Epi Final Review PDF

Topic I: Healthcare System Organization and Delivery Healthcare Hierarchy Primary Care: first point of contact care for individuals seeking healthcare. It focuses on prevention, early detection, and management of common illnesses o Providers...

Topic I: Healthcare System Organization and Delivery Healthcare Hierarchy Primary Care: first point of contact care for individuals seeking healthcare. It focuses on prevention, early detection, and management of common illnesses o Providers: general practitioners, pediatricians, optometrist and community health workers Secondary Care: specialized care for patients referred by a primary care provider o Providers: specialist (e.g. ophthalmologists, dermatologists), specialist nurses and therapists Tertiary Care: provides highly specialized care for conditions that often involve complex procedures and treatments o Providers: subspecialists, surgeons and multidisciplinary teams Quaternary Care: provide experimental treatments or medical research Models of Health/Eye Care Delivery Fee-for-service: providers will charge a fee for each service rendered, therefore payment in based on volume of service provided o Pro: Encourages provision of services and patient access o Con: Can lead to overutilization of services, leading to increased care costs - Example: patients pay for each eye exam, diagnostic test or surgery individually and insurers reimburse based on predetermined rates Managed care: health insurers manage the cost and quality of care, is designed to control costs and improve efficiency by coordinating care. Some types are: - Health Maintenance Organization (HMO): members use in-network providers and obtain referrals for specialist care - Preferred Provider Organization (PPO): allows members to choose providers but may pay higher cost for out-of-network care - Point of Serve (POS): is a combination of HMO and PPO, Value-Based Care: providers are rewarded for achieving specific quality and efficiency metrics in their patient population Practitioner payment methods Fee for service: payment is based on volume of services provided not type. Capitation: providers receive a fixed payment per patient for a specific period, regardless of the cost of services provided Prospective Payment: providers are paid a fixed amount for specific services, conditions or episodes of care, based on predetermined rate Vision Care Plans a. Private Health Insurance: a wide range of plan options that often include routine eye exams, eyeglasses and contact lenses with premiums, deductibles and co-pays as costs b. Medicare: provides limited coverage for medically necessary eye exams and procedures for the elderly and disabled Does not cover routine eye examples, eyeglasses or contact lenses Covers some specialized optometric services such as diabetic eye exams, glaucoma screening and macular degeneration treatment c. Medicaid: provides varying coverage by state and typically covers routine eye exams and eyeglasses for children Covers routine eye exams, glasses and treatment for some visual conditions  Topic 2: Healthcare Financing Healthcare Market The interplay of supply, demand and insurance coverage significantly influences healthcare costs. Supply is the resources and processes involved in delivering goods and services to patients and providers o In healthcare, supply is influenced by regulations, technology and labor market conditions Demand is the level of consumption of medical services that an individual is willing to pay for o In healthcare, demand is influenced by population demographics, disease prevalence and patient preferences The interaction between supply and demand determines the price and quantity of healthcare services, creating an equilibrium point in the market. Changes in insurance coverage, government policies and technological advancements can shift the supply and demand curves, altering the market equilibrium Method of Health Care Payment Direct payment: patients pay for services out-of-pocket including fees for doctor visits, procedures and medications Indirect Payment: are covered by third-party payers like insurance companies or government programs, with patients paying premiums or copays. Shared Responsibility: a combination of direct and indirect methods, with patients and payers sharing the costs. Healthcare costs The US spends $3.8 trillion annually in healthcare o 30%-hospital care o 20% -physician and clinical services There is a projected average annual growth in healthcare costs of 6.5% The rising cost of health care in the U.S. is driven by a combination of the following factors: - growing cost of medical technologies - aging population (growing demand due to higher susceptibility) - prevalence of chronic disease - administrative overhead costs - high cost of prescription drugs - inefficiencies in care delivery - fragmented nature of the healthcare system Factors that impact optometric costs include: o Coverage levels o In Network vs. Out of Network providers o Deductibles and Copays o Benefit limits Healthcare Reform and Optometry The government has the following roles in the practice of optometry: 1. Regulation oversight as they set standards for licensing, education and practice 2. Funding and reimbursement as programs like Medicare and Medicaid provide payments and influence patient access and provider participation 3. Public Health initiatives such as promotion programs on vision screening, eye health education and access to affordable eye care 4. Research and innovation as government funds many opportunities that help drive advancement in treatments and technologies.  Healthcare reform has introduced new policies and regulations that impact the optometry field, requiring adaptation and compliance. Reforms have expanded insurance coverage for vision care, increasing patient access to optometry services. Healthcare reform has emphasized team-based, coordinated care, requiring optometrists to collaborate more closely with other providers. Economics of Optometry Practice Management Optometric practices must account for: o Staffing costs (salaries, benefits, trainings, administrative staff, etc.) o Inventory management (purchasing, storing, and rotating optical supplies) o Billing and Collections (maximizing reimbursements) o Overhead expenses (rent, utilities, etc.) Specialty optometric practices must also consider the role of niche services, higher reimbursement rates, equipment investment patient demand in their practice management. The future of optometry economics will be shaped by advancements in technology, a greater emphasis on preventive care, the shift to value-based reimbursement models, and the growth of telemedicine. o Adapting to these changes is critical to maintain a sustainable and thriving practice. Value-Based optometric care focuses on improving patient outcomes by incentivizing optometrist to provide cost-effective care that maximizes value for patients and payers. Economics of Vision Correction Procedures Refractive surgeries such as LASIK and PRK can correct vision and reduce the need for glasses or contact. The cost of vision correction procedures depends on factors like technology, provider experience and geographic locations Prices range from $2,000-$5,000 per eye Most insurance plans do not cover these elective refractive surgeries, limiting access to patients. Financing Structure and Options Health servicing financing options include private pay, public funding and third-party coverage The financial structure of the US healthcare system is composed of private insurance, Medicare, Medicaid, Out of Pocket payments, and the Affordable Care Act. A. Public Funding Healthcare that is primarily financed by government programs like Medicare and Medicaid o Pros: Accessibility, equity and cost efficiency o Cons: Limited coverage, reimbursement issues, potential for overuse 1. Medicare: a federal health insurance program that provides coverage for individuals aged 65 and older, as well as those with certain disabilities or end- stage renal disease. 2. Medicaid: a joint federal and state program that provides health coverage for low-income individuals, including families, children, pregnant women, the elderly, and people with disabilities. o State administration leads to variations in services o are often lower than private insurance, leading to accessibility challenges for Medicaid beneficiaries in finding participating providers. B. Private funding Patient pays directly in full to healthcare provider for goods and services  o Pros: Freedom of choice, often higher quality care and timeliness o Cons: cost burden, inequity due to exclusion and market inefficiencies 1. Out-of-Pocket Payments/Private Pay C. Third Party Coverage Healthcare paid directly by insurance companies on behalf of patient. Patient will usually contribute through premiums, co-pays, or deductibles o Pros: financial burden of healthcare is distributed across a large pool of individuals, predictable costs of premiums and co-pays and comprehensive coverage for a wide range of services o Cons: high complexity, incentivizes for overutilization, and limitation to in network providers 1. Employer sponsored 2. Individual Health Insurance  Topic 3: Quality Assurance and Legal Issues Quality Assurance Quality assurance is a systematic exercise to identify problems in health care delivery, address the problems and conduct follow-up monitoring to ensure corrective actions are effective Quality assurance is important because it ensures that healthcare services meet established standards, improving patient outcomes and practice performance. o Can be measured by: - Structural indicators (environment, staff, equipment) - Process indicators (appropriateness of care during patient visits) - Outcome indicators (result of care) Critical indicators of quality are ones that require 100% compliance such as CPR certifications Customization of quality indicators is possible based on practice goals and industry standards Key components of quality assurance: o Credentialing - Verifying qualifications and licenses of practitioners o Patient Satisfaction - Surveying patients to assess care quality. o Documentation - Reviewing and auditing medical records. o Utilization Management – Ensuring appropriate use of resources and services. o Risk Management- Development of policies, procedures and training to reduce risks Setting up quality assurance programs must include the following steps: 1. Define your goals 2. Identify your standards 3. Design your processes 4. Execute your plan 5. Evaluate your results 6. Improve your plan Data collection sources for quality assurance can be done through medical records, patient surveys, referral logs and prescription remake logs. Communicating quality assurance results should be through staff meetings, written reports and training sessions. Performing quality assurance in healthcare services can benefit practitioners and providers by: improving patient care, increased customer satisfaction, reducing liability exposure through risk management and increasing revenue through efficiency and patient retention. Implementing quality assurance can present some challenges such as: a large investment of time, resource allocation to perform quality assurance and may also face resistance from staff to implement new changes The future of quality assurance in optometry will be centered on technological integration for data collection and analysis, a greater focus on patient experience, continuous improvement and collaborative care. Customer Satisfaction in Optometry Common patient complaints include long wait times, insufficient communication, lack of personal attention, billing issues, unprofessional staff and not enough time with providers Patient and customer satisfaction involves surveying patients to see care quality o Requires survey design, data analysis and action planning In optometry, eyewear satisfaction follow up is necessary and requires performing a follow up call after dispensing and addressing any concerns by scheduling adjustments or follow up appointments.  Consumer Assessment of Health Plans (CAHPS): are a standardized assessment of patient experience with health plans that evaluate access to care, provider communication and overall satisfaction o Necessary evaluation to achieve National Committee for Quality Assurance accreditation Common Causes of Malpractice Claims Malpractice: is defined as any negligent act or omission by a healthcare provider that results in injury to patient o Occurs when a provider’s actions or inactions deviate from accepted standards of care o The provider’s negligent conduct must be the direct cause of harm for Medical errors: unintended acts or omissions, during any stage of the healthcare process that result in harm to the patient. Types of errors include: 1. Diagnostic errors: Failing to diagnose or refer for conditions such as glaucoma or retinal detachment. 2. Medication Errors: Incorrect prescriptions or dosages causing adverse effects 3. Equipment/ system failures: 4. Surgical Errors: Complications during procedures like LASIK or cataract surgery 5. Errors of communication: Lack of informed consent or inadequate explanation of procedures. Negligence: a circumstance where an optometrist fails to exercise standard of care unintentionally Duty is the legal obligation to adhere to the standard of care Breaching duty of care is when a provider fails to meet the standard of care, falling short of minimum competency expected The standard of care in optometry is defined by state laws, optometry board regulations, or established case law. o It represents the level of care, skill, and diligence that a reasonable and prudent optometrist would exercise under similar circumstances. Economic damages are damages to patients that can be quantified in monetary terms, such as medical costs and lost wages. Noneconomic damages are more subjective and difficult to measure, like pain, suffering, and loss of consortium. Preventive measures should be centered around regular education and adherence to clinical guidelines as well as meticulous documentation and communication with patients. Criminal negligence can include insurance fraud, HIPAA violations and sexual assault Malpractice cases often influence the standard of care by establishing new legal precedents, compel providers to update their practices and promote revision of clinical guidelines to clarify expectations surrounding standard of care Some important cases surrounding malpractice and litigation in optometry/ ophthalmology are: - Schloendorff v. Society of New York Hospital: established physicians have a duty to get a patient's consent before administering treatment - Tempchin v. Sampson: an optometrist's failure to diagnose uveitis, leading to blindness. Proper diagnosis and timely referral to an ophthalmologist could have prevented this devastating outcome. - Steele v. United States: Delayed referral to an ophthalmologist resulted in the loss of the patient's eye.  - Morrison v. McNamara states an optometrist must exercise the degree of skill expected of an optometrist acting under the same or similar circumstances. Failure to meet this standard of care can result in malpractice claims. - Helling v. Carey: landmark legal case in 1974 challenged the standard of care for glaucoma screening in optometry. The court ruled that optometrists had a duty to screen patients over the age of 40 for glaucoma, even in the absence of symptoms. - Keir v. United States: established a new standard requiring optometrists to perform dilated exams on nearly every patient, expanding optometrists’ duty of care. It is a frequently cited when a patient suffers vision loss due to an undetected retinal disorder - Bates v. Gilbert and Evans v. Griswold: cases that ruled that ophthalmologist lack the necessary familiarity with the optometric profession to provide expert testimonies. However, ophthalmologists may still serve as expert witnesses in cases involving optometrists’ failure to refer a patient Key Healthcare Laws Health Insurance Portability and Accountability Act (HIPAA): ensures patient confidentiality and proper handling of protected health information (PHI) o Requires secure data storage, clear privacy policies, and staff training on compliance Occupational Safety and Health Administration (OSHA) protects staff and patients from workplace hazards o Mandates safety requirements, proper water disposal and use of protective equipment Affordable Care Act (ACA/Obamacare): comprehensive healthcare law enacted 2010 that reduced costs, expanded healthcare access and improved quality of care by expanding coverage to individuals who previously didn’t qualify. o Provided consumer tax credits(subsidies), expanded Medicaid to adults at or below 150% of the federal poverty level and supported innovative care delivery methods to lower costs. Optometry Regulations Scope of practice includes the activities healthcare professionals are permitted to perform within their role based on the limit of their knowledge, skills and experience o It is defined by state laws and regulation and can vary across jurisdictions Practice procedures are a series of steps that are used to achieve consistent results o In optometry, some key practice procedures are acquiring informed consent, proper record keeping, complying to referral obligations and adhering to standards of care Billing regulations are designed to prevent fraud and ensure compliance with insurance and government program requirements Unprofessional conduct are actions that violate ethical standards or legal regulations in optometric practice such as unethical interaction with patients, lack of professional integrity and fraudulent claims. Disciplinary actions are imposed by state boards or regulatory agencies to address violation of professional conduct o Can be in the form of fines, license suspension/revocation, probation or mandatory education  Topic 4: Eyecare Workforce and Occupational Health. Demographics & characteristic of workforce 41,390 employed licensed optometrist in the US 9% increase in optometrist jobs by 2033 o 50,870 projected optometrists in 2030 Approximately 1,800 optometry students graduate annually 27% of new optometry graduates pursue residency training 45% of optometrist are under the age of 40 and 37% of optometrist range from 40-54 years of age 59% of optometrist are women Racial diversity in optometry: o 4% - Black/African American o 28% - Asian o 8% Hispanic/Latino o 55% - Whites The number of optometrists per capita varies significantly across different states New Mexico, Ohio, and Maine have a relatively high number of optometrists per capita, while others like California, Texas, and Florida have lower ratios. Optometrists tend to be concentrated in more populous urban and suburban areas, leaving some rural communities with limited access Optometrists in Puerto Rico tend to be concentrated in the San Juan-metropolitan region. o There are approximately 412 optometrists in Puerto Rico. Types of practices Private Practices: Most optometrists work in private practices, either solo or group settings, providing comprehensive eye care services. Hospitals and Clinics: Optometrists also work in hospitals, ophthalmology clinics, and other healthcare settings Retail Optical Stores: Many optometrists are employed by or contracted with retail optical stores, offering eye exams and selling eyeglasses and contact lenses. Academic Institutions: Some optometrists are employed by universities and colleges, teaching and conducting research Independent/Solo Practice: practitioners have full autonomy over their practice and decision-making, allowing them to tailor their services to their specific patient base. o Second highest earning type of practice Collaboration: the opportunity to collaborate with colleagues, share resources, and leverage combined expertise to enhance patient care. o distributes administrative tasks and clinical responsibilities, allowing optometrists to focus on patient care more efficiently. Optometrist that works with ophthalmologist engage in coordination, provide referrals often and co- manage to offer a full range of services o Highest earning type of practice  Factors Affecting Optometrist Earnings 1. Geographic Location 2. Practice Setting 3. Specialty Services 4. Years of Experience Optometry Education and Training Doctor of Optometry (O.D) is a four-year program after completing a bachelor’s degree o The curriculum encompasses comprehensive training in anatomy, physiology, pharmacology, vision science and clinical optometry o Clinical rotations allow students to have engage in hands on experience including community clinics and hospitals Residency programs allow for specialized training in areas like pediatrics, low vision, or surgery o Nearly 300 Residency programs o 26% graduates entering Residency o 496 residents in Optometry o 1-2 residences per Optometrist Enrollment in OD programs present a steady growth over the past decade o 2019-2020: +1.65% o 2021-2022: +0.5% Graduation rates United States has remained relatively stable over the past few years Population and aging trends The following factors drive the growing demand of optometrist: 1. Population Growth 2. Aging Population: - Adults aged 65 and older expected to nearly double by 2060. 3. Increasing vision needs - prevalence of age-related eye conditions like cataracts, glaucoma, and macular degeneration is directly tied to the aging population - vision disorders increase due to screentime 4. Diverse demographics: increasing racial, ethnic, and cultural diversity of the U.S. population will require culturally competent care Challenges affecting optometrist distribution and initiatives to address that Impact of Technology on Optometry Technology that impacts optometry directly include telemedicine, new diagnostic tools and custom eyewear Telemedicine enables optometrists to provide care to patients in remote or underserved areas, improving access o Reduce the need for in-person visits and travel time. o Facilitate collaboration between optometrists, ophthalmologists, and other healthcare providers, enabling a more holistic approach to patient care. Occupational Health Occupation eye safety programs protect workers visual health and prevent eye injuries in the workplace. Some hazards for eye injury are: 1. Physical hazards: harm an individual through physical interaction  - Examples: Eye strain due to poor lighting or screen glare, noise pollution in labs or manufacturing areas affecting hearing. 2. Chemical hazards: Exposure to harmful chemicals that can cause injury or illness. - Examples: Vapors from laboratory chemicals, medications that could spill and cause eye irritation 3. Radiation hazards: exposure to ionizing or non-ionizing radiation. - Exposures: UV exposure during outdoor eye exams, use of lasers in procedures like LASIK, radiant energy from imaging devices. 4. Infectious hazards: disease transmission due to pathogens like bacteria, viruses, or fungi - Examples: Spread of airborne infections in clinics, contact with bodily fluids during eye procedures. 5. Biological hazards: Risks associated with biological substances that pose a threat to health. - Examples: Infections linked to improper disposal of contaminated materials, exposure to allergens from mold in older buildings. Eye Injuries and Prevention The US Eye Injury registry reports that the most common eye injuries are as follows: 1. Blunt Trauma 2. Penetrating Injury 3. Chemical Exposure 4. Thermal Burn 5. Other Prevention strategies: a) wearing ANSI-approved protective eyewear, b) establish engineering controls that consider machinery design, ventilation system and ergonomically designed workplaces c) provide hazard awareness training d) incentivize routine eye exams to correct vision problems that can increase the risk of accidents In 2024, $300 million in treatment, worker’s compensation, and loss of productivity each year Before accidents happen, risk assessments should be performed to identify potential hazards, evaluate levels of worker exposures to the hazards and rank identified risks based on their potential to cause harm and severity o It is important to consult subject matter experts and analyze past incident reports, claims and industry trends to identify emerging or recurring hazards. When incidents happen, employers must document eye injuries and vision-related incidents, perform a Root Cause Analysis that investigates the underlying factors leading to incidents and Implementing measures to prevent similar incidents in the future via corrective actions Safety Standards The American National Standards Institute (ANSI) develops guidelines for eyewear that protect individuals in various environments including dress eyewear and safety eyewear. Safety eyewear is meant to protect the eyes in workplaces, labs, or sports and must meet the key standards:  - High Impact Protection - Side Shield Protection - Marking Requirements (“Z87” label to indicate compliance) - Optical clarity (no distortion or compromise in vision) - Chemical resistance - UV protection Patient Environment and Eye Health At home: o Cleaning, cooking, and other daily tasks can expose the eyes to dust, chemicals, and bright lighting o Hobbies like gardening, crafting, and reading can also lead to eye strain, fatigue, and exposure to harmful UV rays and can present risks of eye injuries from flying debris, chemicals, and sharp tools. o Improper lighting, glare, and shadow contrasts in the home can contribute to visual discomfort and impact task performance. At work: o Prolonged computer use can lead to eye strain, dry eyes, and computer vision syndrome. o Working with machinery, tools, and chemicals poses risks of eye injuries from debris, splashes, and impacts. o Improper lighting, glare, and reflections can cause eye fatigue and headaches. o Workplace hazards, airborne particles, fumes, and other environmental factors can irritate the eyes and pose health risk Temperature, air quality, particulates and humidity can irritate the eyes and hinder visual abilities o A 20°F drop in temperature can trigger irritation, increase the blink rate by up to 80%, and Temperature fluctuations can decrease contrast sensitivity by up to 30%. o Humidity below 5% will cause significant eye strain o Humidity above 80% will lead to fogging and reduced visibility Improving vision performance at work will require setting up ergonomic workstations, incorporate computer vision exercises and ensuring proper task lighting to ensure visual comfort Enhancing visual performance will require corrective lenses, contrast enhancement, brightness adjustment and glare reductions Computer Vision Syndrome Computer Vision Syndrome (CVS), also known as digital eye strain, refers to a group of vision and eye-related problems caused by prolonged use of digital devices such as computers, tablets, and smartphones. Symptoms: Eye strain and discomfort, dry eyes, irritation, blurred or double vision, Headaches, and neck and shoulder pain Best ways to avoid or mitigate CVS: - Follow the 20-20-20 rule (Every 20 minutes, look at something 20 feet away for at least 20 seconds) - Optimize workspace via ergonomics and lighting - Adjust display settings (increase text size, optimize contrast, reduce blue light, increase resolution) - Frequent blinking and use artificial tears to lubricate eyes - Taking regular breaks to stretch and stand - Proper eyewear with anti-reflective coatings - Schedule regular eye exams