The Importance of Increasing OD-to-OD Referrals

With subspecialization and collaboration, optometrists can provide the highest quality care and improve outcomes for our patients. In this article, I will focus on the need for both in our profession to address the increasing complexity of eye diseases, as well as the rapid rate of new diagnostic and therapeutic tools at our disposal. This increased complexity in diseases, diagnostics, and therapeutics makes it impractical—quite frankly, impossible—for a single practitioner to master all areas of optometry, requiring the need for dedicated experts on a condition or subset of conditions.

ADOPT THE RIGHT MINDSET

When optometrists make a decision, whether it be related to business or clinical care, our patients’ best interests should always be top of mind. According to the American Medical Association (AMA) Code of Ethics, “the relationship between a patient and a physician is based on trust, which gives rise to a physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligation to others, to use sound medical judgement on the patients’ behalf, and to advocate for their patients’ welfare.”¹

I have seen colleagues fail to make necessary referrals, even when they know that other optometrists in their area provide specialty services that could improve a patient’s outcome. When asked for her thoughts about OD-to-OD referrals, Pam Theriot, OD, FAAO, says staying patient-centric has taught her to refer to her colleagues who specialize in other optometric specialties. “I love to refer my patients to another provider when I know they will have a better outcome,” she says.

This is an excellent mindset that other optometrists can learn from—the importance of remaining patient-centric to ensure better outcomes—even if it means referring to another optometrist. Specialists offer more advanced insights on certain conditions, making them better equipped to establish solutions to more complex challenges.

US News published a panel discussion on the advantages of the specialized approach in health care.² One of the panelists, Harlan Levine, MD, suggested that many health care practitioners are concerned that referring patients to a specialist may result in them losing those patients, or what’s sometimes referred to as leakage. Dr. Levine explained, “It’s not leakage, it’s helping the patients with access. It’s helping the patients escape the system to get to the place where they can get the best outcome.”²

I do not think it is rational to fear losing patients due to making a referral (and neither do colleagues whom I have spoken with). This is because getting your patients access to services they need increases their trust in you as their primary eye care provider. I spoke with Jennifer Shaba, OD, on this topic, and she explained, “Patients will find the care they need, but if you choose to refer a patient out for something you don’t offer, then the patient will have more confidence in your continued care, and this will lead to a patient you have for life. If you do not refer, they will lose trust in you.”

In other words, referring a patient to a specialist only enhances their trust in your patient-doctor relationships by demonstrating your commitment to their welfare. As the AMA Code of Ethics makes clear, the relationship between patient and physician is based on trust, and in health care services, trust-based partnerships are essential for patients to have confidence in their providers’ recommendations and care decisions. We want our patients to trust not only us, but the health care system because without this confidence, patients will be less likely to seek care for their conditions, leading to increased morbidity and mortality.

WHY NOT REFER TO A FELLOW OD?

A common problem I see in optometry is that ODs tend to refer to MDs rather than fellow ODs. This happens even if there are ODs in the area providing advanced specialty services that could serve the patients’ needs. This is detrimental to both patients and eye care providers for several reasons. First, it devalues the public perception of our profession because, in such, scenarios, the MD is often perceived as the “real doctor” in contrast to the referring OD. In addition, referring to MDs when an OD is available further perpetuates patient access issues in eye care. If patients think they must seek care from an ophthalmologist for any condition other than needing glasses or contact lenses, then MDs are unnecessarily flooded with extra patients, taking their time away from performing much-needed surgeries.

According to the Population Reference Bureau, the number of Americans 65 years of age and older is projected to increase from 58 million in 2022 to 82 million by 2050, a 47% increase.³ As the population continues to age, ophthalmologists will be performing more cataract surgeries and will thus have less clinic time to manage medical eye care. The National Institute of Eye and Health projects the number of cataract surgeries performed annually in the United States to double in the next 15 to 20 years from approximately 4 million to 8 million.⁴

The increase will create the perfect opportunity for optometrists to further specialize, helping address the growing need for medical eye care and allowing MDs to focus on the increase in surgical interventions required by the aging population. Many health care practitioners believe that patient outcomes are enhanced when there is collaboration among primary care providers and specialists.⁵ We need to put this belief into action.

A LOOK AT THE NUMBERS

Most optometrists (71.7%) describe themselves as primary care providers, while 26.1% describe themselves as primary care with a subspecialty, and only 2.2% as subspecialists.⁶ In many other areas of health care, subspecialization is common practice. For example, there are 11 subspecialties within ophthalmology: cataract and refractive surgery, comprehensive ophthalmology, cornea/external disease, glaucoma, neuro-ophthalmology, ocular pathology/oncology, oculoplastic/orbit, pediatric ophthalmology/strabismus, refractive management/intervention, retina/vitreous, and uveitis. Each of these subspecialties exists to address specific, complex ocular conditions.

When asked about OD-to-OD referrals, 70.8% of optometrists stated they refer to other ODs in some way, mostly for vision therapy and low vision.⁶ Many optometrists endorse the idea of optometric subspecialty: 82.4% of optometry students and ODs practicing for 5 years or less, 77.5% of ODs for practicing 6 to 20 years, and 70% of ODs practicing for 21 years or more agree that there should be subspecialties within optometry.⁶ I feel if more optometrists were to similarly specialize in a specific area of eye care, it would enhance the likelihood of OD-to-OD referrals.

What surprises me is that 29.2% of optometrists stated they do not refer to other optometrists at all.⁶ Do these optometrists possess the equipment, knowledge, and skill set necessary to diagnose, treat, and manage every eye condition at the highest possible level? Or are they simply referring to ophthalmologists when they need specialty services? By fostering OD-to-OD referrals, we are not only providing patients access to the most up-to-date health care solutions, we are also improving the public perception of our profession as medical eye care specialists.

According to an article in Clinical Medicine, collaboration between generalists and specialists improves patient lifespan, health span, and technological innovation.⁷ As procedures have become more complex, general surgeons have been replaced by specialists, such as vascular, endocrine, and gastrointestinal surgeons. As complexity increases, surgeons with a specific field of expertise provide better quality care.⁷ The article also points out that patients want specialists because they want access to the best treatments and diagnostics available.⁷ Outcome-based pay models are being set forth by insurance companies, and integrated models of care have been shown to produce better patient outcomes, while improved use of resources leads to decreases in costs.

Both generalists and specialists are essential, but when the two work together, we can better address major chronic health issues.

A WORD ON GENERATING
MORE REFERRALS

There are around 80 ODs and MDs who refer their more complex dry eye patients to my clinic, and I have fostered these referrals through extensive networking. It is imperative to let other providers know what specialty services you offer that set you apart from others. I didn’t open my practice with a full patient schedule, so I spent several hours per week cold calling optometrists and ophthalmologists who have clinics in my service area. I brought a packet of information, including my practice vision statement and trifold pamphlets highlighting the services I provide. I explained to them how these services could help bring superior outcomes and improved quality of life for their patients. I was also sure to let them know that I did not have an optical, nor did I fit contact lenses, so their patients would still return to them for their primary care needs.

My EHR makes it easy for me to keep track of and send follow-up notes to referring physicians. In addition, when I bring a new technology into my clinic, I notify my referring doctors either by visiting them directly or sending them an email. I also keep track of the top 20% of doctors who refer to me most, as approximately 80% of my referred patients come from them. These doctors are the first to know when I add a new service to my clinic, and I make sure to visit them in person at least twice per year (and send them something special during the holidays).

REMEMBER: PATIENTS COME FIRST

In my experience, dry eye symptoms are usually caused by other conditions, such as meibomian gland dysfunction, anterior blepharitis, exposure keratopathy, nasal lacrimal duct obstruction, allergic conjunctivitis, medicamentosa, neurotrophic keratitis … the list goes on and on. I specialize in ocular surface and dry eye disease, and I am happy to see more doctors entering this specialty, as it is a complex and multifactorial condition that I feel requires the management of a specialist in order to provide patients with optimal outcomes.

That said, I do not think specializing in dry eye should be done only “on the side” to increase practice revenue. When you add a service to your practice to generate additional revenue without considering whether you are providing the best service to your patients, you are not placing your patients’ best interest above your own. I am not saying that, as physicians, we must function as a charity and not make any money, but whenever I make such decisions, I first ask myself what value this new service will bring to my patients. Does it offer better value than what I am already providing? Only then do I consider if the service would be profitable. Without being profitable, we would go out of business, and then we would not be able to serve anyone, but the first thing we should be focusing on is the value we provide to our patients. In my practice, I have found that when you provide significant value to your patients, you will generate plenty of revenue.

PRIORITIZE COLLABORATIVE CARE

Primary care optometrists are responsible for the overall health of a patient, while specialists bring their expert knowledge and specialty care to patients with more complex conditions. By working together, primary care optometrists and specialists can create a comprehensive and coordinated plan that addresses the patients’ unique needs and helps them achieve optimal outcomes.

According to neuro-optometrist Jacqueline Theis, OD, FAAO, as science and technology in eye care evolve at an exponential pace, it is both impossible and unrealistic to think you could be an expert in every area. “I am a wonderful resource to my referring ODs when they feel they have exhausted all treatment options for their patients with neuro-optometric concerns,” she explained. “But as I dedicate my time researching and expanding my knowledge on neurologic conditions and the eye, I am unable to stay up-to-date on the newest lens technologies or contact lenses. I rely just as heavily on my comprehensive optometrists as they do on me. Subspecialization isn’t about dividing optometry, it’s about teamwork and co-managing patients to allow an overall higher standard of vision care.”

If there is a provider in your area who specializes in a specific area of optometry, I urge you to call upon them to help care for your patients. Collaboration is essential to achieving better patient outcomes and improving patient satisfaction. It can also help improve the public perception that optometrists are not only the primary care providers of ocular health, but also specialists capable of managing many different medical conditions of the eye.