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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


    We have been able to interact with decision at the federal level. These are the people who make the rules for Medicare and Medicare that drive all health insurance.

    We were honored to have Tom Scully write the foreword to our book.

    In case you missed it: Ebola warning for ophthalmologists

    We have shared this information with administrators and legislators. Some have said we were 10 years ahead of where Washington was.

    I found the political process to be very frustrating in some ways. Elected officials are pulled in so many different directions by so many different constituencies that too often the expedient decision is made at the expense of the best decision. It’s a difficult position and tough choices have to be made.

    DR. NOREIKA: What advice do you have for our younger colleagues who, ultimately, will bear the brunt of the changes to the health-care landscape?

    MELISSA: Doctors are busy doing many different things professionally and in their private lives. Getting involved with politics isn’t seen as an attractive option, but a necessar one. 

    Physicians must get involved. Because if they don’t, it will be the academics, PhDs, and legislative assistants who will write the rules that determine everything from treatment protocols to reimbursement levels.

    Next: "I am bullish on the future of ophthalmology"

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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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