When comanaging is no longer “co”
The ophthalmologist needs to make all final cataract surgery decisions, including IOL selection.
By Karen Auge, Contributing Editor
Ophthalmologists and optometrists who comanage cataract surgery patients are no longer in a league of their own. Comanagement has become increasingly prevalent, no doubt a reaction to meeting the soaring demand of the boomer generation.
But some surgeons allow the optometrist to handle all the pre-op work, including any and all IOL-related decisions. The surgeon just performs the surgery. For those who conduct comanagement in this way, the hazard of serious consequences looms.
“I think it’s very risky,” says Kevin J. Everett, MD, medical director, Henry Ford Optimeyes. “I think that’s extremely important ethically. You’re the surgeon. If something goes wrong, it’s ultimately your responsibility.”
Beyond the ethics
Dr. Everett says he knows some ophthalmologists don’t see patients before performing cataract surgery — they rely on the measurements and presurgery exams of optometrists. He predicts the practice may become more common, and that worries him.
William Trattler, MD, of the Center for Excellence in Eye Care, in Miami, says he doesn’t know any colleagues who perform sight-unseen surgeries. “I’m sure that happens, but I would never operate on the basis of someone else’s exam. You have to do a complete exam to make sure they are good candidates for surgery.”
Beyond the ethics of whether optometrists should take over postoperative care or handle preoperative evaluations, the nation’s largest insurer of ophthalmologists leaves no doubt about its position. Ophthalmic Mutual Insurance Co. (OMIC) “requires as a condition of coverage,” a preprocedure meeting between surgeons and patients, says Hans Bruhn, of OMIC’s risk management department. As evidence of that consultation, physicians provide their consent forms, Mr. Bruhn says. The policy isn’t likely to change anytime soon, he says. “The handoffs from one provider to another are, in our opinion, a particularly vulnerable spot in care.” To make those handoffs run flawlessly, it is crucial for surgeons to evaluate patients, he says.
Industry guidelines updated
The AAO and ASCRS jointly issued revised guidelines last month for comanagement and transfer of care. (See Joint Position Paper of the AAO and ASCRS, page 30.) This first revision to comanagement practice guidelines in 15 years acknowledges that comanagement is happening, is likely here to stay and often benefits patient as well as practitioner. At the same time, the position paper draws distinct boundaries between the optometrist’s and surgeon’s appropriate responsibilities.
The voluntary guidelines state in blunt terms that the ultimate responsibility for preoperative and postoperative care lies with the operating ophthalmologist, “beginning with the determination of the need for surgery and ending with completion of the postoperative care. . . .”
The previous guidelines focused on reminding practitioners that economic considerations should never drive comanagement arrangements — a view that has not changed. However, the revisions emphasize that the ultimate decision maker must be the patient, and that practitioners must fully inform patients of their options and the details of what comanagement entails. The committee identified three circumstances that justify comanagement: if the patient cannot return to the surgeon’s office for follow-up care; if the operating ophthalmologist is unavailable; and if that is what the patient wants.
Kevin Waltz, OD, MD, a partner with Eye Surgeons of Indiana and chairman of the ASCRS Integrated Practice Committee, says the revisions were needed, and represent months of discussion, consensus and compromise. “Some ophthalmologists believe [comanagement] is never OK; some do it routinely. There needs to be some middle ground, consistent with the feelings and ethics of the majority. I think these guidelines do a good job of providing that.”
Dr. Waltz doesn’t expect the new AAO/ASCRS guidelines to alter the practice of those few surgeons who rely on the optometrist to perform the pre-surgery exam and calculate measurements.
“People doing that are not likely to be persuaded by anything short of federal authorities,” he says, adding that ophthalmologists need to take responsibility for the patient’s surgical event with or without co-management guidelines.
Why we’re here
Optometrists’ role in cataract surgery grows as a convergence of forces seems to drive comanagement practices in that direction.
To Daryl F. Mann, OD, a founder of SouthEast Eye Specialists, PLLC in Chattanooga, Tenn., the evolution of traditional cataract surgery comanagement is a matter of expediency, one that allows practitioners to maximize their time to do what they do best, while meeting a growing demand for cataract surgery. The U.S. Census Bureau projects that by 2030, one in five U.S. residents will be over 65. More aging eyes virtually guarantee more cataract surgery. Age-related cataracts currently affect more than 22 million Americans, according to a 2011 Mayo Clinic study, a number projected to rise to 30 million by 2020. And, the study found that more patients are having second-eye surgeries, which means those 30 million Americans might translate to up to 60 million cataract surgeries.
The Mayo group found that the number of cataract surgeons in the study area of Minnesota increased by 27% between 2002 and 2011. Nevertheless, Dr. Everett predicts meeting the growing demand will be a challenge. “There definitely is not going to be enough surgeons to handle the volume,” he says. Despite the aging population on the horizon, Dr. Everett says, “we have not expanded residencies in ophthalmology. In fact, we’ve cut them.”
“What our model helps to do is make our practice proficient and efficient, to elevate the time available for surgeons to do what we [ODs] can’t do,” adds Dr. Mann. “And patient outcome and care is uppermost in that.”
Thank the techies
Current medical technology makes procedures increasingly less complicated. This trend is likely to continue and could even blur the line between what is “surgery” and what is a “procedure” that can be performed in an optometrist’s office. Alongside these innovations, optometrists nationwide are asking for increased access to the arena of patient care. For example, after much lobbying, optometrists in Kentucky won the right to perform laser eye surgery in 2011.
In many comanagement situations, not only is it common for optometrists to make the initial determination that cataract surgery is necessary, it is increasingly common for optometrists to take over postoperative care much sooner than in the past (For comanagement coding and billing information, visit http://tinyurl.com/OMcomanage1).
Joint Position Paper of the AAO and ASCRS
This position paper, co-authored by the ASCRS and AAO, offers guidelines on co-management and transfer of care, and when these arrangements are appropriate.
Federal Medicare policy concerning co-management has been adapted and interpreted by states and carriers with variations in details and restrictions. The qualified operating ophthalmologist has the ultimate responsibility for the preoperative and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the postoperative care contingent on medical stability of the patient. Economic considerations, such as inducement for surgical referrals or coercion by the referring practitioner, should never influence the decision to co-manage, or the timing of the transfer of a patient’s care following surgery. This is unethical and, in many jurisdictions, illegal.
The management of a patient with the participation of a non-operating practitioner rather than solely by the operating ophthalmologist, whether as part of a co-management arrangement or as a transfer of care, may be appropriate when the conditions set forth in this position paper are met. Examples of circumstances in which co-management and transfer of care are appropriate (assuming compliance with conditions in this position paper) include the following:
Patient inability to return to the operating ophthalmologist’s office for follow-up care
• Patient is unable to travel due to distance or the development of another illness.
• Lack of availability of the person(s) or organization previously responsible for bringing the patient to the operating ophthalmologist’s office.
Operating ophthalmologist’s unavailability
• The operating ophthalmologist will be unavailable to provide care (e.g. travel, leave, itinerant surgery in a rural area, surgery performed in an ophthalmologist shortage area, retirement, or illness).
Patient prerogative
• The patient requests and/or consents to co-management or transfer of care to minimize cost of travel, loss of time spent travelling, or the patient’s inconvenience.
• The patient requests and/or consents to transfer of care for any other reasonably compelling personal consideration (e.g. comfort with the non-operating practitioner doctor-patient relationship), provided that the operating ophthalmologist is familiar with the non-operating practitioner and their qualifications (compliance with scope of practice and state licensure).
Change in postoperative course
• Development of a complication.
• Development of intercurrent disease.
When the operating ophthalmologist enters into a co-management arrangement or transfers care, each of the following criteria must be met:
• The patient requests, or is given the option and makes an informed decision to be seen by the non-operating practitioner for postoperative care.
• The operating ophthalmologist determines that the operative eye is sufficiently stable for transfer of care or co-management to be clinically appropriate.
• The non-operating practitioner is willing to accept the care of the patient.
• State law permits the non-operating practitioner to provide postoperative care and the non-operating practitioner is otherwise qualified to do so.
• There is no agreement between the operating ophthalmologist and a referring non-operating practitioner to automatically send patients back to non-operating practitioner.
• The arrangement complies with all applicable federal and state laws and regulations, including the federal anti-kickback and Stark laws and state fee splitting laws.
• The operating ophthalmologist or an appropriately trained ophthalmologist is available upon request from either the patient or non-operating practitioner to provide medically necessary care related to the surgical procedure directly or indirectly to the patient.
• Financial compensation to the non-operating practitioner is consistent with the following principles:
— The non-operating practitioner’s co-management fees should be commensurate with the service(s) actually provided.
— For Medicare/Medicaid patients, the co-management arrangement should be consistent with all Medicare/Medicaid billing and coding rules and should not result in higher charges to Medicare/Medicaid than would occur without co-management.
— The patient should be informed of any additional fees that the non-operating practitioner may charge beyond those covered by Medicare/Medicaid or other third party payors.
— For services that are not covered by Medicare or Medicaid, other fee structures may be appropriate, though they should also be commensurate with the services provided and otherwise comply with all applicable federal and state laws and regulations.
• Transfer of care or co-management is documented in the medical record as required by carrier policy.
• All relevant clinical information is exchanged between the operating ophthalmologist and the non-operating practitioner.
The operating ophthalmologist should consult with qualified legal counsel and other consultants to ensure that his/her co-management practices are consistent with federal and state law and best legal practices.
For the complete position statement, visit http://tinyurl.com/OMcomanage2.
That can be a function of location, says Dr. Waltz, who was an optometrist prior to becoming an ophthalmologist. Depending on a patient’s distance from the surgery center or the ophthalmologist’s practice, it may be unrealistic for that patient to return within days after the surgery. The committee that worked on comanagement policy revisions apparently agreed, citing distance as one of the acceptable criteria for establishing a comanagement practice.
Dr. Mann says his Tennessee practice, which includes roughly seven optometrists and eight ophthalmologists, averages about 500 cataract surgeries a month. To accomplish that, he says, teams of optometrists and ophthalmologists regularly travel to rural communities, where their combined efforts allow them to provide all-day surgery and postoperative care to populations that lack regular access to surgeons.
Christopher Quinn, OD, FAAO, who practices cataract surgery comanagement at Omni Eye Services in Iselin, N.J., doesn’t anticipate a groundswell of optometrists clamoring to perform surgeries. “I don’t think that will happen, unless some revolutionary technology comes along that nobody knows about.”
Building a relationship with the optometrist
Dr. Waltz works closely with trusted optometrists during the cataract surgery process. Often, it’s a matter of necessity. An optometrist who prescribes eyeglasses and performs routine tests on a patient for years may discover a cataract and recommend surgery. The patient will undoubtedly return to that optometrist at some point after surgery, Dr. Waltz says, so it’s important for an optometrist and ophthalmologist to establish enough trust to refer patients to each other.
Dr. Mann says that his practice’s optometrists boast extensive training, and they ensure that surgeons maximize their time performing surgery. Still, those surgeons do not operate without first examining the patient.
Dr. Waltz said he couldn’t imagine taking another provider’s word for what should happen during surgery, or even if a patient should have surgery. Although optometrists may take on an increasingly greater role, one of Dr. Waltz’s previous cases also illustrates why, as the AAO and ASCRS guidelines state, “the ophthalmologist needs to take responsibility for the surgical event.” A patient was referred to Dr. Waltz’s practice. The patient was blind in the right eye, had a horrible cataract in that eye, and a mild one in the other. The referring optometrist told the patient the cataract surgery would only be on the good eye, but Dr. Waltz disagreed. So, the physicians talked and agreed on the best care for that patient. “That level of communication is essential” in an optometrist-ophthalmologist relationship, he says.
Still, those relationships should not be so close that referrals in either direction become expected and exclusive, according to the AAO and ASCRS. Their guidelines spell out procedures for billing, and plainly prohibit “agreement between the operating ophthalmologist and a referring non-operating practitioner to automatically send patients back to non-operating practitioner.”
Conclusion
The optometrists’ role in cataract surgery is expanding to include nearly all aspects of care except the surgery itself: From the Florida practice that boasts its optometrists are “trained in cataract surgery comanagement,” to the Tennessee group offering residency training that provides optometrists an opportunity to learn ocular disease management.” But, with new ground rules in place, ophthalmologists and optometrists may be able to forge better cooperation and close working relationships and move ahead with comanagement. Doing so would benefit both professions, and patients, Dr. Quinn says. “It allows surgeons to do what they do best, and gives optometrists the ability to maintain relationships with their patients. And the truth is, patients are pleased.”
It all comes down to the patient’s welfare, says Charles Zacks, MD, AAO ethics committee chairman and corneal surgeon at the Maine Eye Center in Portland. “When all the decision-making is made in the patient’s best interest, then you won’t run into ethical problems.” OM
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