"Scope of Practice And Credentialing By CPT"


"Scope of Practice And Credentialing By CPT"

Might this become a methodology adopted by some or many third-party payors?

Copyright © 1998 Gil Weber, MBA

Risk contracting shows more clearly than any other managed care dynamic that the practice and business of medicine can't be separated. With groups and networks delivering care under finite funding, yesterday's traditional protocols and practice comfort levels are giving way to tomorrow's more painful, sometimes worrisome, and certainly controversial realities.

Credentialing using current procedural terminology (CPT) is one of the most controversial realities peeking over the managed care horizon. Although not yet common in any part of the United States, it is emerging in some highly penetrated markets where first-, second-, and third-generation managed care systems are no longer on the cutting edge. Credentialing by CPT is a reflection of marketplace dynamics that obligate those who deliver and manage care to think outside the traditional box -- to paint outside the lines. Many will find it distasteful, even insulting. And it's certainly not for every group or network.

But to ignore or dismiss CPT credentialing out of hand without an analysis of its potential positive aspects is to bury one's head in the sand. And in managed care, that means being left behind. The goal of this article is to raise the reader's awareness level and initiate a careful thought process, however uncomfortable that might be.

The Challenge

One premise of managed care is early detection and early intervention will lower long term costs and provide better patient outcomes. To support that premise, particularly under capitation or other risk arrangements, appropriate, high quality services must be delivered by carefully selected providers at the appropriate time, in the most appropriate, cost-effective setting. And no matter what care is provided, systems must be in place to maximize the likelihood that it will be done right the first time. An obvious and immediate question then for eyecare professionals and administrators working in a managed care world is Who should see the patient: an optometrist, a general ophthalmologist, a subspecialist?

Sadly, turf battles between the professions and among professionals continue as managed care grows. Fortunately, forward-thinking physicians and optometrists are beginning to build bridges across traditional chasms. They're establishing integrated networks capable of delivering comprehensive, cradle to grave vision and eyecare services under a single management umbrella, with a single contract, and a single funding mechanism. Long term success, however, means much more than simply circulating provider agreements, putting representatives from all sides on the various management committees, and declaring, "We're a network ready for managed care."

Success will come through team effort and innovation, creativity, and efficiency -- a collective ability to think outside the traditional box. For an increasing number of networks, particularly in mature managed care markets where competition for patients and contract dollars is intense, this has meant juggling a hot potato: credentialing by CPT. Networks are setting internal criteria and determining which panel participants may treat certain conditions and see certain patients. Because it directly affects each participant's compensation, this complex issue might prevent networks from forming or tear apart existing networks.

However, the point isn't to make a case for or against using optometrists, general ophthalmologists, or subspecialists in any particular circumstance, nor is it to find a "magic bullet" answer applicable to all situations, for no generic solution exists. Rather, each network's policies and protocol decisions will reflect the socioeconomic realities of a local marketplace, the demands of the payor community, and the abilities of all parties to get beyond political considerations and cut to the heart of the matter. That is, as eye care professionals and administrators what must we do to maximize quality and minimize costs in order to deliver the best and most affordable patient care within the limits of a fixed budget?

The following shows on a "macro" scale that thoughtfully considered disease or condition-specific credentialing by CPT can be an effective means to achieve these collective goals. Although this article does not present an exhaustive discussion of specific credentialing protocols, it highlights fundamental issues to initiate the thinking process and then uses a real-life example of successful CPT credentialing.

Optometric Scope Of Practice

Credentialing providers by CPT will create many potentially divisive issues, particularly for those involved in network formation and administration. For example, each network's management will need to determine how optometric scope of practice fits into the overall strategic plan. It is clear that although a state may authorize optometrists to use ophthalmic therapeutic pharmaceutical agents and treat or manage certain ocular conditions, or even use lasers, legislative fiat or Board of Optometry decree does not obligate a network to allow any or every optometrist to practice to the full scope of licensure.

How this delicate subject is handled is fundamental to any network's formation and long-term success. Optometrists are highly motivated to show that they are qualified to manage more than routine refractive examinations and optical dispensing. And they won't be particularly enthusiastic about joining any network that restricts them to this basic care. Having optometrists in any network is essential because patients like choice, and an ophthalmologist-only network simply isn't marketable to most payors. Thus, developing the "right" protocols is critical. This requires balancing the wants, desires, and practical realities each viewed from different perspectives and biases.

So, for example, one network's quality assurance and utilization management protocols might stipulate that all laser procedures be performed only by a physician, no matter what a legislature or optometric board might authorize. Or a network might determine that all follow-up care within 30 days of any refractive surgery be done by a physician or an optometrist working directly under the supervision of a physician. Yet another may determine that credentialed optometrists may immediately co-manage post-cataract patients or certain other conditions independent of physicians.

Clearly, the network management will find itself in some very sensitive discussions. Scope-of-practice decisions, including the drafting of clinical guidelines and treatment protocols (preferred practice patterns), must be worked out by cooperative and collaborative efforts between professionals representing all sides. Decision-makers should be those critical thinkers who can quickly distance themselves from purely political issues; who fully understand the cost and logistical constraints, demands, and practicalities of managed care; and who understand optometric education and training going into the millennium.

Within its internal credentialing, quality assurance, cost-containment, outcomes assessment, and utilization management protocols, each network will determine appropriate standards for the services, population, and contract in question. In all cases, however, network management must never lose sight of what's best for the patient's welfare and what brings best value to the collective endeavor.

All decisions should be made openly and early in the network development process so that recruitment and on-going operations are not encumbered by hidden agendas. Optometric credentialing by CPT should never be used to artificially or unreasonably restrict certain panel participants from providing certain services they are competent to provide.

Therefore, in establishing an optometric credentialing protocol it is the network leadership who must appropriately and accurately "measure" qualifications. That means creating a protocol that falls between carte blanche declarations of optometric boards and the position inherent in the adage "If you want to be a doctor, go to medical school." There's a lot of middle ground on which physicians and optometrists can build an effective foundation if they have the collective will.

Ophthalmologist vs. Ophthalmologist?

Regrettably, some see credentialing by CPT as strictly a way to limit optometrists to providing only routine exam and eyewear services. Nothing could be more disruptive to building and managing an integrated ophthalmic network. Credentialing by CPT is more complicated and also involves the qualifications of physicians.

This sensitive and problematic issue may be contained within the panel of general ophthalmologists, or may include both generalists and subspecialists. As with optometrists, many physicians will find credentialing by CPT a bitter pill to swallow. Perhaps no other issue will cause as much dissension among them because, as with optometrists, it will directly impact the amount of work they are authorized to do and, thereby, total compensation.

Many physicians will ask why CPT credentialing is even being considered. After all, doesn't the medical license represent the ultimate authorization to deliver medical and surgical services? What issues necessitate directing certain services and certain patients to a limited subset of panel ophthalmologists? Let's consider one example.

Assume past experience in the local general ophthalmology community indicates to a network's utilization management and quality assurance committees that a certain percentage of specific glaucoma surgeries must be redone. Historically, the original general ophthalmologist might perform the second surgery, If that didn't resolve the case, the patient would be referred to a fellowship-trained subspecialist. A review of the data might indicate that after a glaucoma subspecialist resolved the typical case referred from a general ophthalmologist, an average 2.5 surgeries had been performed and billed.

When claims were sent to a faceless insurance company that bore the risk, nobody on the physician or network side was particularly focused on the financial consequences. But if the network is at-risk, with a fixed pool of expendable dollars (and with the patient care issues momentarily set aside), the management team must consider the system-wide financial ramifications of multiple procedures and patient visits. It's possible, perhaps even likely, had those patients first gone to a subspecialist or to a glaucoma-credentialed general ophthalmologist, only one surgery might have been required.

With every network provider's compensation tied to a fixed pool of aggregated dollars, reoperations take on a new dimension and dynamic. No matter how many additional surgeries are performed, they can't go unaddressed if reimbursements are to remain within an acceptable range and the network is to survive within its fixed funding. Thus a network's committees might determine that glaucoma filtering surgery will only be done by fellowship-trained glaucoma subspecialists, or by general ophthalmologists with documented expertise in glaucoma. Only those physicians would be credentialed for that specific CPT and authorized for compensation.

This will certainly cause concern, even anger, particularly among general ophthalmologists who have been treating a particular condition for years and who, at a minimum, will feel disenfranchised. And when some or many of these higher compensated procedures accrue to just a few surgeons, those not credentialed will certainly ask "How is this better? What's in it for me"? Any network implementing CPT credentialing at any level is doomed if it cannot successfully answer those questions at the philosophical level and through the compensation system.

Changing The Traditional Mind Set

Let's look at a real-life, successful example of credentialing by CPT. Although this is anecdotal and limited to a small subset of eye care procedures, it is typical of cutting-edge strategies used by at-risk networks to improve quality of care, control costs, maximize total network efficiencies, and maximize convenience for the patient who might be spared multiple procedures. It should not be construed as a recommendation to be "cookie-cuttered" into any network, but rather as a model that worked in a particular set of circumstances in which physicians were collaborative and willing to explore untested waters.

A proactive ophthalmology group in a mature, managed care market in California took an innovative approach to patient care and found a way to improve quality of care while, simultaneously, reducing costs. Although at first glance the approach may seem one that used a more expensive provider necessitating additional front-loaded costs, the program actually demonstrated that total costs were less than with a more traditional approach.

The group of 13 doctors (including general and subspecialty physicians) decided that certain disease states should be followed and analyzed closely to minimize high-risk and high-cost complications. They developed an innovative diabetic training program and evaluation system to screen diabetics upon entry into the eye care independent physician association (IPA). All diabetics would be seen by fellowship-trained retinal specialists, not by an optometrist or general ophthalmologist.

From May 1989 to October 1993, 760 patients with diabetes had retinal examinations. This accounted for approximately 74% of the diabetics identified in the system, screened, and trained in the care of their diabetes. At the onset of the study there were approximately 30,000 patients enrolled in the IPA, of which only about 5% were older than age 65. By the end of the study period there were approximately 60,000 covered lives, still with about 5% over age 65. This was the population on which the study was based.

In the 54 month statistical analysis, the 760 patients seen by the retinologists had a total of 1,740 visits, with an encounter rate of 2.29 visits per patient. Over the course of the study there were 189 laser procedures (55 for diabetic macular edema, and 134 for preproliferative or proliferative retinopathy) and there were 61 fluorescein angiograms. Over the study period only 1 vitrectomy with endolaser was necessary.

The patients who required pan-retinal photocoagulation constituted 17.6% of the total diabetic population seen, which correlated well with the roughly 20% of diabetics (nationally) one would expect to go on to proliferative retinopathy. Also, on a national average at the time, approximately 20% of proliferative diabetic retinopathy eyes would be expected to fail on laser photocoagulation and would have required vitrectomy. Using that figure, and with the number of patients seen in this population, 27 vitrectomies would have been expected. Hence, in the course of this study, sending the diabetic patient directly to the retinal subspecialist with early use of lasers resulted in a 96.3% decrease in the number of vitrectomies -- nearly total elimination.

Considering that the facility and professional fees for a vitrectomy ranged around $10,000 per case at that time, this proactive program saved the IPA approximately $250,000 in high cost surgeries. If against that expected savings one subtracted the front end costs of early-use lasers (roughly $67,000 at $500 per procedure), the actual net savings was approximately $180,000.

Because the laser surgeries were performed on an outpatient basis with the patient generally returning to normal activities within 24 hours of the procedure, the actual dollar savings were compounded by the economic advantages from less patient down time than would occur after a vitrectomy. (That is, if after a vitrectomy and endolaser the patient likely would have had a recovery time of ten days to two weeks, the unrealized economic losses resulting from missed work and disability payments represented considerable additional savings to patients.)

Thus, this proactive program identified diabetics in a captured patient population and sought an effective and innovative way to change the traditional treatment paradigm through CPT credentialing. It demonstrated that early and aggressive laser photocoagulation markedly reduced the need for high cost vitrectomy procedures. This study reaffirmed that higher quality care can be realized through the use of innovative disease management programs under the direction of select practitioners. Most significantly, higher level of care can be delivered with a marked reduction in high cost procedures and with important quality of life advantages for those patients who have diabetic retinopathy.

Getting Everyone To Buy-In

Although the example was not a controlled study, the results are impressive. Everyone involved in the patients' care was happy: the patients, payor, network administrators, and the retinal surgeons who were paid for their services. But what about other network practitioners -- the general ophthalmologists and optometrists who were excluded from the care of these patients? What incentives do they have to make this work if they are not credentialed for the services in question?

In this example dealing with just one condition and a limited set of services, the network garnered approximately $180,000 in savings (retained in the network bank account and representing funds that otherwise would have been deducted from the finite pool). It seems obvious that any network setting up such a system should ensure that the savings are paid out, in significant proportion, to the practitioners who fundamentally made the savings possible -- the general ophthalmologists and optometrists.

This does not mean that every dollar saved is paid out. It does mean if CPT credentialing is going to work and benefit the network as a whole (the old Three Musketeers ideal), then those who "bought-in" at the front end and put their personal interests second to the network's need to reap significant rewards from the overall good results. This principle applies whether those doctors are equity owners or employees, and may even apply in certain circumstances to subcontracted panel participants. In part that consideration will be driven by competitive pressures and the number of physicians and optometrists seeking entry to the panel.

The compensation can be paid as a quality assurance or quality improvement bonus, a utilization management bonus, or a cost-containment bonus. It really doesn't matter as long as the positive and comparative results are made known to all and disbursed in a timely fashion. Nothing works to change incentives or achieve performance targets as quickly as significant positive impact on the paycheck. And that even applies to the thorny issue of credentialing by CPT.

Those last sentences are not meant to be uncomplimentary but are rather a reflection of reality. Physicians and optometrists will work collaboratively under appropriate and thoughtfully crafted CPT credentialing protocols. They will work toward a common goal of improved patient care and network efficiency. But they won't go to the gallows and bring their own ropes!

Gil Weber is a nationally recognized author, lecturer and practice management consultant to practitioners and the managed care and ophthalmic industries, and has served as Director of Managed Care for the American Academy of Ophthalmology.

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