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    Analysis: Profession must revise provision of care

    Optometrists, opticians can aid offering of high-quality, economically sound services


    J.C. Noreika, MD, MBA
    Efficiency. Productivity. Industrialization. Ophthalmologists may be forgiven if they think they have mistakenly stumbled upon the latest issue of Forbes or the Harvard Business Review when perusing the ophthalmic literature. Leading voices of professional organizations have discovered the need to revise the model by which comprehensive vision care is provided.

    Care of the visual system is unusual because it features three different categories of practitioners, each with its own unique and overlapping skill sets. These categories include ophthalmologists, optometrists, and opticians. Each is divided into subspecialties, and each is supported by technicians and assistants. It is only recently that organized ophthalmology has proposed a concerted effort to integrate the three pieces into a unified whole.

    I have employed optometrists and certified technicians in my practices since 1984 and thus bring bias to the discussion. Allowing competent professionals to operate within the context of their training and bound by its constraints permits greater practice efficiency and patient care effectiveness, in my opinion.

    Facing new challenges

    Three causes are driving ophthalmologists and their organizations to rethink how service is delivered. In no particular order, these include the baby-boomer demographic "tsunami" that will be felt when boomers born Jan. 1, 1946, turn 65 in 2011. The incidence of cataracts, age-related macular degeneration, and glaucoma, and the epidemic of adult-onset diabetes, will overwhelm even the most efficient classic delivery model.

    The second cause is the steady-state production of new ophthalmologists by the nation's training programs. Even if programs can be ramped up, it will take several years before any meaningful impact on the profession is realized. This situation is compounded by the simultaneous feminization of medicine and the advent of the Generation Y professional—both women and members of Generation Y regard flexibility and control of their time as important as compensation.

    The third instigant concerns the inevitable decrease in payment for the services that ophthalmologists provide and the well-recognized downward pressure on income as the cost of doing business escalates.

    According to physician income surveys published by Ophthalmology Times' sister property Medical Economics, ophthalmologists' position relative to the income levels of other specialties has eroded alarmingly in the recent past. Despite technologic advances in refractive surgery, premium IOLs, and sight-saving treatment options for wet macular degeneration, little validation exists that ophthalmologists will be rewarded for these innovations. Unlike bankers and financiers, whose labor input is equivalent whether the amount in question is thousands or billions of dollars (exponential labor), ophthalmologists are limited by the finite amount of "piece work" they can do in any given period (arithmetic labor). Thus, enhancing income level by increasing volume of services produced is a risky alternative for provider and patient.

    The cost of labor

    Manufacturing, on the other hand, can employ many tools to diminish the unit cost of its product. Tactics such as robotics, outsourcing, and employing low-cost, off-shore labor markets are not applicable to many service businesses. Services are constrained in that production usually is followed by immediate consumption. In medicine, only rationing of care can produce inventory. Instead, services must rely on strategies designed to reduce the cost of producing the work.

    The cost of labor is the primary expense in most medical practices. Important cost centers are the ophthalmologist-employee, the optometrist, and the certified ophthalmic technician. Unless ophthalmologist-employees and optometrists are compensated on an "eat what you kill" model, that is, straight productivity with an offset to reflect the cost of business and a return on investment, ownership assumes economic risk. Therefore, it is essential that highly compensated personnel be assigned only those tasks that training and skill make them uniquely qualified to perform.

    Certain tasks, for instance fitting and following contact lens patients, become a cost center instead of a profit center because the inherently small profit margin can be offset by the high compensation commanded by the professional. Contact lenses can contribute to the earning stream of a practice as long as the requisite economic inputs—cost of the fitting professional, the training technician, patient follow-up, the contact lens itself, professional liability, shipping, and billing—do not exceed the cost at which a reasonable return can be realized. Otherwise, maintaining a contact lens practice can be rationalized if the ophthalmologist enjoys providing the service (a hobby), has the time and space (unfilled capacity), or contact lenses are used to entice higher-value patients into the practice for, say, refractive surgery (a loss leader).

    Proceeding from this premise, it becomes untenable to justify an ophthalmologist or any highly compensated professional routinely performing refractions in the clinic. An essential part of the analysis of the visual system, refractions can be time-consuming and labor intensive while providing little value to the practice's bottom line (although an unhappy patient with a poor refraction can do much harm).

    Employing optometrists and refracting technicians for 25 years, I respect their skill and commitment to their work. Optometrists can enhance patient care in an ophthalmic setting. Neither optometrists nor certified technicians are low-cost labor, however. My review of Internet compensation sites and employment surveys reveals that full-time optometrists command six-figure salaries with benefits.

    According to the 2009 benchmark survey published by the Health Care Group of Plymouth Meeting, PA, certified ophthalmic technicians are paid wages averaging $17.41 to $37.01 per hour. It is insufficient to advocate the employment of high-cost labor in an ophthalmic practice without providing a plan to use its talents best. These professionals must be employed to render the highest-value services that conform to their skill, experience, and training. Hiring an optometrist or certified ophthalmic technician to do refractions makes little economic sense.

    Reduce costs with technology

    Advantages of labor-saving technology must be included in the discussion of retooling the method by which vision care is provided. Practice ownership and management first must critically analyze how the clinic's services are delivered. The vital question is, where and how can higher-quality service be provided at a lower unit cost?

    Before 2006, my practices employed optometrists and refracting technicians to produce the optical prescription. Quality was assessed by tracking the number of "doctor remakes" and by spot telephone surveys of patients who purchased glasses in our optical dispensary. Since then, I have purchased a refraction system (Epic 5100 with 3-D Wave, Marco/Nidek). Technicians, only one of whom had previous manual refracting experience, perform the wavefront refractions. The refraction system console is complemented by automated refracting units (TRS, Marco/Nidek) in some exam lanes. To eliminate transcribing errors, the data automatically are entered into the practice's electronic medical record and are printed to the optical dispensary.

    The practice has lowered the cost of service and now provides a higher-quality product. The system provides data that cannot be conveyed by a manual refraction. Using the same quality metrics as before, the dispensary's remake rate is negligible, and the need to reassess the patient's glasses is a rare event.

    I also can hire inexperienced job applicants who possess intelligence, exceptional people skills, and diverse employment backgrounds and quickly teach them refracting technique. Recently, I have retained a valuable and experienced employee who sought new challenges to avoid job burnout. I still use optometrists to provide care for the more difficult refractive problems, such as prism therapy and keratoconus correction.

    This is but one example of how technology can be used in the ophthalmology clinic to reduce the significant cost of finding, training, and retaining skilled personnel. The new realities of ophthalmic practice necessitate that highly compensated optometrists and ophthalmic technicians perform tasks that bring value to both the patient and the practice's stakeholders. To be prepared for rapidly evolving demographic and economic change, ophthalmologists must embrace the labor-sparing, cost-saving, and quality-enhancing offerings of the industry's best technology when remaking the method by which services are provided.

    J.C. Noreika, MD, MBA, is the founding partner of Excellence in Eyecare, Medina, OH. Responses to this column may be sent to Ophthalmology Times Associate Editor Christina Phillis at
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