This blog will depart from my main theme of the primary health care role for optometry in health care reform. This week, I had the unique opportunity to see two patients, back to back, in our neurorehabilitation clinic who were seeking optometric care to manage their intraocular devices.
The first patient had an implantable miniature telescope (IMT) to manage age-related macular degeneration, and the second had an Argus II Retinal Prosthesis System (Second Sight Medical Products) for blindness from retinitis pigmentosa.
The first patient had the IMT in one eye, which provided a small-field magnified image that will need to sync up with the fellow eye. He had no central vision but a full peripheral field. The rehabilitation requires modified applications of binocular vision therapy combined with telescopic refraction, magnification and eccentric viewing techniques of traditional low vision rehabilitation. The development and execution of this rehabilitation program is uniquely applied optometric science.
The second patient had the Argus II implant in one eye and bare light perception. The fellow eye had similar function, and this patient’s advanced retinitis pigmentosa had rendered him blind for the past 15 years. As a master of cane travel, Braille and an array of auditory aids, the return to the use of any meaningful visual input was truly a spiritual rehabilitation session. Working with high-contrast shapes and movements and converting a pattern of light flashes and quiet zones into meaningful visual information was as challenging as it was rewarding.
The second level of work that used our Sanet Vision Integrator (SVI) to translate light stimulation into tactile body movements provided another transcendental moment. Both the patient and I felt the need to double check to be sure we were still in the clinic and not on the “holodeck.” Gene Rodenberry would again be proud to see another one of his science fiction gadgets make the leap from Star Trek to real life.
My role, as an optometrist member of a health care provider team, actually crossed over three teams: one as a member of the IMT program that included retinal surgeons, anterior segment surgeons, optometrists, occupational therapists and low vision professionals; the second one as a member of the Argus II team of retinal surgeons, bio-electric engineers, optometrists, occupational therapists, orientation and mobility professionals; and the third as a member of the neurorehabilitation team that includes physiatrists, optometrists, occupational therapists, physical therapists, audiologists, psychologists and a host of various rehabilitation experts.
The cost of providing long-term rehabilitation for these types of patients as well as many of the patients that we see with concussion, stoke and acquired brain injury will be open-ended and extensive in the current fee-for-service health system.
I expect an expanded role for optometry in the rehabilitation field, but I also expect that health care reform will dictate payment to the respective teams in a capitation, diagnosis-related group (DRG) or a type of outcome-based, “pay-for-performance” system. To be compensated in these future models, optometrists must be part of the health care delivery teams, and the sessions of optometrist care must be quantified and priced as part of the package of required services.
The provision of this type of specialty optometric care will require the same philosophic planning I have been suggesting in my blogs directed to the primary care aspect of optometry. Specifically, these issues are related to re-evaluating optometry’s role in primary care and team building.
The second aspect of this planning is being a part of the development of both the information flow between health care providers and the follow-up contracting and re-imbursement that will flow from accountable care organizations and medical home/medical neighborhood/medical community models that will feature coordinated care. These programs will be generically organized as health systems and are rapidly developing all over the country.
So, no matter what your particular clinical interest and expertise in optometry is, you must be preparing your career and your practice in a manner that is consistent with the principles of health care reform. You must read and study the health care trends and step outside of your individual practice and look at the development of independent practice associations, ophthalmic communities, hospitals, health systems and managed care plans. You have much to offer these systems, from a new entry point for primary care to the unique optometric specialty services. Your local involvement with set the stage for our bright future in the new health care system.