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Comanagement without Fear
With proper planning and teamwork, comanagement arrangements can work well.
BY AMIR ARBISSER, M.D., AND LISA ARBISSER, M.D.

Comanagement engenders spirited discussion among ophthalmic surgeons. Without question, comanagement increases access to care for geographically challenged patients and/or their families. But comanagement also carries risks. In this article I'll recommend a thoughtful and well-planned course of action that will lead to productive comanagement arrangements.

The Roots of Comanagement

Successful general ophthalmology practices typically require a potential population base of at least 20,000 individuals. This statistic excludes most communities within the United States from hosting an ophthalmologist office within their zip code unless the community offers a large unserved surrounding patient base. 

Capital equipment for the operating room and qualified personnel such as surgical scrub nurses or technicians pose related issues. If we find ourselves reluctant to invest six figures to equip an operating room within an ASC — much less construct an ASC to begin with — why would a modest but responsible community hospital do so for the few hundred anticipated cases annually? How would either the ASC or the hospital justify the addition of an experienced full-time scrub nurse?

Of course, few physicians consider entering solo practice today. Group practices, with their efficiencies of volume and scale, have improved patient care with shared responsibilities. They have enhanced doctors' lifestyles in matters like decreased on-call time and longer vacations. The growth of larger group practices centered in high-population areas further decreases the number of communities able to support ophthalmology practice.

With surgeons remaining distant resources, comanaging with local providers seems a logical response to the challenges posed by small communities or insufficient practice population base.

Medicare tacitly approved comanagement arrangements by providing us with at least three suffix coding modifiers:

-54 Surgical Care Only. This modifier is reported when one physician performs a surgical procedure and another provider offers preoperative and/or postoperative care.

-55 Postoperative Management Only. This modifier is reported when one physician provides only the postoperative care after another physician has performed the specific surgical procedure.

-56 Preoperative Management Only. This modifier is reported when one physician performs preoperative assessment and evaluation prior to another physician performing the surgical procedure.

Over the past two decades, multiple nearby ophthalmology and optometry practices sought our participation in, or at least tolerance of, their comanagement arrangements.

Referrals were implied.

For years, we consistently refused to comanage patients with independent nearby practitioners because we couldn't adequately control the quality of patient care and because we viewed such arrangements as potentially abusive of Medicare's intentions.

Obviously, we welcome referrals; we provide both clinical service and offer the 24-hour availability appropriate to global surgical services.

Comanaging Correctly

Surgeons aggressively seek optimal outcomes for their patients. For repetitive procedures like cataract surgery, standards of care improve the results. To pursue standardization with the associated quality results, surgeons must establish benchmarks and share those with comanaging doctors via an educational process.

We are aware of several practices that instituted some degree of training to accomplish this goal. In our practice, Lisa Arbisser, M.D., and Patricia Winters, O.D., assembled a CD-ROM and handbook outlining perioperative cataract care, with the intention of sharing that material with other practitioners. The project was partially funded courtesy of Alcon and the handbook is available through the American College of Eye Surgeons. An associated lecture presentation was made at an American Optometric Association annual meeting, and periodically to comanaging M.D.s and O.D.s within our practice and to other practitioners in our territory.

Insisting that a doctor meet the surgeon's educational or other standards frequently evokes vociferous objection from potential comanagers.

"I've been to optometric school (or ophthalmology residency). I know how to diagnose and treat iritis," they opine. True enough, however we note disparity between experienced physicians within a single professional organization — much less different practitioners employing different equipment in a variety of locations.

The surgeon retains ultimate responsibility for patient outcomes and expectations whether or not a comanaging doctor is involved. We feel no need to defend any decision regarding shared patient responsibility.

By creating an educational program, the surgeon hopes that a comanager is more likely to fulfill the surgeon's high expectations. Moreover, the course also provides "face time," enabling the surgeon to better assess the other doctors' clinical acumen as well as their communication skills —with the surgeon and the patients and families.

Act as a Team

The comanager should provide evidence of emergency service availability matching the surgeon's. Patients everywhere may interpret the absence of pain as evidence of the normal postsurgical course. Some patients hesitate to "bother" their doctors after office hours, at meal times or during hours of religious observance out of courtesy. The comanaging doctor AND the surgeon must communicate their availability and welcoming attitude to postoperative patients and families to avert potential tragic consequences.

In addition to the surrogate doctors themselves and their emergency availability, I believe we have a legitimate obligation to know about the comanager's diagnostic equipment.

Inadequately serviced or knockoff equipment may contribute to a less than optimal outcome of your patients' surgical experience. If the comanager provides ultrasonographic A-scan measurements or keratometry readings upon which IOL calculations depend, be sure there are documented calibration schedules, which should match your personal office's standards. Be aware that a different surgeon's factor or A-constant may be required for your IOL calculations than those from your in-house IOLMaster.

The American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery have issued statements disapproving of comanagement arrangements which exist if economic considerations drive the arrangement. The Office of the Inspector General of the Department of Health and Human Services has also expressed concern about comanagement based upon economic incentive.

Document All Aspects of Comanagement

A paper trail should be created documenting your concerns regarding standards of care for your perioperative patients. That paper trail could well include communications that emphasize quality pursuits between you and the comanaging doctors. The files might include, for example, documentation of timely calibration of important diagnostic equipment affecting patient outcomes. Finally, your records should certainly include written assent from the patient regarding his or her acceptance of comanagement ahead of the scheduled case.

That agreement should outline for the patient the separation of clinical responsibilities between surgeon and comanaging doctor, including any economic consequences.

To achieve optimal outcomes, surgeons must personally provide or arrange an appropriate alternative for quality postoperative management. Productive surgeons discovered the sharing of responsibilities both within and outside their actual practices long ago.

Medicare's acknowledgement of some of these shared arrangements have resulted in CPT codes that facilitate the transparency of the responsibilities with associated economic reality.

The patients' ultimate outcomes and satisfaction may rest upon the comanager's ability to carefully document the postoperative course, to communicate any deviations to the surgeon, and then to accurately redirect postoperative management. All must occur in a timely fashion without — or only minimally — upsetting patient or family.

Remember, patients assess the outcome of your surgical intervention based upon more than Snellen acuity.

Amir Arbisser, M.D., is a pediatric and medical ophthalmologist and co-founder of Eye Surgeons Associates, PC, with main offices in Bettendorf, Iowa, and Rock Island and Silvis, Ill. Lisa Arbisser, M.D., is also a member of Eye Surgeons Associates. She is an anterior segment surgeon and former president of the American College of Eye Surgeons. Dr. Amir Arbisser may be reached at yayinmaven@aol.com.