Letters

Readers Voice Their Opinions

The “Medical Home” concept

■ I was unaware of just how severely and negatively the “medical home” concept will affect our profession until a recent encounter with a long-term diabetic patient of mine.

She presented to me for her annual dilated eye exam, but reported having a “dilated eye exam” at her primary-care physicians's (P.C.P.'s) office. (This is an M.D. to whom I faithfully send a nice diabetic letter report every year, by the way.) The P.C.P.'s eye exam report recommended the patient see an ophthalmologist, and she wondered why since I've seen her annually for many years.

The P.C.P.'s office is one of 13 in Oregon that participates in the state's “medical home” pilot program. The P.C.P.'s website touts the “eye exam” as part of its participation in the program. It's marketed to patients on the P.C.P.'s website as “your annual diabetic dilated eye exam performed in the convenience of our office” and was sold to my patient as such an eye exam. (See Editor's note that follows this letter.) In reality, a technician dilated my patient's eyes and then took digital retinal photos. Those photos were sent via e-mail to The Wilmer Eye Institute at Johns Hopkins for a reading by an unspecified person (one hopes it was a retinal specialist, not a general ophthalmologist or a technician—the report did not specify).

My patient came to me instead of an ophthalmologist due to her trust in our long-term doctor-patient relationship. My dilated eye exam found 20/20 uncorrected acuity despite just a few juxatafoveal hard exudates: There was no retinal thickening. Ocular coherence tomography also proved the lack of diabetic macular edema per Early Treatment Diabetic Retinopathy Study guidelines, so referral to an opthalmologist would have been a waste of the patient's money and everyone's time. I am perfectly qualified to simply observe this situation and refer to the retinal O.M.D. if any edema develops.

Photos vs. an “exam”

I practice in Oregon, where there is no legal definition of what constitutes an “eye exam,” but I think all types of eyecare professionals can agree that “retinal photos only” does not replace an eye exam. The battery of tests that usually make up an “eye exam” were not performed by the P.C.P. However, when patients are told they've had an eye exam by their P.C.P.'s office, won't most conclude that there's no need to visit the O.D.? If so, the opportunity to catch other ocular disease through a comprehensive eye exam is lost.

In such a system, consider the increase in patient and insurance company costs through over-referral. And if the patient does happen to return to the O.D. for an exam, the O.D. likely won't get reimbursed for another set of retinal photos—the P.C.P. submitted the claim first.

As a “medical home,” the P.C.P.'s office is trying to offer all the tests through their own office and off-site telemedicine. If pathology is found, they will refer to a fellow M.D., not an O.D. Will a P.C.P. refer the patient back to you? No, I would argue that the report from The Wilmer Eye Institute along with Johns Hopkins' reputation will trump your existing patient relationship.

Several studies in diabetic journals (not eye journals) conclude that digital photos and telemedicine, with direct referral to O.M.D.s, is an acceptable substitute for a true diabetic dilated eye exam. The studies claim that the technology will ensure more patients get their annual “eye exams,” and any retinopathy will be found and treated early. The studies also claim the technology will detect AMD too, so consider the loss of patients who are found to have just a hint of drusen as well.

Several insurance companies have issued local coverage determinants indicating they agree that these retinal photos taken at a P.C.P. office are an acceptable replacement for a dilated eye exam performed by an eyecare professional. For more information, search on PubMed (www.pubmed.com) for the terms “Digiscope dilated diabetic eye exam,” and do a Web search on various insurers. View the published studies and insurance company position papers (and marketing) to understand exactly how this technology will redirect your patients and impact your medical services income.

Where is organized optometry?

Organized optometry is wasting precious time and resources arguing about board certification while the P.C.P.s use digital telemedicine to quietly circumvent O.D.s entirely. If I were board certified, it wouldn't have changed the P.C.P.'s referral to the O.M.D. O.D. board certification, or lack thereof, won't stop insurance companies from saying retinal photos are a replacement for true dilated eye exams.

Consider how many diabetic patients who have never set foot in an O.D.'s or O.M.D.'s office will be given an “eye exam” at the P.C.P.'s office. These patients will never set foot in an O.D.'s office, since they're being directed preferentially to the O.M.D. on the basis of this “eye exam.” In this light, board certification is a distraction from the real issues here.

Online retailers of contact lenses and glasses are squeezing our profession. We can't make up lost optical revenue by increasing our medical services if the patient never steps into our offices in the first place. What services or products will finally be left for O.D.s to provide? I think this is truly the greatest threat our profession has faced in a long time. So what are our local and national leaders doing to address this threat? What can each of us as primary eyecare physicians do to address this threat? Read the journal studies, understand the technology and marketing, and then let's discuss how to save our profession. OM

Rebecca Uhlig, O.D., Portland, Ore., via e-mail

Editor's note: Since Dr. Uhlig wrote this letter, the M.D. website has changed its marketing copy from “your annual diabetic dilated eye exam performed in the convenience of our office” to “your digital screening for diabetic retinopathy in the convenience of our office.” However, the headline above this copy continues to read “Eye Exam,” and according to Dr. Uhlig, the P.C.P.'s diabetic educator still insists that the telemedicine exam can replace the need for a dilated eye exam.