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    Insider secrets to improve value-based medicine

    Drs. Gary and Melissa Brown share lifelong vision for improved patient quality of life


    Sight Lines By J.C. Noreika, MD, MBA

    Editor’s Note: In this installment of Sight Lines, Gary Brown, MD, MBA, and Melissa Brown, MD, MN, MBA, discuss their work quantifying the value of ophthalmic care as it relates to the improvement of patients’ quality of life. Their use of Quality-Adjusted Life-Years methodology allows comparison of cost-effectiveness of medical, pharmacologic, and surgical interventions within and across specialties.


    J.C. Noreika, MD, MBA

    DR. NOREIKA: Tell our readers what led you to this mission.

    MELISSA: I come from a long line of medical practitioners. My father and grandfather were physicians. While beginning my medical career in nursing as a clinical nurse specialist and nursing educator, with the support of my husband, I returned to school. I earned my medical degree at Jefferson Medical College, completing my ophthalmology training at Wills Eye Hospital. I maintained a private practice in comprehensive ophthalmology and in 1998, Gary and I founded the Center for Value-Based Medicine.

    Did you see this? Patients who lost eye insist they can still 'see'

    It was clear to me that health-care policy needed to change to keep up with the growing health-care expenditures but appreciated the clear need for improved quality care. The undertaking has focused on collaborate work with other physicians on developing a systematic approach that could meet both objectives in the United States. My long-time concern for maintaining quality health care for our patients and family has remained the incentive for my efforts.

    GARY: After graduating from Colgate College, I attended medical school in New York. I did my ophthalmology training at Wills Eye and stayed on to complete a vitreoretinal fellowship. My early career was influenced by the mentorship of Dr. Jerry Shields who remains a colleague and good friend.

    More from Dr. Noreika

    After my fellowship, I joined the faculty at Wills Eye Institute and have enjoyed the rewards of an academic career—research, writing, teaching, speaking. I’ve had a keen interest in empowering ophthalmologists and saw early on how the system favored payers over providers and patients. This led Melissa and I to our next adventure.

    DR. NOREIKA: You started a health insurance company. I remember Gary speaking about it years ago to an ovation at an American Academy of Ophthalmology mid-year forum. Tell us about this.

    Next: If docs want to be in charge of the system

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      Re: focal points presentation of the editorial advisory board appearing in Ophthalmology Times May 2015 “At the Center of Pursuit for Value –-Based Medicine" Dear Dr. Noreika, I read your Sight Lines article about the timeless work and lifelong vision of Gary and Melissa Brown toward improving the evaluation of patient quality of life that we provide our patients by our medical care. I am well aware of their work and of the dedication of these two timely physicians as well as the increased concern voiced in the medical literature and by CMS demanding our attention in this regard. The problem I have is with the chronic dependency of ophthalmology and optometry upon utilizing chart visual acuity in the measurement of our outcomes, and, as you are aware it is the basis of the Brown's research in evaluating ocular procedures against others in defining their Quality – Adjusted Life – Years (QALY) methodology. The difficulty of this is that while we have measured vision outcomes using chart acuity for more than 160 years, this method is a poor psychophysical threshold and, contrary to popular belief, has never been validated against visual performance. To the contrary, studies such as the Smith-Kettlewell Foundation’s measurement of visual decline in normal eyes of aging individuals (60 – 90) demonstrate that it only very poorly detects the severe decline in vision performance, even in these “normal eyes"(1). While ophthalmic surgeons and optometrists have utilized this measurement as justification for what we do, it would be similar to the orthopedic surgeon evaluating the outcome of their surgical manipulation or joint implantation by measuring the position of the limb before and after surgery but failing to measure the range of motion, stability of the joint, strength of the joint, the pain associated with operation of the joint, or the performance of that joint in a number of desired daily activities (playing golf, hitting a tennis ball). I recognize that for FDA trials in which ophthalmologists participate, recompensed by pharmaceutical companies, very often quality-of-life visual function questionnaires are recorded as well as measurements of visual acuity. However at meetings, patient reported outcomes are never reported. Why? because “docs don’t want to hear about this.” I have informally polled approximately 200 retina specialists, 100 cataract surgeons and more than 50 LASIK surgeons, but outside of such pharmaceutical trials, VFQ’s are never performed in the office. I have read the Brown's book, “Evidence – Based to Value –-Based Medicine” published in 2005 and applaud their work in their attempt to prove to the rest of the medical world “that the benefit ophthalmology provides for them (these baby boomers) and society as a whole is enormous but won't be rewarded unless we educate those who determine our compensation and formulate regulations to ophthalmology's value." In order to define the value that our surgical procedures and office work provide to our patients, we must proceed beyond the mere measurement of chart acuity or chart contrast sensitivity measurements. Enabling that direction, I have invented an iPad-based application that allows the patient to easily record answers to standard visual function questionnaires (such as the NEIVFQ-25) in large print while sitting in the waiting room, waiting to see the doctor. The results are uploaded to the cloud where they can be compared against prior measurements, measurements of other patients, or other’s results as well for research. The app also provides printouts that are meant to be given to the patient providing general recommendations to assist the tasks for which they have noted difficulties (and acknowledging the physician’s concern and caring). I believe that apps such as this should be strongly recommended for physicians to add to their examinations in justifying the office and operating room procedures for which we ask reimbursement. Certainly as David Parke has commiserated with me, in the future we will just be relegated to the Wall Street Journal’s list of overpaid clinicians. In the zero-sum dollars competition for medical care allocated payments we have to use every method feasible to demonstrate to the world our value at a time when the baby boomers need us the most. I would encourage you to publish an article regarding this and perhaps other related apps and encourage their use. Stephen Sinclair Sinclair Retina Associates (http://sinclairretinaassociates.com) Sinclair Technologies (http://sinclairtechnologiesllc.com) 200 E. State Street, Suite 301 Media, Pa. 19063 610-892-1708 [email protected]


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