APR 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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24 EW NEWS & OPINION April 2013 Insights The kabuki dance of healthcare reform by J.C. Noreika, MD, MBA J.C. Noreika, MD, MBA I n polite company, it is judicious to avoid discussing religion, politics, and ex-spouses. The following may chafe some of my colleagues. Yet a thought piece should provoke. Don't kill the messenger. An astronomical conjunction occurs when two or more celestial objects seem to align. It is all perspective. In healthcare reform, there exists a conjunction between the consequences of the Affordable Care Act and lesser, peripheral initiatives. Perspective can influence legal construct. Consider three realities: (1) the unsustainable cost of state-sponsored healthcare, Medicare and Medicaid; (2) the confluence of pent-up demand of an estimated 30 million newly insured, the burgeoning number of Medicare baby boomers, and the inexorable march of costly medical innovation; and (3) the broadening scope of practice of paraprofessionals such as nurse anesthetists, nurse practitioners, and others. Coincidence? The state of California is considering whether nurse practitioners may establish independent practices. Convenience clinics in CVS and Walgreens pharmacies and Walmarts are pervasive and growing. Scope of practice is hardly news to ophthalmology. Organized optometry is Sisyphean in advancing its agenda through state legislatures and federal programs such as the Veteran's Health Administration. An inexorable erosion of ophthalmology's professional turf has occurred despite the expenditure of millions of PAC dollars to shore up its perimeters. This battle is lost. Local skirmishes may be won but the deck is stacked. Think Napoleon and Moscow. Unlike the little corporal, geography won't defeat organized ophthalmology's effort. Demography will. The numbers are revealing. The Accreditation Council on Optometric Education recognizes 20 programs in the United States and one in Puerto Rico. These produce more than 1,200 optometrists per year. An optometrist completes his degree requirements in roughly eight years beyond high school. Ophthalmologists require twelve or more. An optometric graduate is younger than a comparable ophthalmologist. Her career will last longer. There are more than 36,000 optometrists practicing in the U.S. today with projected growth to 43,200 by 2018. The number of ophthalmologists is expected to remain static. Despite the efforts to differentiate ophthalmology from optometry, the public's and, more importantly, lawmakers' perception is that there is a difference without distinction. I've employed optometrists in my practice since 1986. I know better. Is the public culpable? A recent study of illiteracy revealed that 23% of our nation's adults or roughly 53 million citizens couldn't locate the date and start time of a meeting in a typewritten directive. Lawmakers? The American Optometric Association PAC contributed over $250,000 more than the American Academy of Ophthalmology (AAO) in 2012 to representatives in Washington. But it is at the state level where scope of practice is determined and optometry's state societies are well funded and proactive. Many policymakers regard organized medicine such as the American Medical Association and the AAO as perpetuation of medieval guilds. Labor unions wield leverage among the ruling class; professional guilds are perceived as selfserving anachronisms. It gets tricky. Assume the following: no meaningful increase in the number of ophthalmologists anytime soon; the demand of an aging boomer population and newly insured outstrips the supply of ophthalmic services; the Affordable Care Act favors consolidation such as Accountable Care Organizations or, as one pundit called them, "HMOs on steroids"; by outsourcing vision care services, ACOs abet a quasi-private practice ophthalmic model; and the demographic gender trend of colleges, medical schools, and residencies continues. Demography cuts both ways. Due to the burgeoning market power of commercial entities such as LensCrafters, optometry is witnessing a tidal change in its practice model. The cost of establishing a modern practice is a formidable barrier to entry. The feminization of optometry surpasses that of ophthalmology. Two-thirds of applicants to optometric programs are female. The opportunity? Advantages of an integrated vision care model offer an attractive alternative. A wellmanaged ophthalmic practice presents an optometrist the chance to practice within the scope of her license, provides professional learning and challenge, renders job security and reduced liability, and furnishes a work place with advanced technology and attractive hours, i.e., no Sundays. The integrated care model requires a change in ophthalmology's mindset. The AAO has promoted the concept of the "eye MD" to differentiate the ophthalmologist. The integrated model mandates the evolution to "eye surgeon," ophthalmology's primal distinction and percipient advantage. People are familiar with brain and heart surgeons; it's an easier sell. The demonstration of manual dexterity by residency applicants will be as important as traditional attributes. Successful training programs will endow their acolytes with the technical magic to safely, efficiently, and ethically work in tomorrow's demanding surgical environment. No more refractions. This brave new world will uniform the ophthalmologist in surgical scrubs. Generations of video game mavens and the introduction of virtual surgery platforms may result in more surgeons with "gifted" hands. I think that ASCRS is onto something in reaching out to optometrists. In "The Art of War," Sun Tzu observed that a battle rarely decides a war. He could predict which army would prevail by inferring seven considerations. One speaks directly to ophthalmologists: Which camp has the better-trained leaders and warriors? Will ophthalmology leverage its advantage? EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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