A perfect scenario ... perfectly bad!

A friend phoned me today with a question about medical homes and coordinated care. After hearing his scenario, I responded, "Perfect!" Unfortunately, it was a perfectly bad scenario that describes exactly how unprepared optometrists will start losing access to their own patients. I'm sorry to say it, here's the bad news ... then some good news.

An optometrist sees a patient for a regular eye health exam, does the usual diagnostic testing, and then some, and determines the patient needs to see an ophthalmologist. The patient visits the ophthalmologist who happens to be involved in a care team through an ACO or medical home. Although the patient had chosen the optometrist for the initial visit, the ongoing care is now turned over to the care coordinator whose job it is to coordinate all the care of the patient. The care coordinator schedules a follow-up visit with the care team's optometrist instead of going back to the referring optometrist.

Yes, we can hear the outcry. Unfair. Wrong. Bad business. And no doubt there's some merit to those cries. It'll happen nevertheless. The reason may constitute an unfair betrayal but it may also be legitimate. 

This scenario sits in the middle ground between legislation and reality. The legislation says patients may choose their Medicare provider but the reality is they'll often just go along with the recommendation of their doctor's office. Remember that medical homes and care coordinators are incentivized, so some will be rather convincing about the reasons to see team doctors. Also remember that there may be legitimate new reasons to have patients switch specialty providers.

What if the referring optometrist does not use EHRs? Or, the O.D. has EHRs but doesn't use them for communications. The optometrist may know nothing about care teams or medical homes, so hasn't attempted to connect with the local provider network. All of these are reasons a provider cannot be included - doesn't qualify - when it comes to team delivery of care or bundled payments.

On the other hand, let's say that optometrist is you, and you have implemented not only a certified EHR but also DIRECT communications capabilities. Admittedly, in this case you'd have been proactive enough not to end up here in the first place. But supposing you did somehow, you'd now be in a position to step in and prove value to that care team, perhaps even add more value than the incumbent optometrist. 

Do you have questions or scenarios for which you'd like to see an explanation? Submit them through the Comments and Reactions area below this post, or email us. We'll be happy to respond.

Alistair Jackson, M.Ed.