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Clinical Care and Practice Advancement

Hospital Privileges Manual: Part II: The Importance of Optometry to the Hospital

Optometrists are widely recognized as valuable members of today’s health care delivery system. The provision of optometric services in a hospital setting is beneficial to all parties concerned. The improved access to eye health care services is a benefit to the community; patients receive accessible, excellent care and the hospital realizes revenues and cost savings resulting from appropriate utilization of resources and staff.

The American hospital industry is undergoing significant fundamental change, prompted in part by government reform, but more importantly by the health care buyers: insurance companies, employers, and individuals. Changes in reimbursement to hospitals by Medicare and other third party payers have had significant impact on their profitability. All third parties are demanding more cost-efficient care with outcomes data to justify appropriateness. As a result, hospitals have had to make changes in the past few years. The average number of hospital beds is decreasing. Inpatient services are relatively stable, while outpatient services are dramatically increasing. These changes have forced many services, traditionally provided in hospitals, to be shifted to freestanding outpatient facilities.

The trend to outpatient services has forced hospitals to re-evaluate their position in the medical marketplace. Less efficient hospitals are closing; others are being purchased by larger systems. All hospitals are concerned about ways to decrease expenses and are exploring options such as physician hospital organizations (PHOs) and other structural links to providers. Managed care and an increased emphasis on primary care are recognized trends throughout the health care industry.

Optometrists fit very well into many of the above segments of a changing hospital operating scheme. Optometrists, being primary care providers, can help the hospital deliver eye care services in a very efficient manner. As buyers of health care services continue to demand an appropriate level of care from primary care providers, with specialist services performed only when necessary, optometrists will continue to find an increased role in hospital practice. Outpatient services continue to provide a higher proportion of a hospital’s income. Optometrists are primarily providers of and referral sources for outpatient services, and are valuable contributors both directly and indirectly to hospital income.  Hospitals can only generate income through patient services, and patient services primarily are derived from a good blend of providers, both at the primary level and at the surgical and specialty level.

Cataract surgery is the most frequently performed surgery for Medicare recipients. It is a major potential revenue source for hospitals, both large and small, metropolitan and rural. It is an outpatient procedure, and one that can be performed with measurably good outcomes in the patient’s own “local hospital.” In the Battelle study of cataract surgery patients, 74 percent of the postoperative care for cataract surgery was delivered by optometrists.2 The typical optometric practice has thousands of patients who are age 55 and older, the same age group that not only may need cataract surgery services, but also accounts for most inpatient hospital bed use. This is an asset that hospitals recognize and continue to foster.

Many rural hospitals have added cataract surgery to their list of services. Woods Memorial Hospital in Tennessee added optometrists to their staff and began offering cataract surgery services in 1995. Through the utilization of mobile equipment, very little expense was incurred by the hospital for equipment or overhead expense. Within two years the hospital was providing services for nearly 175 cataract surgeries per year.  Most importantly, however, was the 47 percent rate of first time patients coming to Woods for health care services.3 This might translate into added future revenues from the new patients who had good surgical outcomes and a pleasant experience in their hometown hospital.

Utilization of laboratory and imaging services is another direct increase in revenues that a hospital may realize by having optometrists on staff. While optometry does not generate high volumes of these services, cultures, CT scans, orbital x-rays, MRIs, carotid Doppler ultrasounds, blood tests, etc. are ordered by optometrists. As a primary care provider, optometrists need access to specific diagnostic tests provided by hospitals.  Examples may include but are not limited to:

  • A culture to identify the specific microorganism causing a corneal ulcer and a sensitivity test to determine the appropriate antibiotic for treatment are common procedures needed in the optometric practice.

  • A sedimentation rate to rule out temporal arteritis or glycosylated hemoglobin and/or a fasting blood sugar to rule out diabetes are examples of blood tests that may be needed.

  • Optometrists commonly remove corneal foreign bodies.  An orbital X-ray may be needed in the case of a high velocity foreign body to rule out penetrating foreign material.

  • A patient with suspected low tension glaucoma may need imaging tests to rule out other causes of optic nerve disease before initiating glaucoma therapy.

  • Visual fields are performed daily in optometric offices and often find defects indicative of intracranial strokes or other neurological diseases. Diagnostic imaging, including CT scans and MRIs, are ordered in many of these cases to more specifically diagnose the patient’s disease and either begin optometric treatment or make the appropriate cost-effective referral.

Optometrists, available as staff members, give the hospital access to eye care services both in the emergency room and for inpatient services.  Ocular trauma, infections, foreign bodies, and corneal abrasions are common reasons for emergency room visits. Inpatients may need an eye consultation for dry eyes, flashes and floaters, headaches, diplopia, or any other ocular symptoms that optometrists diagnose and treat in their offices each day. The hospital and the staff medical physicians need to have access to optometric consultation services for their patients. Affordable equipment that is already owned by the optometrist can be used in the hospital setting without any outlay of expenses by the hospital.

Laser vision correction is a growing procedure performed in the United States.  The lasers required to perform these procedures are often located in freestanding laser centers or ophthalmological surgery centers, but sometimes they are also in hospitals. If the setting is a hospital, optometrists should be a part of the referral network and an integral part of the hospital staff providing both pre and postsurgical care, ensuring cost-effective use of the laser and associated staff.

Optometrists perform nearly 70 percent of the primary eye care examinations in the United States4 and are often the providers that patients consult first regarding refractive surgery. With most refractive surgery being performed in larger metropolitan areas, rural hospital emergency rooms may be faced with postoperative complications. When they occur, new decisions regarding evaluation of the postrefractive surgical cornea after trauma must be made. Optometrists can provide these services in hospital settings, just as they do in their offices.

Managed care is impacting all elements of health care including hospitals. Hospitals have realized the importance of linking with providers, both at the primary care and specialty care levels. This may be through a very structured affiliation, such as employment of providers, or through a loose link, such as a physician hospital organization (PHO).  The ability to capture and provide all of the health care for a patient is becoming much more important. Eye care is one aspect of this complete package and the availability of optometric services is extremely important to hospitals. Optometrists can provide numerous eye care services; they have a database with thousands of patients that are important to hospitals as potential patients. Hospitals may start eye departments and employ or contract with optometrists. They may bring optometrists into the PHO as providers or, as many hospitals have done, bring optometrists onto the hospital staff through the same credentialing and privileging process that medical physicians undergo.

Hospitals need optometrists both for direct generation of revenues and for the indirect benefits of access to more primary care patients and the associated surgical care of these patients. Hospitals can benefit by utilizing optometrists to provide timely and appropriate eye care to inpatients, outpatients, and emergency room patients. Optometrists can provide increased revenues through increased utilization of laboratory and imaging services. Hospitals are the uniting force in many communities. As they help direct the coordination of providers, inpatient and outpatient services, and urgent and emergency care, optometry can prove to be a valuable asset to hospitals.