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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


    Gaining the confidence of legislators and their staff is crucial and doesn’t have to consume a lot of time. We need to become their educators of health-care needs. Ophthalmologists have to get into the game.

    GARY: I am bullish on the future of ophthalmology, because our society is so dependent on images and visuals.

    The need for our services will only grow as the baby boomers reach older age. The benefit that ophthalmology provides for them and society as a whole is enormous. But it won’t be rewarded unless we educate those who determine our compensation and formulate regulations to ophthalmology’s value.



    More about Drs. Gary and Melissa Brown

    One constant in the chaotic evolution of America’s health-care delivery system is its mandate to demonstrate the value of medical intervention. Encompassing cost and benefit, the concept of value is highly subjective. But it affords a model to quantify the quality of care. Utilizing but distinct from Big Data, it is most informative when correlating the patient’s perception of quality of life with a therapy’s cost.

    Gary Brown, MD, MBA, and Melissa Brown, MD, MN, MBA, have been at the forefront of this movement for almost two decades. Their articles have been published in ophthalmology’s most prestigious journals including Ophthalmology, the British Journal of Ophthalmology, and the Transactions of the American Ophthalmological Society. Along with co-author Sanjay Sharma, MD, their book “Evidence-Based to Value-Based Medicine” was published by the AMA Press in 2005 and is referenced by health-care decision and policy-makers worldwide. Thomas Scully, head of the Centers for Medicare and Medicaid Services under President George W. Bush, wrote its foreword.

    Leveraging their careers in private practice and academia, they witnessed the unrelenting socio-economic changes affecting both.. With a strong interest in the changing needs of health care, in 1998, they co-founded the Center for Value Based Medicine. Melissa serves as the president and chief executive officer while Gary is chief medical officer. Gary, professor of ophthalmology and director emeritus of the Wills Eye Hospital's Retina Service, has published widely and has been recognized and honored by the specialty’s organizations. He continues to practice full time at Mid Atlantic Retina and Wills Eye Hospital.

    His partner and spouse, Melissa, professor of ophthalmology at Thomas Jefferson University, has retired from a private practice in comprehensive ophthalmology in Flourtown and at Wills Eye, now invests her time and energy in the work of the center. She has been a two-time nominee for U.S. Congress (PA13) and is pleased to be able to contribute to the ongong health-care reform process, both polliticall and through active research, teaching, and consulting.

    —J.C. Noreika, MD, MBA





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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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