Porch Views: Corrective lenses, COVID-19, OHIP underfunding and the future of eye care

Editor’s note: Welcome back, Mark Woermke! We’re grateful that Mark found time for this Porch Views during his summer “holiday” as we know that between gardening and historical research there aren’t any real holidays at his house. His views on eye care in the province – particularly in rural Ontario – are timely as, given the recently announced departure of Dr. Atfield, The Current plans more articles about local recruitment of healthcare professionals.

The ways we live, work and do business have changed. Each time we venture from our homes, we experience new protocols designed to protect personal and public health. Masks, for example, are now de rigueur for public events and venues across Eastern Ontario.  Personally, I find them a little inconvenient – they fog my glasses and make it a little harder to breath, but when you compare mask-mortality rates with COVID-19 mortality rates, it’s a no-brainer. I can live with a little fog on my lenses.

Speaking of lenses, I have been wearing them since 1974 when my teacher, Mrs. Bernarde, called home to report I couldn’t see the chalkboard. In short order, an appointment was booked with Dr. St. James. He ascertained I was near-sighted; fitted me with sensible frames from the discount rack since I was only nine and likely to break them; and provided my eye care for the next fifteen years. (Inset: Mark Woermke has been wearing corrective lenses since 1974 when his teacher noticed he was having trouble reading the chalkboard. Photo submitted)

Two weeks ago, I learned that an eye-glass dispensary in Ottawa’s Glebe neighbourhood was booking appointments and charging a $50.00 fee to select frames. I was initially annoyed, but after some thought, I concluded that, given the risks of COVID-19 transmission, staff must be provided with PPE, customers must be socially-distanced and everything to which they come close – countertops, mirrors, seats and the frames themselves – must be sanitized after each session.  All things considered the fee seemed justified. I also learned that the fee would be reimbursed should the individual purchase frames.

Then, I heard from Chelsea Bray a young optometrist with deep roots in the Madawaska Valley. She works in Guelph, but was in Barry’s Bay visiting her mom, Camille Conway. She shared her COVID-19 experience as a health care professional and provided insight into an OHIP billing issue that has been troubling Ontario optometrists for years but which the current pandemic has exacerbated. After exchanging a few emails with Dr. Bray, I also reached out to my optometrist, Dr. Agnieszka Cudowska Franzmann from Kanata, and Dr. Les Galek who practices optometry two days a week at the St. Francis Health Centre in Barry’s Bay.

Bray was off work from March 15 to May 31.  When her clinic reopened June 1, it was with significant staff and scheduling changes. While the clinic hasn’t lost staff, only three of the six optometrists work each week to limit the number of staff and patients on the premises. New protocols have been established. When patients arrive, they text or call from the parking lot as there is no indoor waiting area. Patients are required to wear masks and wash their hands upon arrival. After screening, they go directly to an examination room. Optometrists wear PPE when examining patients and a new cleaning regimen of regular sanitizing and deep cleaning has been adopted in the clinic.

Pre-COVID-19, Bray saw between 16 and 20 patients per day and squeezed in emergencies as necessary. Now she works week-on-week-off; and because appointments have been increased to 45 minutes, she only sees 10 patients per day and she can’t squeeze-in emergencies. They are directed to hospital emergency departments.

Galek doesn’t work in a clinic; he has his own practice and works alone in two locations – one in the Roncesvalles neighbourhood in Toronto and the other, two days per week, at the St. Francis Health Centre in Barry’s Bay. “Things are a little different for me,” he says. “I run a small location, so it is easier for me to limit contact with patients than for the large clinics.“ While Bray and Franzmann report  50 percent reductions in the number of appointments, Galek says his appointments are down 30 to 40 percent, but that is still a significant reduction. He noted that urgent need appointments are problematic given all of the new protocols and that, in Barry’s Bay, emergency cases will likely be sent to emergency departments in Ottawa.

Readers are probably imagining how these changes will affect their own experience of eye care in terms of increased wait times for appointments and the loss of dispensary walk-ins for adjustment, repairs or shopping. But the effects of COVID-19 are much more than just an inconvenience. The Ontario Association of Optometrists (OAO) estimates that during the next year two million eye appointments will be postponed or deferred. Emergencies present more serious consequences as patients may not get immediate care. And if they are re-directed to hospital ERs, these cases will create a new health care problem.

Perhaps the most dramatic effect of post-COVID-19 changes in optometry relates to the bottom line. Normally Dr. Franzmann and I chat about Barry’s Bay and Kaszuby because her family has a cottage on Wadsworth Lake, but recently our conversation centred on money – specifically the billing formula from OHIP.

Franzmann explained that OHIP “covers” eye examinations for Ontarians who are under 20, 65-plus, who have health conditions like diabetes and glaucoma, and who are on some forms of social assistance. However, the provincial insurance only reimburses optometrists for about half of the actual cost of the service.

Bray provided specific numbers: “The Ontario Association of Ontario (OAO) has determined the basic cost for providing an eye exam is $80.00. OHIP pays $47.00 for a senior’s eye exam, $42.50 for a child’s eye exam, and $43.80 for a patient with an eye disease or diabetes. As you can see, the OHIP remuneration doesn’t cover the cost of providing the service, and the optometrist or clinic is subsidizing the rest.“

Franzmann pointed out that over the last 30 years the OHIP rate has only increased by 8 percent while during that same time, inflation has increased by 75 percent.  Galek who has been practising for over 30 years agreed: “Over the course of my career, I have only seen two increases in OHIP rates, the last one being in 2009.”

As noted by the veteran optometrists Franzmann and Galek, the billing issue existed well before COVID-19. So now, consider the additional effect of fewer appointments and the cost of PPE and deep cleaning regimens on an optometrist’s business. Yes, optometrists, like other health care professionals, are also business people. They are committed to the health of their patients, but to serve their patients they must employ staff, manage properties, and make a profit. The current system of OHIP billing, however, is making that difficult. An OAO survey on the impact of the current pandemic on optometry practices revealed that 95 percent reported a revenue drop between 75 and 80 percent since mid-March.  This prompted its president, Dr. Sheldon Salaba, to state on the association’s website: “Optometrists can’t reopen practices that have been financially devastated by COVID-19, only to provide OHIP-insured services at an even greater loss. If this happens, practices in both rural and urban communities will struggle to survive.”

When I read that, the phrase “practices in both rural and urban communities will struggle to survive” struck a nerve since I recently learned my physician is closing his practice in Barry’s Bay and moving to Peterborough. I think the last thing we need in rural Ontario is to lose more access to health services, and not being reimbursed for the true cost of examinations is a real disincentive for optometrists anywhere.  

I took a look at the 2016 federal census data for Bray’s home, Guelph, which is an urban location and my home, Madawaska Valley, which is rural. The percentage of the population in Guelph that was under 20 and over 65 was 38 percent. For MV, the percentage was 48 percent. Now, I am not a statistician, but it seems that these numbers demonstrate that in our rural community an optometrist would be significantly more reliant on OHIP billing than in an urban setting. It’s already difficult to recruit and retain health care professionals here, but such dependence on OHIP rates that don’t cover the true cost of services must certainly make the area less appealing for optometrists.

Dr. Salaba of the OCA says, “We are fighting not just for our survival, but for a long-term solution that protects patients and public health. We ask the government to come to the table with a commitment to succeed where previous governments failed. Either cover the true cost of eye exams or give optometrists more flexibility in our billings. Optometrists are ready to adapt to ensure Ontarians get the accessible and quality eye care they deserve.”

Dr. St. James helped me see the chalkboard. Dr. Franzmann keeps my vision clear in the age of progressive lenses. She and her fellow optometrists Bray and Galek also helped me see how historic underfunding of optometry examinations by OHIP risks access to eye care for Ontarians.

For more information on this issue, or to show your support for Ontario’s optometrists, visit saveeyecare.ca