-of-practice limitations imposed by the specific state in which the practice is located. However, many ophthalmologists surveyed for this article said that they are happy to utilize their employed optometrists for any and all tasks that fall within the approved scope-of-practice, including the routine use of newer, high-technology diagnostic equipment that is now a part of optometrists' training.

Conversely, in most retina practices O.D.s appear to still be performing only highly limited tasks, such as refractions and providing low-vision rehabilitation. Because their patients primarily come to them as referrals specifically to be seen by the subspecialist, retinal physicians typically do not permit O.D.s to be involved in any retina-related evaluations. But that, too, may be about to change as retinal physicians seek to create efficiencies in the face of increased costs and declining reimbursement.

"In a retina practice, optometrists could perform routine diabetic and age-related macular degeneration exams," says Andrew Antoszyk, M.D., a retinal specialist with Charlotte Eye, Ear, Nose and Throat Associates, Charlotte, N.C. "They could be trained to assess the need for fluorescein angiograms and optical coherence tomography (OCT) scans. Angiograms would be interpreted by the retina specialist but OCT could be interpreted by the O.D., with clarification provided by the retina specialist in more challenging cases. O.D.s have the core examination techniques and could be trained to perform postoperative retinal exams. There are a multitude of reasons why O.D.s would be a benefit in the retina practice.

"They increase the number of patients seen by the practice per unit hour, which increases revenue for the practice and allows the retinal specialist to focus on patients with surgical pathology," continues Dr. Antoszyk. "O.D.s would help with patient education, communication with referring physicians, ancillary study interpretations and chart documentation. The question is not whether a retinal practice can successfully integrate an O.D. into the practice, but when is the appropriate time to implement such a plan?"

One M.D.; One O.D.

But while retina continues to see a circumscribed role for its optometrists, many general ophthalmologists see their employed O.D.s as key members of the practice.

Michael Korenfeld, M.D., of Comprehensive Eye Care, Washington, Mo., is in solo practice and employs one optometrist.

He says that his optometrist is involved in all the tasks and responsibilities "that are allowed under the law." That includes seeing postop patients, performing full work-ups, referring surgical patients to Dr. Korenfeld, participating in the diagnosis/treatment of glaucoma and all other medical eye care.

"The O.D. in my practice makes full use of all the same equipment I use and has access to the same technical support staff," notes Dr. Korenfeld. While most refractions are performed by a technician, Dr. Korenfeld's O.D. has primary responsibility in fitting contact lenses, treating and monitoring dry eye patients, checking most of the postop cataract patients and conducting some initial consults with refractive patients.

Jennifer Peek, O.D., conducts an essentially independent practice at the Eye Centers of Tennessee satellite office in Cookeville, Tenn.

"The O.D. does no informed consents," says Dr. Korenfeld. "That is exclusively done by me."

Dr. Korenfeld finds his O.D. especially useful when he is in the O.R. or out of town.

"He keeps the practice going and enables my patients to have access to emergency eye care all the time," says Dr. Korenfeld. "I really rely on my O.D. because he is the best optometrist I know. We work together wonderfully and discuss all interesting or tricky patients. He is motivated, extremely skilled, caring, has great follow-through, and if he says there is a retinal tear in the far periphery at the two o'clock position, I better keep looking until I find it, because he has only been wrong five times in the last 9 years (I keep score)."

Steven Silverstein, M.D., of Silverstein Eye Centers, Kansas City, employs an O.D. who works exclusively for him, although there are two other ophthalmologists in the practice.

"He serves as an M.D. extender and remains separate from shared practice overhead," says Dr. Silverstein. "He sees all of my postops, takes first call on weekends and carries his own load of general eyecare patients. He is fellowship trained and feels very comfortable caring for the pre- and postop needs of cataract, refractive, glaucoma and corneal patients. He also plays a leading role in all of our research studies and functions as our community O.D. liaison."

In the area of diagnostic technology, Dr. Silverstein says that his O.D. can evaluate visual fields, OCT, topography and wavefront analysis at a level comparable to an ophthalmologist. The O.D. is not asked to evaluate fluorescein angiograms.

"For dry eye patients, the O.D. can put in punctal plugs if indicated and prescribe Restasis (Allergan) as needed," notes Dr. Silverstein. "He also monitors glaucoma patients for progression up to the point where they would require laser treatment or surgery."

Dr. Silverstein finds his relationship with his O.D. both personally rewarding and cost effective.

"He literally functions as a partner. By doing my postop care, it freed my schedule to see one-third more paying patients, which has had a direct positive impact on surgical volume and revenue, without adding significantly to overhead."

An O.D. Speaks

Christopher Quinn, O.D, president of OMNI Eye Services, Iselin, N.J., is in a practice that employs both M.D.s and O.D.s. He concurs that optometrists usually have a greater chance to display all of their skills in a smaller practice.

"In a smaller practice, by working closely together it is usually easier to develop mutual respect and a true feeling of partnership," says Dr. Quinn.

Dr. Quinn says that in larger practices, the ophthalmologists tend to see optometrists strictly as employees and to use them primarily as screeners, freeing the M.D.s to deal with surgical and more complicated cases.

"I think optometrists would like to believe that a comprehensive eyecare practice does not necessarily have to be an ophthalmology-led practice. The goal is combining the expertise of both professions for the benefit of the patient," asserts Dr. Quinn. "The ophthalmologists should know that we as O.D.s work confidently within our scope-of-practice limitations and won't overstep them. They also should not inhibit us from making our best possible professional contribution to the practice."

O.D./M.D. Practice Models

Andrew Rabinowitz, M.D., who specializes in glaucoma at Barnet Dulaney Perkins Eye Centers, Phoenix, Ariz., believes that the best model for a larger eyecare practice includes having strong subspecialist M.D.s for glaucoma, cataract, refractive, oculoplastics and retina, backed up by highly competent O.D.s.

"I am not an advocate of having general ophthalmologists in a larger practice," says Dr. Rabinowitz. "I would prefer to have top subspecialists and first-rate optometrists. I would also hire a good O.D. over an older ophthalmologist who no longer does surgery."

Dr. Rabinowitz says that one drawback to giving O.D.s greater responsibility is the consumer culture that exists in the country today.

James Muse, O.D., performs a basic eye exam at an Ocala Eye office in Ocala, Fla.

"Today, patients expect to spend a lot of time with their ophthalmologist," he notes. "Many patients will object if it is an O.D. who is examining them or counseling them."

Ray Mays, practice administrator for Eye Centers of Tennessee, Crossville, Tenn., says his practice follows a somewhat different model.

"We have (the equivalent of) two-and-a-half M.D.s and six O.D.s practice-wide," says Mays. "In our four satellite offices, the O.D.s basically have independent practices. We believe in allowing all of our employees — techs, opticians and O.D.s — to practice up to the limit of their licensure. In fact, we demand it."

Mays says the O.D.s are an integral part of both the practice and the practice business model.

"I want the M.D.s to do only those things that no one else can do, which is mainly surgery and consults," he asserts. "With the training that young O.D.s receive today, they are very capable of handling most of the issues that come up in our practice. We are a general eyecare practice and refer most cornea, retina and glaucoma to specialists so, for us, we try to make as little distinction as possible between the M.D.s and the O.D.s."

A Range of Roles

At Ocala Eye, Ocala, Fla., Peter Polack, M.D., provides another, more traditional way that employed O.D.s can be highly useful to a practice.

He reports that the practice employs two O.D.s to support nine ophthalmologists. The practice has in-house specialists for glaucoma, retina and cataract. It also employs a refractive coordinator. Thus, the O.D.s do not routinely participate in any of these areas or in postop care. The O.D.s are not involved in patient education or the informed consent process. They do, however, help train ophthalmic assistants and are active in community education.

"With a high-density senior population, our patients expect to be seen by an ophthalmologist," says Dr. Polack. "We see our optometrists as specialists in our practice. They are experts in their field of refraction and fitting contact lenses."

At The Center for Sight, Lufkin, Texas, Richard Ruckman, M.D., is the only ophthalmologist covering two offices that are approximately 40 miles apart. However, he has three O.D.s to provide primary care.

"The optometrists each have their own patients," says Dr. Ruckman. "They perform eye exams, fit contacts and take care of straightforward medical problems. Under Texas optometric scope-of-practice, each is considered ‘therapeutic’ and approved to manage glaucoma. They are also involved in dry eye management and treatment of minor problems, such as conjunctivitis. In addition to seeing their own patients, we share in postop care."

Dr. Ruckman says that his O.D.s are actively involved in almost all types of testing except fluorescein angiograms, which are only performed under his personal supervision.

"I feel very fortunate in having optometrists as part of the practice," concludes Dr. Ruckman. "Their focus on primary eye care encourages a broader range of patients to visit the practice. As part of a vision plan, they may see a patient routinely, but this introduction to the practice opens the door for the patient to return for medical issues later on."

Assisting a Specialist

As a leading — and very busy — cataract surgeon, David Chang, M.D., Los Altos, Calif., has found a way for his O.D. to save him much precious time in the patient education process.

"Many cataract patients are also good candidates for refractive IOLs or astigmatism-reducing procedures," says Dr. Chang. "After performing the refraction and reviewing the patient's responses to the Dell questionnaire (on patient lifestyles), the optometrist is in an excellent position to anticipate what refractive options the patient might be interested in. The optometrist will typically select appropriate educational handouts or videos for patients to review as they wait to be dilated. This focused education will efficiently set the stage for the cataract surgeon to subsequently discuss these options with a better informed patient."

Optometrists also handle less traditional tasks at Maloney Vision in Los Angeles, where Uday Devgan, M.D., is a principal in a surgery-only practice.

"We perform the full spectrum of vision surgery, including LASIK, phakic IOLs, cataracts and premium IOLs," reports Dr. Devgan. "We do not do any primary eye care or general ophthalmology. In our practice, the O.D.s are able to help with topography, pre-op and postop refractions, digital photography, clinical examinations and IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) measurements. The O.D.s also can help with patient education."

The Economic Case for O.D.s

Jay Pepose, M.D., of Pepose Vision Institute, Chesterfield, Mo., employs two O.D.s to go with the two ophthalmologists in the practice. While his O.D.s tend to perform traditional O.D. functions such as contact lens fittings, postop follow-up and monitoring dry eye and glaucoma, they also are capable of using the latest diagnostic equipment, such as wavefront analysis.

From the standpoint of cost-effectiveness, Dr. Pepose echoes many ophthalmologists and practice administrators in saying that the use of optometrists is most warranted when they can free up surgeons to spend more time treating and counseling surgical patients.

Kevin Waltz, M.D., of Eye Surgeons of Indiana, Indianapolis, has a slightly different rationale for hiring O.D.s for his practice.

"Our O.D.s provide a level of service that is different from M.D.s," he notes. "This variety of service helps the practice match the best provider with the patient and his or her needs. Our O.D.s are always in the office. They are more available to speak to our referral network and develop their own unique relationships, which in turn promote better communication with our referral network."

And finally, from Dr. Rabinowitz: "With regard to hiring, I believe O.D.s provide a cost-effective option for first-line patient care. They are a better choice than hiring ophthalmologists who have given up surgery and, if properly trained, can offer a more versatile skill set with more upside and less baggage. In general, O.D.s must understand and accept their role in the patient-care process when working for ophthalmologist-owned practices and among ophthalmologists." OM