Providing Ophthalmic Services in a Contracting Environment: Concluding Remarks

Abstract

Dr. Goran stated that alternative delivery systems (ADSs) will become the predominant payment mode in the future. As these payment methods are significantly different from traditional fee for service, we must become more knowledgeable about them. Specifically, with ADSs there is limited access to specialty care, gatekeepers manage patient care and referral to specialists, and in some systems, physicians are reimbursed through capitation. Under these systems, physicians must assume more financial risk. Specialists will have to accept reduced payment for their services if they wish to participate and must be willing to alter their practice patterns to conform with cost-effective quality care. Government will encourage enrollment in these systems to shift the financial burden to the managed care providers. Ophthalmologists will be less influential in ADSs. For more power, the ophthalmologist has several options: (1) to join an IPA, which will negotiate risk and payment contracts with an ADS for primary and specialty care; or (2) to form a national preferred provider organization (PPO) network of ophthalmologists, a specialty network, offering primary vision care services and specialty packages. Dr. Rich presented some helpful practical information about how to participate in ADSs, what to expect, and the importance of participating in the policy-making activities of ADSs. Specifically, he notes that ADSs artificially divide eye care into refractive services and medical/ surgical eye care services. Usually, ophthalmologists must contract for these services separately. It is important to remember that access to these services is controlled by