Other health systems collaborating with optometrists affiliated with for-profit Vision Source include CoxHealth, Springfield, Mo.; WellMed Medical Group, San Antonio; and Baptist Health South Florida's 600-physician Baptist Health Quality Network.
The general public visits optometrist offices more frequently than any other part of the healthcare system, and savvy providers are learning how to leverage that to their patients' advantage. A 2013 white paper published by insurer UnitedHealthcare said “the eyes are the window into a person's overall health.” The white paper was titled “Integrating Eye Care With Disease Management: It's Not Just About Diabetes Anymore.”
UnitedHealthcare found that eye-care professionals were effective in identifying patients with diabetes, high cholesterol, hypertension, juvenile rheumatoid arthritis and multiple sclerosis. In a study released in May, the insurer reported that eye exams were effective in re-engaging patients in needed healthcare. The study followed 2,300 UnitedHealthcare members and identified those with chronic conditions who had not sought care within the past 18 months. According to the study, 33% of these patients made an appointment with a specialty physician or primary-care doctor within 60 days of an optometrist visit and another 24% were engaged after 60 days.
UnitedHealthcare has used this information in its Bridge2Health program, which integrates medical and vision-care data while aiming to close gaps in care, identify opportunities for intervention and monitor 23 chronic conditions.
Greenwood welcomes the insurer's recognition that optometrists can play a broader role in care. He's seeking to expand his network's collaborations with provider systems and insurers, but is finding that sometimes it can be a hard sell. Before joining Vision Source in 2013, he acknowledged that he himself saw optometrists as “the doc in the mall” who gave eye exams and sold glasses and contact lenses. “That perception is shared by roughly 90% of healthcare executives,” he said. “It's a mountain that's going to be hard to climb.”
Greenwood has launched a campaign to show how optometrists can help primary-care physicians improve patients' outcomes by identifying patients whose health is at risk—especially those with diabetes—and getting them more engaged in managing their health. One tool is new technology that allows diabetics to see images showing the condition of their own retinas. “It's literally opening eyes of diabetics about the risk they are facing—loss of their vision—if they don't take better care of their disease state,” Greenwood said.
Dr. Linda Chous, an optometrist and chief eye-care officer for UnitedHealthcare, shares Greenwood's vision of a broader role for optometrists. “People more often visited their eye doctor than their primary-care doctor,” she said. “That gives an eye doctor increased opportunity to identify and monitor chronic diseases.”
UnitedHealthcare's most recent white paper on eye care detailed how chronically ill patients became re-engaged with the healthcare system after an optometry visit. Chous said that under UnitedHealthcare's Bridge2Health program, a medical history of eye-care patients is now taken in which patients are asked about their medication history. Often, patients tell their optometrist that they used to be on certain medications but stopped because of side effects or a lack of positive outcomes. “We hear this over and over,” Chous said. “So we counsel these patients that they need to see their primary-care doctor.”
Greenwood and Chous said they are not aware of any concerns from primary-care physicians or ophthalmologists about optometrists performing population-health management-related tasks or monitoring for chronic conditions. That's at least partly because physicians either don't have the time or because patients simply aren't going to them.
Chous predicted that the relationship between optometrists and physicians will grow when it's understood that chronic-disease complications and costs can be reduced by optometrists' monitoring. She estimated in her white papers that reducing blood-sugar levels can lead to decreased medical utilization and result in annual savings of $1,200 to $1,872 a patient.
Dr. Michael Earley, an optometrist and associate dean of academic affairs at the Ohio State University College of Optometry, said it helps that students in different healthcare fields including optometry are being taught to work together. On the first day of classes, Ohio State brings together 800 to 900 students of medicine, dentistry, nursing, optometry, pharmacy and other healthcare disciplines for a full-day program on how they interact to benefit the overall health of their patients. “Students are being taught to coordinate care and treat the patient as a true patient—and not just a pair of eyes,” he said.
In addition, optometry students now must take full courses in anatomy, pathology and pharmacology. “Optometry students are taking systematic pharmacology courses sitting in the same room as the dentistry students,” Earley said. “All the different health professionals are seeing that their patients need this kind of comprehensive care and the current medical model is not designed to do it.”
When it comes to increasing scope of practice, Earley said, optometrists have to show that their training goes “far beyond” what they're asking for. For example, Ohio optometrists can't perform injections, but Ohio State optometry students still learn how to give them.
Earley said younger physicians are more accepting of the expanding role for optometrists, but older physicians occasionally are resistant. “Some docs still say, 'No, I'm not going to send my patient to an optometrist, I'm only going to send them to an M.D.,' ” Earley said. But younger physicians are less likely to have the stereotype of an optometrist as someone who only flips different lenses in front of a patient's eyes.
The role of optometrists in primary care and population health will increase, Earley predicted, because there aren't enough physicians to meet the demand for eye care and because the points of contact are much more frequent. “We catch a lot of patients who never go in to see a primary-care doctor,” he said. “We need to have our place in the system.”
Carolinas HealthCare's Furney said that in the past his system's clinicians had problems obtaining the results of their patients' eye exams after referrals to optometrists. But work is being done to develop an interface between the Carolinas electronic health-record system and Vision Source optometrists' offices. Since last summer, reports have been transmitted over a dedicated fax line and then scanned into the Carolinas EHR.
“It's been a great relationship,” Furney said. “If they identify patients at risk for health problems, they refer patients to our physicians who have become their local partners in care.”