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Is it time for a new model for optometry?


Stef Kriel graduated from the Witwatersrand Technicon in 1976. In 1996, he completed the CAS – DPA (NEWENCO), followed by all the CAS courses that represented the didactic coursework required for the NEWENCO OD programme and a Masters in Health Professions Education (UFS) Cum Laude in 2003. He is a founder and for past twenty years, the owner of the Graduate Institute of Optometry, which offers various short courses in specialty fields through the GIO – NECO (Boston) affiliation. Stef has served the SAOA in various capacities for ten years, twice as President. He served on the Professional Board of Optometry for twelve years, one term as Chairman and two terms as head of the Education committee. He is in private practice in East London.

If optometrists are realistic and take note of the changing world around them, they should realise that South African Optometry needs a new model if it wishes to survive the next ten years as a Health Care Profession.

The business landscape as we know it will change, mainly due to disruptive technologies such as online shopping, online refractions and virtual consultations. It is part of the information revolution that has already transformed other industries by the likes of Uber, Air B&B and Amazon.

If optometry fails to take advantage of this changing landscape, it will fight a losing battle of protectionism and become employed by new players who will seizethe opportunity.

The situation obviously did not happen overnight, but developed over several decades, whilst the profession lived in an ever-decreasing comfort bubble.

This new disruptive trend will not go away and optometry cannot expect to remain a healthcare profession with its current education, training,scope and business model.

How did it get this far?

The main reasons are simple;

  1. Education and training was not adjusted to meet the public need in South Africa. To my knowledge, the profession has made no attempt to measure the public need objectively and training remains embedded in a British model.
  2. Optometric practice is based on a business model that is probably as old as the profession itself, serving only a quarter of the population. The opportunity to replace the eye test with an eye exam has repeatedly been ignored since the profession was admitted to the HPCSAin 1974. Materials therefore remain the main income stream, whilst the medical aid “benefits” are linked to a biennial eye test.

Who is to blame?

Nobody and everybody in the profession. Time to move on!

Which needs should be measured?

  1. The public need
  2. The need of the State
  3. The need of the health insurance industry
  4. The need of the profession; priorities being, education and a new business model
  5. Moreover, the need to start the conversation with all the role-players

 What needs to be explored in each sphere?

  1. Broadly speaking, the public need covers the concepts of affordability, accessibility, and equity. Each one deserves to be measured against what optometry has been offering over the past forty-three years and what the public really needs;not just at primary care level, but also at secondary care level
  2. What the State gets vs what it needs from the profession in exchange for education and training
  3. How the insurance industry partners with the profession to address the public need and keep the profession viable
  4. What needs to change in educating a profession that will address the above needs
  5. How the profession uses all the latest technology to serve a population where seventy-five percent cannot afford the current care that is on offer
  6. The makeup and role of organised optometry in transforming the outdated fundamentals

Are there essential points of departure that all role players must recognise?

Yes. The starting point must be a clean slate from where the ideal is to be developed. Optometry may find it can use very little of its current base,but when survival is at stake, it calls for radical innovation.

Those who wish to take part must recognise the following;

  1. Optometry is rooted in the wrong foundation if it wishes to survive the information revolution and fulfil a meaningful health care role.
  2. Africa needs a different eye care provider
  3. Strapping new skills onto the old model is essentially flawed and self-limiting
  4. The profession has not filled the primary care space adequately. Moreover, there is a large void between this inefficient primary care offering and a betterorganised secondary care offering by ophthalmology
  5. Training as diagnosticians of ocular pathology is inadequate and limits the profession’s ability to play an effective role in the prevention of blindness.
  6. The foundation needed for therapeutic privileges is lacking and/or taught without purpose
  7. With current training, a meaningful role in the public sector is not possible.
  8. The profession has failed to measure the public need against how it trains to meet that need.
  9. A sustainable business model is lacking becausethe future reliance on materials as a revenue stream is unsustainable.
  10. A brave step is required to allowdispensing of materials to be deregulated, because it hamstrings professional development, inflates the cost of corrective appliances, and drives the profession into commercial locations, away from the community it needs to serve as a health care provider.

Is there an educational model in the health care professions in South Africa, which optometry can use as a base to plan?

Currently a five-yearprogramme for optometry is under development. The goal remains the same; to develop an independent licenced practitioner with a limited scope of practice. A South African optometrist is limited to treating primary conditions and those representing manifestations of systemic diseases, which affect aone organ system – the eye and adnexa.

A review of health professions education in South Africa reveals that the most suitable curricular model, with the most parallels in terms of degree of independence, length of training, and scope of practice, that is largely limited to a single organ system, is dentistry.This presents the opportunity to use the foundation of a model that already exists.

Some may say we will not get the funding. However, if we look at the potential benefits for the public and the State, the funding argument falls away.

Simply put, the benefits offered by aneye care provider that can fill the void between primary and secondary care, justifies the fundingof a new model, with the view of graduating optometriststhat will be more employable in the public sector. The new graduate will be able to offer meaningful community service years and can work in close collaboration with ophthalmologists in the private and public space.

Moreover, it will reduce the cost of managing primary conditions, reduce the number of costly downstream interventionsvia early detection (prevention), and reduce the dependence on an income stream based on materials.

In short, optometry can only expect to earn a respected standing in health care, by improving thefundamentals; education,training, and a new business model.

A costly alternative to the State would be, to train more ophthalmologists and ophthalmic assistants to fill the void, but this will not reduce the cost of delivering eye care.

Is this a different qualification?

Stay with the term optometrist as there is a need to embrace those who will want to hang onto the status quo but differentiate the degree itself; BMO (Bachelor in Medical Optometry).

What business model is suggested for the private sector?

Modern optometry did not lose materials in countries where dispensing was deregulated. In some countries, it was never regulated.

Good advice will be to get rid of “the monkey on the shoulder”and move onto an income stream based on clinical skills and knowledge with less dependence on materials.

The biennial model of reimbursement is yet another handbrake to the profession. It may help health insurers to budget and limit risk, but it does very little for growth and the expansion of the scope of the profession. The reason for this is simple, most optometrist do not charge for follow-up examinations (no benefits), and there is no way that disease conditions can be managed or monitored within the “two year” reimbursement model.

Reimbursement must, primarily be based on professional fees and lens codes must be limited to clinically essential generic lenses. Frames and add-ons to the generic lenses must be left to open market forces.

Professional fees must acknowledgeand reward advanced diagnostic investigations, speciality fields and the medical management of primary conditions.

The paradigm shift for the profession will be to embrace, as its primary role, the diagnosis, prevention and management of ocular disease. In doing so, it will retain the supply of spectacles and contact lenses. This is supported by The Optometric Medical Model Initiative or TOMMI. (Review of optometry 02/14)

Solo practice is a luxury that has become more challenging as group practice outside the commercial setting will be the more attractive future option in order to curb overheads,invest in state of the art equipment and improve efficiency.

Who will sell the concept?

Every optometrist must recognise the necessity of taking the profession to the next level. It is a matter of survival. Every single optometrist must become vocal in their support of the new strategy and to demonstrate that as a lobby group, it is a force to be reckoned with.

Strong leadership is required to orchestrate a coordinated effort, which will take optometry to a level, which will secure its future.  A white paper will be required to document the process and the required outcome.A coordinated effort is required, which will necessitate engagement with, the department of health, universities, the health insurance industry, supported by an advocacy exercise. Moreover, the potential to learn from other countries who have travelled this road remains a reality.

If the profession continues with its sideways trend, what will the most likely scenario look like?

  • Increased exposure to interventions by artificial intelligence.
  • Enforced de-regulation by outside forces
  • Continued and enhanced dominance of fees by medical aids.
  • Refractionists in the public sector, hospital based – technology is likely to replace them.
  • Employees in a corporate model, with NHI links and single exit prices for medical devices such as lenses.
  • Mall based practices will be unable to sustain the annual increase in rent
  • A growing employed group in ophthalmology practice where they and Ophthalmic Assistants will fill the primary care space neglected by optometry.
  • A minority in community based practice that will represent the profession at a level it once aspired to

A final thought

If technologies like OCT, Topography, X – Linking and Myopia control are widely available, will members of the profession be held liable for not offering this to their patients or at least refer to a colleague that does?

South African Optometry must seize the opportunity to set new standards of care and each and every optometrist must recognise the importance of supporting the notion of changing our mode of practice. At the very least some sign of support is required.