The Evolving Role of the
Primary Care Provider

By James V. Aquavella, M.D.

From the controversial introduction of refractive keratotomy in the early 1980s through the more recent development of PRK and LASIK, the refractive surgeon has been the star. As such, he or she has commanded the largest slice from the payment pie, which covers pre- and postoperative care, use of the facility and the surgical fee. In the current environment, however, perceptions are changing with respect to the value of the various components of the refractive surgery package.

YOU'RE THE ONE HOLDING THE REINS NOW

The number of refractive surgery patients being treated today is significantly less than even the most conservative projections of a few years ago. Per-case profits are small, and with the exception of a few very high volume locations, the numbers are far too few to support high technology and maintenance costs. Given the size of the market, there are far too many facilities and surgeons, increasing competition and driving down surgeons' fees. The net result is a decrease in the dollars we expected would ultimately flow to the surgeon.

True, we're beginning to see slow signs of increasing volume, but the future success of refractive surgery is now more dependent upon the primary eye care provider. The prevalence of managed care has inhibited direct patient access to subspecialty surgeons. As a result, primary eye care providers have expanded their influence over a large number of refractive surgery candidates. Patients also develop a bond with their primary eye care provider, often asking them about refractive surgery. The responses they receive may cultivate or stifle their interest. Therefore, it's now the primary eye care provider who controls the flow of patients into refractive surgery. The refractive surgeon's efforts to bypass the primary care providers by marketing directly to the potential candidates is an expensive process.

THE VALUE OF PRE- AND POSTOP CARE

Similar to prescribing contact lenses, comanaging refractive surgery is another type of specialized service that requires a large time commitment from the primary eyecare provider and his staff. Refractive surgery candidates are a whole new breed of patients who want to know everything about the procedure and the alternatives. Postoperatively, the primary eyecare physician must counsel patients about the healing process, monitor and manage their ocular health and vision, and when indicated, discuss the option of enhancement. Some of this care entails hand-holding, but it needs to be done.

Awareness is increasing regarding the importance of proper comanagement care for the satisfaction of the refractive surgery patient. This further substantiates the primary care provider's position as an integral part of the success of refractive surgery. If you haven't already, it's time to recognize the value of incorporating refractive surgery into your practice.

LOOK FOR QUALITY CARE PLUS FAIR COMPENSATION

In this environment, the increased value of the primary care provider -- who does not perform refractive surgery but selects the candidates, refers the patients and performs pre- and postoperative evaluations -- has had an impact on reimbursement. While this evolving economic environment is positive from the perspective of primary care optometrists, ophthalmologists and opticians, it's incumbent upon them to associate with the most qualified surgeons and facilities, regardless of the financial incentives they offer.

It's important to recognize your increased worth, but don't be swayed by the highest bidder. Look for comanagement partners who compensate you appropriately for your time and value, but remember to keep your patients' best interests at heart. Refractive surgery is a team event. Associations between caring and competent primary eyecare providers, surgeons and facilities will continue to best serve the needs of our patients, regardless of the cost and reimbursement issues. CLS

Dr. Aquavella is chairman of the Genesee Valley Eye Institute and director of the corneal research lab at the University of Rochester.