The American Society of Caract and Refractive Surgery's magazine, EyeWorld quoted Dr. Dominick Maino extensively on his views concerning the role optometry and ophthalmology should play in the integrated practice.

1. The Best of Ophthalmology.....EyeWorld News Magazine
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Advanced Search FEATURE Ophthalmology and optometry:
working together
EW WEEK No. 4
by Michelle Dalton, EyeWorld Contributing Editor
· Bayer, Regeneron
initiate Phase III
VEGF Trap-Eye study A decreasing number of ophthalmologists, coupled with an
in Asia increasing patient base, has led numerous physicians to embrace an
· ifa Systems buys integrated eye care model—where optometrists, ophthalmic
Inoveon
technicians, and ophthalmologists all work under the same roof to
· B+L introduces provide efficient and effective patient care.
iPhone app for
Others prefer co-management—where different practices refer
Crystalens
patients across boundaries and leave the optometrist as the primary
· Celtic Therapeutics
to license Resolvyx care physician to handle a majority of eye care complaints. In the
dry eye treatment majority of states, optometrists can diagnose and treat glaucoma,
program refractive errors, numerous anterior segment diseases (such as dry
eye), and can prescribe oral and topical drugs. With the current
View this Issue healthcare reforms, it's likely that "co-management will take on a With the current state of
greater role, as will integrated eye care," said Michael Fu, OD, in healthcare reforms, most
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private practice at D'Ambrosio Eye Care, Inc., Lancaster, Mass. optometrists think working
"Primary care providers are going to provide more care to more with ophthalmologists
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people," and with some major insurance companies no longer provides the best patient care
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accepting consultation codes, integrated practices may be more model
Subscribe efficient, he said.
Noting that "integrated eye care can have nothing to do with co-management," the former is likened
Monthly Poll to a vertical integration in the same practice, and co-management comprises different practices
where both jointly manage the patient, said Jimmy Jackson, OD, president of InSight LASIK,
Lafayette, Colo.
Do you believe The pressures of healthcare reform—as it currently stands—"will favor practices with multiple
refractive volume practitioners in them, whether it's large optometry practices with consulting ophthalmologists on staff
will rebound during or vice versa," Dominick M Maino, OD, MEd, FAAO, FCOVD-A, a professor of pediatrics/binocular
2010? vision at the Illinois Eye Institute/Illinois College of Optometry, Chicago, and an adjunct professor of
pediatrics at the Centro de Optometria, Madrid, Spain, and is in private practice in Harwood Heights,
Yes
Ill. He believes an area that has not yet fully embraced the idea of integration—but should —is
No pediatric ophthalmology and optometry.
When executed well, both optometrists and ophthalmologists benefit, experts say. The primary care
physician (usually the optometrist) probably knows the patient "better than anyone else, and is a
fully engaged member of the team," Dr. Jackson said. The surgery centers win in this scenario, he
View Poll Results said, because each member of the team has access to the most complete patient records and
ophthalmic surgeons can spend more time on surgery and less time on routine care and post-op
Resources care. Optometric practices benefit as well—"the best way to retain patients in the long-term is to
facilitate the best secondary and tertiary care and be an integral member of the post-op team," Dr.
Jackson said.
Ophthalmologists Dr. Fu agreed, saying co-management/integrated eye care is a "more efficient way of treating
patients. The specialists are busy perfecting their surgical techniques, and we can easily handle the
Practice Managers
primary care aspects. In this model, we see numerous potential surgical candidates, not just those
Patient Education who have no problems in their post-op or those who don't have a need for surgery."
Of concern to the American Medical Association and the American College of Surgeons is that the
EyeSpaceMD most appropriate trained professional be responsible for post-op care – and that co-management is
not approved by those societies when based on economic decisions to transfer care of patients after
IOL Calculator surgery, and in fact, may be illegal.
Keys to success
As with most business plans, integrated eye care can only succeed if there is mutual respect
between the ophthalmologists and optometrists. "There's no magic formula or true secrets that
someone knows that will magically make your practice a successful one," Dr. Jackson said. "There's
no secret beyond having a solid business plan, working really hard and paying attention to details."
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2. The Best of Ophthalmology.....EyeWorld News Magazine
His practice follows three tenets: high-touch (meaning every team member pays attention to every
detail of patient care), high-tech (continuous investment in new technology and education for all staff
members), and high respect of all team members in co-managing all patients.
Some practices have continued to thrive simply by putting patient care first, said George Rickard,
OD, in private practice at Laurel Eye Clinic, Brookville, Pa. "We've continued to prosper over the
years because of our model. We support area ODs and our commitment to integrated eye care.
When new surgeons join our practice, they have to share the company philosophy and show they're
committed to the model we've created or they wouldn't fit in," he said. Laurel Eye Clinic has three
main offices and several smaller offshoots, and each team member is committed to the founder's
philosophy, he said.
At Illinois Eye Institute, "we have 'advanced care area' with incredible ophthalmologists who work
with us. It is a very good working relationship. In that sense, it's an integrated environment," Dr.
Maino said. In that case, there's a three-physician office with a full referral list of ophthalmologists
"whom we know we work well with and with whom we've built a long history."
As a practice, Dr. Fu said the group has "a mission statement to deliver the best possible eye care.
You have to have a mission statement inn mind to focus on what you want to do. We have to
continually train and motivate staff. We close our office once a month to discuss the mission
statement with everyone on staff," he said. "The goal is to consistently ensure patient care is the
first and foremost topic in our minds. It's imperative to the success of a practice to listen to the
patient, follow-through, etc. It doesn't have to mean spending a lot more time on the patient care.
Our staff meetings include updating each other on the latest research and treatment, what's new in
the journals, etc."
Pros and cons
For some optometrists, the advantages of an integrated eye care practice are numerous. For one,
optometrists have readily available access to specialty care for their patients, Dr. Fu said.
"The patient already knows the practice and doesn't have to travel further to go see a specialist, or
worry about not being familiar with the practice," he said. Additionally, he believes that for
optometrists who are so inclined, working in an integrated practice can be a "great learning
experience." Further, since everyone on staff has access to all the charts, there's an immediacy co-
managed practices cannot offer.
"Immediately after someone's been referred to the ophthalmologists, we can see what the diagnosis
was, or how patient care proceeded with their specialist. We're never caught waiting for referral
letters back from another office," he said.
Dr. Rickard noted one advantage of an integrated model is the ability to control the quality of care
because everyone is under the same roof. "There's nothing wrong with the quality of care of an
independent doctor, but an integrated model might be more attractive to groups of surgeons in
terms of oversight and control whereas the traditional model of a single 'storefront' might be more
applicable to a surgeon who's by himself because of logistics," Dr. Rickard said. "For instance, if
you're the sole eye care provider in a small town, you might better serve your patients if you've got
a network of specialists you can use."
If surgeons prefer to maximize their time performing surgery, "then the integrated model is good
because the surgeon is using his skills and training to the maximum," Dr. Rickard said. "If you're the
type of surgeon who enjoys handholding and spending a lot of time with patients without necessarily
doing a high volume of surgery, or you enjoy the interaction with patients after surgery, then co-
management might be for you."
The advantages of an integrated eye care practice are "significant if there is, indeed, mutual respect
for the skills of each profession," Dr. Maino said. "What I find in the day-to-day interaction for most
practitioners is that the mutual respect is there. Optometrists find the ophthalmologists who value
our abilities. Integrated eye care can only work when both professions have a god understanding of
what each other does and allows each to do what we do best for the patient."
Optometrists interviewed for this article could not name many disadvantages to an integrated eye
care practice. For the most part, the only down side remains a somewhat territorial attitude about
patients, where once referred to the practice's ophthalmologist, patients are not "handed back" to
the optometrist until it's time for the annual vision exam. One disadvantage to a co-managed
approach is a potential for poor communication between the two practices which could inadvertently
lead to complications with insurance paperwork or even patient records if practices are on different
electronic health records systems.
Politics
In most states, optometrists are not allowed to perform
intraocular surgery or use lasers. Beyond that, however, most
optometrists believe their role as the primary eye care
provider should place them in a leadership position, working in
cooperation with a specialist.
"Despite what the ophthalmic community might say, an
appropriate healthcare system should be under the leadership
of the primary eyecare provider, which is usually the
optometrist," Dr. Maino said. "In most states, optometrists
practice medical ophthalmology at the highest level,
diagnosing and treating glaucoma and anterior segment
problems. When something goes beyond our scope of
expertise, we'll make an initial diagnosis and refer out to an
ophthalmologist. What benefits everyone in that situation is
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3. The Best of Ophthalmology.....EyeWorld News Magazine
that it frees up the ophthalmologist to do what he or she does
best, which is more surgery. The more surgery they perform,
the better they become, the better the patient outcomes.
Conversely, the more optometrists are managing the patient
as a primary care practitioner, that individual also becomes
more skilled at a much higher level."
In Massachusetts, optometrists are allowed to place punctal
plugs and perform punctal occlusion, but "we can't prescribe oral medications. We can prescribe
topical, but not oral," Dr. Fu said. The state legislature has been debating the issue "for years and
years," Dr. Fu said, but Massachusetts remains the sole state that makes it illegal for an optometrist
to prescribe glaucoma medications. "Overall, optometrists have shown across the country they are
well-trained to diagnose and treat glaucoma and are very willing to refer for those cases they can't
handle or when patients are progressing even with treatment."
At the core of the issue, Dr. Jackson said, is that optometry is a regulated profession, yet there's no
universal agreement among the states as to what an optometrist can and cannot do. "Because I
have lived and practiced in different states, I've seen the legislative battles in all of them, and I'm a
little cynical on the process," Dr. Jackson said. "Optometry as a profession is continually going back
to the legislature to deal with advancements and how to allow the physicians to change and grow."
He adds that legislative battles are only about patient care and not monetarily based "is complete
baloney. There are scores of practitioners who get along wonderfully well, but in the hierarchy there
are some fundamental differences."
On the other hand, continuing to define optometry "as a non-surgical profession and I don't have a
problem with that," Dr. Rickard said. "Some optometrists out there don't feel we should be that
limited, but the vast majority are okay with the laws the way they are. Of course, there are some
ophthalmologists who begrudge optometrists for what we're allowed to do. Some, not most, but
some."
Moving forward
Dr. Fu believes integrated eye care will continue to gain in popularity, mainly because optometrists
"can learn quite a bit by being that much closer to the specialist, and can become more comfortable
with patient care because of that relationship. The ophthalmologists in our practice have helped
make us all better diagnosticians." Overall, he said optometrists are not trying to "steal" anyone's
patients; they're comfortable "treating what we treat and we know when we need a second opinion
or something is out of our comfort zone."
Co-managing patient care is "the most cost-efficient care model for the patient," Dr. Jackson said,
based on the greater geographic distribution of ODs in general.
"There's going to be a greater interest in co-management because it makes fiscal sense for the
overall healthcare system," he said. "There's always going to be patients who need to be referred
out. No matter how good an individual state law is, and no matter how comfortable an optometrist is
performing various procedures, there are patients who are going to need secondary and tertiary
care."
With patient loyalty dictated more by insurance company coverage than actual quality of care these
days, "if you tell a patient they've been diagnosed with X, 'here are some practices I work with for
you to go see,' the patient isn't going to feel you're involved in their disease management. You're
not helping them navigate the surgical aspects of their disease. If, however, you refer the patient to
an individual doctor, or tell them you've created a lists of people who can provide the best care for
their diagnosis but you will be the point person and provide all the pre- and post-op care, you're in
essence doing what you can to foster some sort of patient loyalty."
Any business model that can "improve efficiencies in the delivery of care is going to succeed," Dr.
Rickard said. In the future, he envisions practices vying or bidding for government contracts and
integrated eye care groups will be better positioned to compete in that scenario than a typical co-
managed practice.
Saying a colleague of his noted optometry "is no longer just on the menu, we're on the table," Dr.
Maino said, "our associations have spoken to lawmakers. Because optometry has taken such an
approach to our involvement of healthcare at state and national levels, I hope our ophthalmic
colleagues will realize working together is the only way to achieve good patient care."
He firmly believes that if the two professions do not work together to provide patient care,
"lawmakers will gobble us up. They'll dictate to us what system they want for eye care delivery and
they'll determine who's the least expensive to provide it."
Dr. Jackson agreed, "To be true partners with ophthalmologists is the ultimate. That being said, a lot
of optometrists and ophthalmologists go into practice because of the autonomy. You will give up
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4. The Best of Ophthalmology.....EyeWorld News Magazine
some of that when you join an integrated practice. One of the beauties of our profession is that it's
so broad and there are so many options available to us, we do have the best of all worlds."
Editor's note: No one had a financial interest to disclose aside from a vested interest in his practice.
Contact information:
Fu: (978) 537-3900; michael.fu@dambrosioeyecare.com
Jackson: (303) 665-7577; jimmy@insightlasik.com
Maino: (312) 949-7280; dmaino@ico.edu
Rickard: (814) 849-8344; gsr849@aol.com
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