Vision Care Issues of Today

In this podcast, Denise Balch is joined by François Couillard, the Chief Executive Officer of the Canadian Association of Optometrists, to discuss some of today’s important issues in optometry and vision care. François will comment on why the scope of practice for optometrists is expanding, the place for virtual care, the concerns over online frames and lenses, and the valuable role of advanced diagnostics and imaging in today’s vision care plans.

--

To speak with the CAO, contact info@opto.ca. Learn more about how vision care is changing from the Canadian Association of Optometrists at dontlosesight.ca. Plus look for more podcasts, blogs and posts on vision care, comprehensive eye examinations and best practices coming to you throughout 2023.

--

Brought to you by the Canadian Association of Optometrists in association with Connex Health Consulting.

Find out more information on upcoming podcasts and webinars at www.connexhc.com.

Transcript

Denise Balch: 0:00

My name is Denise Balch and I'd like to welcome you to this Canadian Association of Optometrists Podcast. Today I'll be talking with François Couillard, who is the Chief Executive Officer of the Canadian Association of Optometrists, and we'll be talking about some of the issues in optometry including the scope of practice, virtual care, and the future of vision care. Just a little bit more about François before we get started. Early in his professional career, he worked in the healthcare sector for Johnson and Johnson, and MDS Nordion in both Canada and Europe, and after returning to Canada, he held executive roles at the Canadian Red Cross and VON Canada and held a position as the CEO of the Canadian Association of Medical Radiation technologists. François joined the CAO is their CEO - lots of acronyms today - three years ago. In his role, he leverages his deep advocacy, stakeholder engagement and marketing communication experience on behalf of eye health and vision care in Canada. François has also served as a volunteer with various organizations, and he also holds a degree in chemical engineering and an MBA from McGill. He is also an avid cyclist and a cross country skier, so we often see him on posts. He's probably the fittest member of the CAO team. Today, he's been kind enough to join us here today and take time out of his busy schedule to talk about optometry today and vision care, so thanks for being with us, François. It's a pleasure.

François Couillard: 1:36

Thank you for the invitation, Denise, it's great to chat with you today.

Denise Balch: 1:40

Great. So maybe you can tell me a little bit about the CAO and its mandate and your role as chief executive officer because some of our listeners may not be that familiar with the CAO's role.

François Couillard: 1:54

Certainly, I'd be happy to do that, Denise. So the CAO is the national association of optometrists in Canada. So we represent about 7700 optometrists and their assistants. We're the national voice of optometry, providing leadership and support to our members and to also help enhance the delivery of healthy eyes and clear vision for all Canadians. As the CEO of the association, if you'd like, my role is to steer the ship. I have a team of very capable staff, and we also have many, many optometrist volunteers, and my role is to make sure everyone knows the direction we're heading and is rowing in the same direction. Yeah, so just steering the ship.

Denise Balch: 2:47

That's great. Why don't you tell us a little bit about what are the biggest issues on your radar since you joined the CAO?

François Couillard: 2:56

Thanks. I've been at the CAO for a little over three years now, and I must say it's been a very exciting time to work in optometry. The profession is being propelled by several technological innovation at the same time as more and more Canadians are recognizing the importance of good vision, health, and regular comprehensive eye exams, and I'll give you some examples, so AI is all the talk these days. Everybody's talking about ChatGPT and, well, AI-enabled medical imaging of the retina of your eye allows for easier diagnosis of a lot of diseases and eye conditions such as diabetic retinopathy, which can lead to blindness. Conditions like myopia, which affect many kids, and which the World Health Organization anticipates will reach about 50% of the world population by 2050, used to be something there was not much you can do about, but now you can slow down myopia progression. There's new technologies, spectacles, contact lenses, that can allow optometrists to actually help slow down the progression of myopia, and myopia can lead to severe myopia which can lead to vision loss as an adult, so that's great news. Unfortunately, technology has also had some perverse effects. Unscrupulous online vendors can sell contacts and spectacles online without the need to provide a valid prescription, which encourages fraud and puts patients at risk, so that keeps me awake at night. Now, I said earlier that there's greater public awareness, and that's been reflected that the House of Commons, the parliament in Canada, where there was a member of parliament, Judy Sgro, that has put forward a private member's bill, Bill C-284, that is aiming at creating a vision health strategy. So it's very exciting. We've got all these new technologies and at the same time, so much more awareness of the public politicians of insurers.

Denise Balch: 5:18

Yeah, I mean, you bring up some really good areas that are on your radar, and I want to explore those a little bit further as we continue our discussions. I know, just a reminder to people or to let people know that are listening that in terms of myopia, we were actually fortunate enough to speak on a podcast, I think it was late last year, on myopia with an international expert in the field. If people go to the don't lose sight dot CA(www.dontlosesight.ca) website, they'll be able to listen to that podcast, so thanks for bringing that up. I'd like to first focus on the scope of practice, and to what extent the services offered by optometrists have changed in the last 20 years or so, and how that affects benefit plans. Maybe you could just let our listeners know what some of those changes have been.

François Couillard: 6:12

Great question. Historically, optometrists primarily provided vision care services, such as prescribing eyeglasses and contact lenses, maybe identifying and managing common eye diseases like conjunctivitis, or red eyes and dry eyes. However, with advances in diagnostic technology and changes in healthcare policies, optometrists are increasingly playing a more significant role in diagnosis and management of eye conditions that previously were the exclusive domain of ophthalmologists. For your regular eye care, an optometrist is really your primary care provider. What we're seeing is that, as the demand for eye care services has grown, and the number ophthalmologists has remained relatively constant, there's been a greater emphasis on expanding the scope of practice for optometrists, and today, optometrists are trained to identify and manage a wide range of vision eye diseases, including conditions like glaucoma. Really, optometrists or the GPs for the eyes, they're your general practitioner for the eyes. They use a variety of diagnostic tools such as visual field testing, optic nerve imaging and intraocular pressure measurement to detect and monitor all sorts of diseases. They can also prescribe and manage medications to treat various eye conditions. Is that helpful?

Denise Balch: 7:45

Yeah, I think that's very helpful. I guess one of the issues that we've struggled with is: coverage under benefit plans is quite limited, yet, as you said, the optometrists, their scope of practice is really quite large. So what are some of the challenges there?

François Couillard: 8:06

Yeah, that's another great question, Denise. If you're a Canadian, you're either covered by a public plan, or private insurers, or nothing at all. So, public plan coverages vary greatly from province to province. Where coverage exists, it's typically for children and seniors, or those under social assistance. In some cases, coverage exists for diagnosis of severe disease. But some widespread medical imaging procedures, like optical coherence tomography (OCT) scans and fundus imaging, which look at your retina, can which can help diagnose and manage conditions like glaucoma, again, or macular degeneration, are typically not reimbursed by our public system. To make an analogy, what would you think of a healthcare system that doesn't reimburse the full costs of X-rays, CT scans or MRIs? Now group benefit plans have not changed in years and years and years, and they have not adapted to these new tools and the new scope of practice of optometrists. As a result, patients have to pay higher out of pocket costs for their eye care than they would as a percentage for dental care, for example, or for drugs. It's very easy to fall between the cracks. The minute you need a little bit more care or you need complex optics, you're going to pay a lot out of pocket, because there's a gap between what the public plans will pay and what the and what the private plans will pay.

Denise Balch: 9:53

Yeah, thanks for that. I know that it's an issue, and I was actually speaking to Dr. Wes McCann, who is an optometrist practicing in London, and he echoed your remarks. He was really concerned about the baseline that can be created from some of these more sophisticated diagnostic imaging and tests, that it's really quite necessary for adults, particularly, to have these tests, as well as the background on an individual's family history and current health status. It's really important to get that baseline as well by doing some of these modern diagnostics. In terms of some of the other things that are going on in optometry and vision care, we've heard quite a bit recently about virtual care, and we've heard it in many other areas of the healthcare sector, but it's something that we are just starting to really understand in optometry. Perhaps you can share with us a little bit more about virtual care.

François Couillard: 11:03

Yes, thanks. As you know, in Canada, virtual care became more and more popular in recent years, especially because of COVID-19. My own GP, for example, worked mostly virtually during the past two years and has only recently in the last few months returned to in-person care. During during the first COVID wave, most optometry offices in the country were closed, they were not allowed to practice, and virtual care was the only way an optometrist could see patients. Now as you can imagine, optometry care requires some sophisticated equipment, so it's not obvious that you can you can deliver that good optometry care virtually, it's pretty limited what you can do. In addition to that, not all provincial or private health care plans pay for virtual care, there's no code for that. Now, interestingly, there's now technology available to allow optometrists to do comprehensive eye exams remotely, the full exam, the full gamut, including these tests that I talked about- OCT and fundus imaging. That can be done, provided the patient is in a room with all the required equipment, and there is an assistant with the patient. Then the optometrist can be 100 kilometers away in a different room. That can be done. That solution of virtual care could be interesting for remote regions of Canada, I don't think there is need for that in the large cities, but if you think of indigenous communities that are hard to access, this might be a very interesting solution. That technology exists, it works, and it is being further tested in many parts of the country right now.

Denise Balch: 12:56

Particularly with high rates of diabetes in the indigenous populations, I would think that virtual care is is really critical.

François Couillard: 13:04

Yeah, and specifically for diabetes, actually, there are these AI-enabled kiosks that you can set up, that will do some basic screening of patients who have diabetes, and you can identify and grade the type of, if they have any diabetic retinopathy, and then they can be referred to an optometrist or an ophthalmologist as needed. The eye is a complex structure, but it gives you access to a lot of information. So when you look at the back of the eye at the retina, you can see blood vessels, you can see nerve structures, that you can not get so easily anywhere else.

Denise Balch: 13:57

It's very interesting. I have been working with the CAO, as you know, for a few years now. Coming from the benefits background, typically benefits folks think about vision care as a dollars-in, dollars-out benefit, or that it's just a frame and lens benefit and a quick exam every two years, but what I've realized in the last few years is that it's much more than that, and you and I have been around the CAO for around the same amount of time now. You work on it all the time every day and I'm just kind of in and out, but I've certainly learned a lot about optometry and the scope of practice. It's really quite impressive, the extent to which optometrists, through their various modern diagnostic tools, can identify signs and symptoms of other diseases in the body as well as eye issues and eye diseases. I'd like to turn now to frames and lenses because this is something that has has cropped up, like a lot of other things that are available online now, and there are several companies that have entered the market in recent years, and there has been some controversy over this. What are some of the reasons that customers you think are attracted to these suppliers? What are the pluses and minuses of these types of vendors?

François Couillard: 15:19

You're talking specifically about online providers, correct? I think they're probably attracted to the convenience and promise of a lower price. To me, those are probably the two main factors. Some of those online retailers can offer lower prices compared to traditional brick and mortar stores, because they have lower overheads. So those are probably the major factors - convenience, you sit at home, you can order your glands and your glasses, and you hope it's going to be cheaper.

Denise Balch: 15:55

That's right. For me, personally, I find that personal touch where you're in the optometrist's office, and they can make the adjustments to the frames and lenses, to me, that probably outweighs the convenience of going to an online vendor.

François Couillard: 16:11

Well, yes. There are many reasons that I Yeah, I can certainly see that. What's been the response by probably would not recommend going online if you need the contact lenses or spectacles. Our members see patients all day long, and they're telling us that frequently they see in their office patients that are complaining about lenses purchased online. There are several drawbacks, and they they include fit and comfort issues, poor quality, prescription accuracy, difficulty of doing returns and exchanges, but also from an insurer's or plan sponsor's perspective, online sales, they actually opens the floodgates to fraud. So let me expand on all of these a little bit if you'd like. Without trying the frames in person, it can be very difficult to know how they feel and fit on your face. So some online retailers may use lower quality materials for the frames or lenses, which can impact the durability and the clarity of the lenses so that the whole fit and comfort is one factor. Errors in prescription can lead to headaches, eye strains, other issues, and that's really critical. Returning or exchanging glasses can be made really difficult when purchasing online as the process may involve shipping glasses back group plans? I mean, I haven't been that close to this and forth, et cetera. Now for the plan sponsor's and insurer's perspective, when an online vendor doesn't require a particular issue. prescription - and that's very frequent - this should sound all sorts of alarm bells. Contact lenses and spectacles are regulated medical devices. The opportunity for fraud is quite real. There is nothing to prevent the claim being made for someone who is not insured under the plan, for example, or for corrective lenses without a legitimate prescription. Insurers don't have the same checks and balances in the system to verify the claim is legitimate. So it can significantly increase the cost to sponsors over time, though I

like to make the analogy: 18:28

what would you think of a pharmacy that doesn't ask its clients for a valid prescription before dispensing a prescription drug? As an insurer or as a sponsor, would you accept that? Would you accept claims that were made by your employees, or whoever, that were made in a pharmacy that doesn't check prescriptions? This is the same thing. It's a We're still educating them to a certain extent to the pitfalls medical device, they need to be sold with a prescription. Unfortunately, a lot of online vendors, all they ask is that you input some digits. They offer if you want to provide a prescription, you can, but you don't have to. So that type of behavior is really opening the door to a lot of fraud. of this sort of practice. Some group plans offer as a service to their members, the ability to get lower price spectacles and lenses through online vendors. We've recently started to make them aware of the issues in that some of these vendors do not have proper prescription verification, and so they are examining this and taking this very seriously. We've talked to a few insurers already, and we are talking to very large brokers, and they're taking this very, very seriously.

Denise Balch: 20:15

Yeah, I can understand that. You've made some really good points about some of the challenges of online frames and lenses. I think knowing that the Canadian Life and Health Insurance Association and its members have had a very robust strategy that's been developed over the last sort of five years or so on fraud, anti-fraud, there's a conference in Manitoba in June that's the CLHIA Claims and Anti-Fraud Conference, so I know that it's a big issue for them, and they've shown interest in collaborating with the CAO about fraud. So it's very interesting. So if we skip to the future, where do you think, say in five years, vision care should be?

François Couillard: 21:09

Ah, five years, so that takes us to 2028. That's a very short time span in my world, but let me try to look a little forward here. Well, since we're talking about insurers, I'm hopeful that private plans will have been modernized by then, and by filling gaps in coverage based on needs to improve access to standard diagnostic tools like these OCT scans and fundus imaging to those who need them. Also, that they'll incorporate increases in the frequency of follow ups for those with complex conditions, and pay for advanced lenses, again, for those who need them. It's not about paying for fancy glasses with all sorts of gold hinges and all that, it's about providing the type of quality optics that are required to help our patients. We really are hopeful, all of us, that with all our efforts to modernize the insurance industry, a lot of it will have changed by then. I think, also, by then we'll have recognized this broad detection and screening power of eye exams, not only for early detection of eye conditions, but also for many other physical ailments. The eye is the only place in the body that provides a non invasive view of blood vessels and nerves, which makes it an important tool for detecting and managing chronic conditions beyond visual problems. Diabetes, tumors, high blood pressure and other cardiovascular diseases are just a few examples that can be detected by looking into the eyes. A few other things, I think these AI-enabled solutions that I talked about will accelerate the diagnostic power of optometry and will be fully integrated in vision care within the next five years.

Denise Balch: 23:22

So there are more developments to come.

François Couillard: 23:25

Oh, yeah. I mean, I get at the office on a daily basis, a collection of news releases from all over the world, and every week, there's probably three or four news items of either new research or new investments being done in the field of AI-enabled detection of diseases in the eye. You mentioned when you introduced me that I worked for the Canadian Association of Medical Radiation Technologists before, so that was medical imaging - X-ray, CT, MRI - and it's wonderful what you can do with these tools, but you need a hospital or big clinic to house this equipment. It's very costly, and it takes time, but what you can do in the eye, which is very compact and with much lower cost, it gives you this view of so many things that before you couldn't do without, again, that big equipment. It's very exciting. I guess the last thing I probably would like to see by 2028, I think with the help of CLHIA, there will be measures in place to make sure the risks associated with online sales have been greatly reduced. This idea that you can just order your lenses from anyone, anywhere, without a prescription, is going to be a thing of the past.

Denise Balch: 25:14

It seems to make common sense. There's something that I wanted to come back to you on, and it's the idea of a follow up. We've talked about expanding the scope of comprehensive examinations through the modern diagnostic tools and imaging that were created, really, in the last 20 years or so, that aren't really reflected in an allowance for comprehensive exams under benefit plans. We've talked about that, but what we haven't talked about is the follow up portion, and why somebody would need a follow up exam. My understanding is that, just like in any other healthcare issue, if you have something where there's a diagnosis, or there's early signs and symptoms, you don't want to wait two years until you get it checked out. You want to get back to that healthcare professional to see how things are going. I think that's something too, that I know hasn't traditionally been covered under group benefit plans, but it's an area that needs to be fixed, isn't it?

François Couillard: 26:27

Absolutely. I'll give you a personal example. I have dry eyes. My eyes have always bothered me a little bit, but the last time I saw my optometrist, she says, by the way, do you know you have dry eyes? I said no. She said, well, let's test you to confirm it. She did all the tests, and then she suggested a few things I should do, and obviously, I tried them, but then there's a need for me to go back and see her and say, okay, well, that worked, that didn't work, can we try something else? There's a whole armamentarium of tools and solutions to treat dry eyes, and again, yeah, I'm not going to wait two years to go back. My dry eye is annoying, but for some individuals, it's so annoying that they become actually suicidal. This is how bad dry eyes can be. Can you imagine, you just leave them on their own, or they have to pay all sorts of out of pocket money to get the treatment they need. So that's just one example.

Denise Balch: 27:37

I think glaucoma, macular degeneration, diabetic retinopathy, for any of those conditions, the individual needs to be seen more often.

François Couillard: 27:47

Some of these conditions will progress faster, and you need to monitor the progression, so that you know when to make a more complex intervention, either yourself or refer to an ophthalmologist. So, yeah, this thing of a standard two year follow up interval, it doesn't make sense. It's not healthcare, right? Our bodies are not scheduled every two years to do something different, right? Not the way it works.

Denise Balch: 28:18

It might be fine for your prescription lenses, but for serious eye diseases, it's obviously not going to be adequate. The other thing that I want to just pick up on that you mentioned, is that with the new technologies that are being developed, and a lot of the things that we're talking about that are gaps right now in group vision care plans, are the technologies that have been been developed in the last 20-25 years. But as you said, there's more coming that the average person layperson doesn't really know about. I think we need to start thinking of vision care, not as a stagnant benefit, but as a true insurance that is addressing the healthcare needs of a population with ever-increasing advances in technology that are going to improve, not only an individual's vision outcomes, but also help their healthcare outcomes through early detection, so that individuals can be referred to their family physician or a specialist for further for further diagnosis and treatment.

François Couillard: 29:32

Absolutely. It's going to help the individuals, it's going to help the sponsors, it's going to help our economy. If you have better eyes, you have less absenteeism, you are going to be more productive at work. You're going to be a happier person, better families, so it helps everyone. With so many people working in front of screens, we're all much more aware of the importance of our eyes, and good eye care. Health benefits are so much more than paying for fancy glasses. So, so much more. It's a health condition, and you ask anyone, what's the one thing you don't want to lose, in terms of priority? It's your eyes. Let's treat it like that, then.

Denise Balch: 30:27

Absolutely. I know that we're all working hard to launch our filling the gaps campaign in vision care benefits. So maybe you can just let our listeners know what's coming in terms of that campaign and where they can find it.

François Couillard: 30:47

First of all, I want to thank you, Denise, you've been a great source of expertise and supporter and cheerleader, so thank you for everything you've done. Over the years. We've published webinars, podcasts, we've spoken at conferences, we've published an industry publication, and a lot of that is available on our don't lose sight dot CA(www.dontlosesight.ca) website. Finally, if you want to speak to one of us, if you want to speak to me, we have a small department that's working on this insurance industry modernization project, and if you want to speak to us, you can call the CAO, and ask to speak to me (François), or to Erin, or to Ibrahim, and we'll be happy to have a chat with you and start exploring ways you can get on the bandwagon and modernize your own vision care benefits.

Denise Balch: 31:41

Absolutely, and people can always reach out to me as well. Well, it's been a real pleasure to have you with us here, François. I know that this initiative is very important to you and the CAO, and we're very happy to have had you with us here today. Thank you so much.

François Couillard: 32:05

Thank you, Denise. You're so kind to have invited me. Thank you.