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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


    GARY: It was obvious that if doctors were to be in charge of the system, they had to become involved on the payer side of the equation. In 1995, I decided to enlist the talents and support from some colleagues, evaluate the opportnity to, and subsequently, launch a physician’s-owned insurance company within the state of Pennsylvania.

    More from Sight Lines with Dr. Noreika

    There were a lot of challenges and obstacles for this undertaking. However, we raised money, put together a panel of more than a thousand doctors, and insured lives across the state. It was not sustainable over the long haul. We were undercapitalized given the industry’s increasing requirements for adequate reserves and found that the health insurance playing field wasn’t level. Health systems and hospitals provided favorable rate structures to big, deep-pocketed players and the smaller companies like ours were at a pricing disadvantage. Although not successful, we learned a lot.

    DR. NOREIKA: And this led you to establish the Center for Value Based Medicine?

    Melissa Brown, MD, MN, MBAMELISSA: Yes and no. Gary and I realized we needed to be more knowledgeable about business. We completed a Masters of Business Administration in the executive program at St. Joseph’s College here in Philadelphia. It was a good experience.

    Our classmates were people who worked in business and industry. There was a lot of cross-pollination of shared ideas and experiences. They brought a mature perspective beyond medicine and allowed us to gain insight into how health care and its professionals are valued.

    Office-based surgery coming sooner that you think

    GARY: Not exactly. Sanjay Sharma, then a vitreoretinal fellow at Wills, understood the Canadian health system and was acquainted with the use of Quality-Adjusted Life-Years (QALY) methodology that the Canadian system and Britain’s National Health Service use to do cost-benefit analysis of medical interventions.

    QALY also permitted an objective way to compare interventions across specialties. It is a tool that was first used in urology to gauge cost and benefit of renal dialysis. Since then, its database has expanded to cover nearly all medical and surgical interventions.

    QALY is based on a scale of 0 to 1.0. Zero equates to death while 1.0 defines perfect health. There are conditions with negative numbers, conditions worse than death.

    Next: How QALY affects treatments

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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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