Cataract comanagement criteria

When to hand off post-op visits, how to find a simpatico OD.

By Robert Murphy

Eye surgeons who comanage cataract patients must decide when is the proper time to send a patient back to the comanaging doctor — a trickier decision than perhaps it should be. Many ophthalmologists prefer to see the patient at least at the one-day postoperative visit to ensure there are no complications before passing the patient back to the referring doctor. But in instances in which the patient lives a considerable distance away, this may be inconvenient. It may also be the case that the comanaging doctor expects the patient back right away almost as a quid pro quo for the initial referral.

Cataract surgeons comanage some 14% of their own patients, and optometrists provide the postoperative care in more than two-thirds of these cases, according to David Glasser, MD, chairman of Health Policy for the American Academy of Ophthalmology and an assistant professor of ophthalmology at the Johns Hopkins University School of Medicine. “Comanagement in general should be done in the patient’s best interest,” Dr. Glasser says. “That’s true whether we’re talking about comanaging at [day one] or later in the postoperative course.” But how do you ensure that is the case?

It usually comes down to this

A 2000 joint position paper of the AAO and the American Society of Cataract and Refractive Surgery outlines situations they deem are justifiable circumstances for comanagement. One is that the surgeon for some reason is unavailable. Another is when the patient cannot travel to the surgeon’s office.

“[Most comanagement occurs] because either the surgeon can’t travel to where the patient is, or the patient can’t travel to where the surgeon is,” Dr. Glasser says. “A lot of these patients are elderly, and they need someone to drive them. And sometimes they just can’t get from A to B in a timely fashion.”

What patients need to know

The guidelines further state that the surgeon must inform the patient about any predetermined comanagement arrangement, and have the patient consent to this in writing. The surgeon must also inform the patient about the financial arrangement of the postoperative care. Comanagement should not be done as a matter of routine policy. The surgeon should follow the patient until he is stable postoperatively. And patients should know that they will always have access to the surgeon following the procedure.

Gray areas

These are best-case scenarios. In practice, cataract surgeons acknowledge that comanagement is sometimes driven by financial concerns.

“I comanage patients who are an hour or two hours away, and I feel comfortable with that because there’s an actual reason for doing it and there’s a convenience to the patient,” says Richard S. Hoffman, MD, a clinical associate professor of ophthalmology at the Casey Eye Institute, Oregon Health and Science University.

“The comanagement part is really meant as a way to have the patient avoid having to travel for an hour or two, and there’s a competent optometrist or ophthalmologist in their area who can see them postoperatively. But what has happened is that it’s turned into basically a government-OK’d kickback, so that the doctor sends you the patient, you do the surgery, and then they get a comanagement fee. And if they’re three blocks away, that kind of borders on what I consider to be unethical.”

Evaluating comanaging ODs

For those ophthalmologists who do comanage, perhaps the first issue to address in deciding whether to comanage at day one is the comanaging doctor’s level of training and experience. Cataract surgeons recognize that optometrists generally are well trained and capable of providing proper postoperative care. They find that it’s important to find a comfort level with the optometrist with whom a surgeon may wish to comanage.

“It really is a matter of core knowledge and experience,” says Lisa Brothers Arbisser, MD, an adjunct associate professor at the Moran Eye Center, University of Utah. “Optometrists are great observers, and many of them are better at basic eye care than some ophthalmologists. And they’re perfectly capable of seeing the things we’re looking for and caring about the patient and dealing with the patient and calling you when necessary, which is rare.”

However, Dr. Arbisser believes a shared understanding and fund of knowledge must exist between MD and OD; it’s crucial to make sure both parties are on the same page before they begin comanaging. “You can’t have their 4+ cell and flare be your 1+ cell and flare, and vice versa,” she points out.

One approach to ensuring a viable comanagement relationship is to bring the optometrist into the office to observe surgery and discuss postoperative care.

“Some ophthalmologists will actually bring the optometrist in from the community and say, ‘Look, we’re going to be in a big comanaging relationship, come on in, I want you to watch me do surgery, I want you to see how I do things. Let’s talk about how I deal with my postoperative care so we’re all on the same page,’” says Farrell C. Tyson, II, MD, of the Coral Eye Center in Coral, Fla. “And so that allows for a better feeling of, okay, we’re all managing these patients the same.”

This is a way of carrying out the surgeon’s responsibility for assuring the patient’s proper postoperative care.

It may not be easy to ascertain whether a prospective comanaging optometrist possesses a certain skill level. Some may find it disrespectful to have their abilities questioned. “I guess you can ask them what their experience is seeing post-op patients both in training and in practice, and how much experience they’ve had, how many patients they’ve seen.” Dr. Arbisser says. While such a direct approach might seem practical and efficient to the ophthalmologist, optometrists may take umbrage. “Optometrists tend to feel they own their patients, and are very insulted by any question you would ask,” Dr. Arbisser explains. “It’s a touchy deal.”

The case for the one-day visit

There’s a compelling case for the surgeon seeing the patient at one day. For one thing, any complications that may arise, such as corneal edema, a pressure spike, cystoid macular edema, or inflammation is more likely to happen early in the postoperative course.

“The issue of comanaging at day-one post-op as opposed to a week or two weeks [later] is a little bit different because I think there are potentially greater risks, specifically serious complications where you need intervention,” Dr. Glasser says. “That’s rare after cataract surgery. So I think the person who is in the best position to diagnose and institute the proper management of a potentially disastrous complication is the surgeon who did the surgery.”

Some surgeons favor seeing the patient at day one because of what they can learn from the near-term outcome, particularly in the case of a new technique or novel IOL, and how they can use that knowledge in future cases.

“You don’t know what you’re doing right and wrong unless you see the patient postoperatively and see what they look like on the first day,” Dr. Hoffman says. “There are a lot of surgeons who don’t see the patient on the first postoperative day, and there’s a lot to be learned. I mean, you change your technique around a little bit, the cornea is getting cloudier on the first day and you realize maybe that’s not a good way to approach a cataract.”

He believes the surgeon should at least see the patient on the first day to ensure the eyes exhibit no excessive inflammation or excessive corneal edema, and that the patient appears to be on the road to recovery. Once those issues are confirmed, the surgeon can send the patient on to the optometrist.

Or delegate, then trust?

Other surgeons feel this is usually unnecessary. They maintain that a qualified comanaging optometrist can certainly convey clinical data to the surgeon at day one that indicates the early postoperative picture. Dr. Tyson reports he receives the day-one visit information this way. “So I get to really see, ‘Did I hit the target, no, what’s going on?’ I do about a 3.5-, 4-minute cataract, so I really don’t have corneal edema, so the next day I better be 20/20-20/40 vision,” Dr. Tyson says. “And they’re going to be able to tell me, ‘Hey, this is what I’m seeing,’ and give me an autorefraction or refraction so I can make some adjustments if I’m really missing the mark.”

Dr. Tyson, however, will see the difficult patients the next day; he notes the optometrists are perfectly happy to turn those cases over.

Scheduling concerns

One argument for comanaging patients at day one is that when you see them postoperatively it may take up time in your schedule when you might rather be doing surgery. But surgeons who manage their time efficiently say this need not pose a problem.

“I like to see my own work,” Dr. Tyson says. He contends that post-op exams need only take about five minutes, and schedules his own one-day exams over his lunch hour, scheduling them at five-minute intervals. “My techs work them up, visual acuities, pressures. And I just walk in, ‘Hi, how are you doing, great to see you, you’re seeing great, that’s awesome. Let’s just take a quick peek. Okay, everything looks good. Let me go get you ready for the second eye.’ So it’s not really taking a lot of time to do those post-ops. But yeah, you want to see them, and [provide] the hand-holding and interaction.”

As for the financial angle

Fact is, postoperative care is not all that remunerative. The Centers for Medicare & Medicaid Services sets the postoperative portion of the global cataract surgical fee at 20%. If the global fee is perhaps $700, the postoperative reimbursement comes to $140. Such a small fee argues against any financial impetus to refer the patient back at day one.

“So divide that by 90, it’s about $1.50 a day,” says Paul Koch, MD, of Koch Eye Associates in Warwick, RI. “It’s not a lot of money. So if you send the patient back to the optometrist a week later, you’re talking about 10 bucks. The optometrists don’t have to worry about any problems; we took care of that. The money, in my experience, is not a big thing at all. The optometrist does not want to see a patient with complications. Especially not for $1.50 a day.”

Instead, the optometrist’s chief concern perhaps is not so much the near-term comanagement fee, but rather the long-term ongoing retention of the patient.

The patient’s wishes

Ultimately it’s down to the patient to decide who will handle his postoperative care. “It should be 100% up to the patient,” Dr. Glasser says. “Comanagement shouldn’t be done for the convenience of the surgeon. And it certainly shouldn’t be done for financial or referral reasons.” OM