In 1987, optometry obtained parity under Medicare with a small change in wording that added optometrists to the list of health care providers classified as “physicians.” Since then, many optometrists have adopted this title and have coined the term “optometric physician.” This became increasingly more relevant as optometrists expanded their scope of practice in all 50 states to add privileges to prescribe medications for treating eye disease. The practice model that most optometrists adopted was not that of a physician; rather, most assumed the role of a medical ophthalmologist.
About this same time, managed care programs became popular, and the family physician began to assume a more aggressive role in health care delivery. The terms “primary care” and “primary care physician” were coined. The American Optometric Association eventually launched a major public relations program to define the role of the optometrist as primary eye care provider and cast optometry as the “primary eye care profession.” The optometrist became the primary care provider of the eye care system. This model served the profession well for many years.
In this new age of accountable care, electronic health records and meaningful use, optometry must once again consider its appropriate role in the new health care system. For many years, optometry has been viewed and classified as a primary care provider and has been favored for better reimbursement by Medicare and other physical health payers. Ironically, reimbursement within the traditional eye care system – third party refraction and eyeglass programs – has not kept pace with the health care system, as optometric services are not valued for their role in health care. Paradoxically, optometrists are more of a liability to the vision insurance companies, as they generate the eyeglass prescriptions that drive up utilization.
Scott A. Edmonds
I pose this question: Why does the health care system favor primary care in general and optometry specifically? The answer is that primary care providers are the first health care providers to interface with patients with minor symptoms or complaints and are in a perfect position to identify risk factors and affect the course of behavior. This process can lessen the chronic and long-term illness and dysfunction that are the real causes of escalating health care costs. This, coupled with a decrease in long-term pain and suffering of the population is why accessible, convenient primary health care is the key to any successful health plan.
Optometry in particular is in the best position within any comprehensive system to deliver primary health care services to people who do not otherwise access the system. One of the key drivers of this is myopia. This disorder starts in childhood and requires yearly visits to the optometrist. Most of these young patients are otherwise healthy yet are in their formative years for the development of life habits and lifestyle choices that can dramatically affect their risk for systemic disease as they age. For most of these years, the optometrist is their primary care giver – and for optometrists willing to accept the responsibility, the optometrist is their physician.
Optometrists have been slow to accept this role, as much of their training and continuing education have revolved around the treatment and management of eye disease. In the new millennium, however, more and more courses are available on topics such as diabetes, hypertension and obesity. Electronic heath records for optometry are detailing vital signs and broadening the health history to include a review of systems, medicine reconciliation and social history and require a judgment on the patient’s mood and orientation. Optometrists must meet the same requirements as physicians in generating clinical summaries and transferring data to other health care providers to qualify for meaningful use of electronic health records.
Optometrists who practice low vision rehabilitation or geriatric eye care see the effects of a lifetime of chronic systemic disease such as diabetes, hypertension and hypercholesterolemia come home to roost. These diseases, along with poor lifestyle choices such as smoking, poor nutrition and alcohol and other substance abuse, are key factors in the development of age-related diseases such as macular degeneration. The optometrist must consider that the best management of these chronic, long-term, life-altering vision disabilities should be prevention, and that the profession of optometry must consider playing a larger role on the front end of life to affect better long-term eye health.
Optometrists should indeed consider themselves physicians and should embrace their role as primary health care providers. A physician does more than collect health care data for the sake of correctly documenting the chart or just to upload these data to other health care providers. The optometric physician must review these data at the conclusion of each encounter and provide general health care education and counseling in addition to eye health, refraction and visual function advice that is currently the model. The optometrist, both in the new physician role and in the traditional eye care role, must educate and counsel for the lifelong prognosis of each patient. The eyes and visual system do not exist in their own unrelated environment but are affected by the total health and well-being of the patient.
Sometimes the only doctor a young, healthy patient sees is the optometrist.
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Scott A. Edmonds, OD, FAAO, is a member of the Primary Care Optometry News
Editorial Board, the chief medical officer of MARCH Vision Care and the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia. He can be reached at Suite 1010 840 Walnut St., Philadelphia, PA 19107; (484) 326-9017; firstname.lastname@example.org