Developing the medical model

"It happened after 9-11," Texas practitioner Tom Annunziato, O.D., says. His then-traditional, vision care-oriented optometric practice "basically collapsed - as a lot of practices did," Dr. Annunziato recalls. Uncertain about the future, people were putting off both routine preventive and problem-focused examinations. Patient count was down, so were revenues. "I was laying staff off," he recalls.

Naturally, Dr. Annunziato brought up the practice downturn in the course of conversations with his fellow optometrists. "Is your practice down as much as mine is?" he would ask. He found many practices were in the same situation. "Then I talked to several friends with medically oriented practices and they said 'no,' apparently a bit surprised that the question had even been asked," Dr. Annunziato remembers.

"I had an epiphany," Dr. Annunziato said. "Patients with medical conditions such as glaucoma or even patients with dry eye, foreign bodies or post-surgical patients cannot put off care. They cannot wait until they feel more certain about the economy to get better before going to the optometrist's office." Having concentrated his practice on vision exams and the dispensing of eyeglasses and contact lenses, Dr. Annunziato had made it a policy to refer virtually all patients who presented in his practice with eye health conditions to an ophthalmologist, providing only occasional treatment for minor conditions as eye irritation. That was a disservice to patients who were being denied prompt treatment and needlessly forced to make another visit to a doctor's office, Dr. Annunziato now says. It was also a near-fatal practice management error, he adds.

Dr. Annunziato set out to radically restructure his "optically' oriented optometric practice around a medical model. "I made it my objective to provide my patients the complete scope of care I am authorized to provide them under law," Dr. Annunziato said. The result has been a significant increase in patient satisfaction and retention as well an enhanced image for the practice in the community. It has also meant substantial increases in gross revenue, net income and patient encounters - all of which have largely been maintained through upturns and downturns in the economy over the last eight years.

AOA surveys find optometric practices by and large have become important sources of medical eye care. The AOA 2009 Scope of Practice Survey found a typical optometric practice, over a six-month period, will now diagnose an average of 104 cases of anterior segment disorders - including 24 cases of glaucoma - and will provide all of the treatment to four-fifths of those anterior segment patients and two-thirds of the glaucoma patients. However AOA surveys also find some practices continue to provide much more medical eye care than others. The survey finds a typical optometrist now prescribes or dispenses pharmaceuticals to patients more than 400 times over a six-month period. However, the most actively prescribing practices, an optometrist may prescribe or dispense pharmaceuticals more than 1,600 times over the same period. That is because some practices now place emphasis on the providing of full-scope medical eye care (in some cases having residency-trained associates in the office specifically to provide such care) while many other offices continue to emphasize basically vision care, Dr. Annunziato said. In some major markets, optometric medical eye care referral centers have been developed to accept patients from practices that provide only limited medical eye care. Moreover, AOA surveys indicate many practices provide some types of medical eye care but not others. And even many optometric offices that emphasize the providing of full-scope medical eye care to patients have yet to adopt the full medical practice model, Dr. Annunziato notes.

In Dr. Annunziato's case, the transformation to medical model practice was relatively swift (accomplished basically over the course of a year) and dramatic. The practice, which eight years ago was 90% to 95% percent vision care, is today at least 40%to 50% medical care, he reports. It ranks among the top five optometric practices in Texas with respect to volume of prescriptions for glaucoma medication - perhaps among the top three, pharmaceutical representatives say. Dr. Annunziato attributes the successful transition to careful planning. He recommends practitioners who wish to adopt the medical model consider retaining a consultant who specializes in the development of medical optometric practices, take a continuing education course on the development of such a practice, and talk extensively with other practitioners who have already made the move. Dr. Annunziato started by visiting the offices of fellow Texas practitioners John Coble, O.D., Craig Thomas, O.D., and John McCall, O.D. Those offices quickly became models for his practice, Dr. Annunziato said. He then took one of several comprehensive courses (5- to 7-days in length) in medical practice development offered by West Coast practice consultant Mark Michaels, O.D.

Central to the transformation was the complete re-equipping of the office. A quarter million dollars was spent over a three-month period to provide GDx^TM scanning laser polarimetry (Carl Zeiss Meditec, Inc.; Dublin, Calif.) retinal cameras and a complete range of the latest diagnostics instrumentation. "Two of everything," Dr. Annunziato notes -- one for each of his offices in Fort Worth and Weatherford (about 45 minutes away). In addition to providing a broader scope of diagnostic capabilities in the office, the new equipment digitally captures and prints out data, eliminating the need to read meters and note data on patient records manually, Dr Annunziato adds.

Dr. Annunziato then reorganized the practice staffing, hiring four new ophthalmic technicians - who were all experienced veterans of area ophthalmology practices and familiar with medical model practice - to supplement his optical and reception staff. The new staff essentially "brought the medical model with them" from their previous practices, he observed.

Medical examinations, especially when they involve complex conditions or extensive testing, can be time-consuming, Dr Annunziato acknowledges. Proper utilization of staff is critical to practice efficiency, he says. The ophthalmic technicians are charged with performing all pretesting, taking patients histories and "scribing" Dr. Annunziato's notes. "I am basically shadowed by an ophthalmic tech who accompanies the patient through the practice and into the exam room. I review the result of the pretesting and I may say 'I think this patient has glaucoma,' then order the tech to perform GDx or other additional testing. After reviewing the results of those additional tests, I can make a final diagnosis, develop a plan of treatment, and issue a prescription," Dr. Annunziato says.

Dr. Annunziato says he enjoys good professional relations with area ophthalmologists, to whom he refers patients for surgery or consultations in the case of, for example, retinal problems. He comanages surgical or laser refractive correction patients with a number of area MDs. "However, I try to provide any service that I can provide for the patient in my office within my state's scope of practice," he says.

In addition to the new instrumentation and staff, the practice's records and billing systems were completely revamped. Dr. Annunziato said. The Houston-based practice consultancy, Rose & Associates, was brought in help the practice establish a medical practice billing system. Dr. Annunziato did not implement an electronic health records system in conjunction with the new equipment; however the change in the practice's recordkeeping was still substantial. The practice's traditional one-page patient record was replaced with a four-page record, typical of those used in medical offices, with separate pages for:

• Insurance information
• Patient history
• Test results, and
• Examination results.

Each record is kept in its own binder.

Rose & Associates consultants then train practitioners and staff in coding, billing and documentation of medical eye care services. (The consultancy is staffed primarily by former Medicare auditors, Dr. Annunziato notes.) The ophthalmic techs handle claim filing as part of their duties. As a result of that extensive training, claim rejections and billing disputes have proven relatively rare, Dr Annunziato reports. Patients are prescreened to make sure they are covered by a health plan for which Dr. Annunziato's practice provides care. Patients are referred to an appropriate nearby practitioner, if he does not.

Dr. Annunziato has joined about 12-15 medical eye care provider panels since making the transition to the medical model. However, joining the medical panels did not prove a problem, he says. He had been providing care under a variety of managed care vision plans. Under Texas insurance laws, if an eye care practitioner provides vision care under a managed care plan, the plan must cover any medical eye care provided by the practitioner.

In all, it took about six months to institute the medical model in the practice and a year to get the new system working smoothly, Dr. Annunziato recalls. However, it was well worth the effort, he says. Practice gross revenues increased 40%. Increases in net income have been at least in line with revenue increases. "Reimbursements for medical services tend to be on the high end of the spectrum," Dr. Annunziato notes.

The medical practice has grown almost entirely from treating eye health conditions diagnosed in new or existing vision care patients who in the past would have been referred to other practitioners for care, Dr. Annunziato reports. "That means retaining patients who otherwise would have been lost to the practice, at least for a period of time," Dr. Annunziato observes. Patient base therefore has not increased commensurate with revenues; however, many patients have been retained in the practice - and patient encounters have increased markedly. That is because many of those eye disease patients - such as those with glaucoma - will require regularly scheduled programs of care that effectively increase the volume of patient visits in the practice. "The patient who might have been seen once a year for an eye examination will now be seen four times a year in the practice," Dr. Annunziato said. A year after implementing the medical model, Dr. Annunziato took on a new associate to keep up with the additional demand for services in the practice.

Dr. Annunziato says he has not undertaken any marketing effort to raise awareness of the medical eye care available in his practice. Some new patients have come to the practice as the result of its inclusion in medical plan provider lists, he reports. The practice has also benefited from some good "word of mouth" on the part of patients who were particularly happy with the practice's treatment for dry eye, he says.

Medical model practice requires periodically updating to provide state-of-the-art care, Dr. Annunziato says. Since initially adopting the medical model, Dr. Annunziato has spent another $200,000 on additional equipment. However, he has "more than recouped" the $450,000 he has spend on instrumentation since implementing the medical model. The equipment has produced at least a 10-fold return on investment, he reports.

Dr. Annunziato's office is often visited by optometrists who are considering a medical model practice. "Some go right out and implement the medical model. Some decide it is not right for them," he acknowledges. However every optometrist should at least consider whether the medical model might be appropriate for their practice, Dr. Annunziato suggests.

"I wish every practice could undergo such a transition," Dr. Annunziato says. With the proper instrumentation, staff, practice protocols, record and billings system, any practice can, he believes. Just be sure to plan carefully and get expert advice through consultants, training programs, professional literature, or at least other optometrists who have made the transition first, he advises. "Don't go it alone," he says.