At ME Live 2014, leading ophthalmologists and optometrists sat down to discuss the challenges of comanagement, offer pearls for MD-OD collaboration, and share projections for the future of integrated care. This roundtable features a synopsis of their discussion.
Elizabeth Yeu, MD:
In deliberating the points of concern associated with comanagement, many physicians cite several different lawsuits illustrating issues that arise in the challenge of collaborative care. What do you feel are the main legal concerns, and how do you handle them?
Derek N. Cunningham, OD:
The comanagement model is split up into many different aspects. There is the integrated eye care model, in which there is an optometrist within the practice itself, and there are other models that are heavily dependent on community optometrists sending in patients. Overall, an important aspect to understand about the comanagement model is that there is a liability aspect on both ends. Just as the surgeon is going to have some liability in the optometrist comanaging some care, the optometrist is going to have liability in sending that patient to the surgeon and making sure there is appropriate care. Independent practitioners, independent licenses—that is key to remember with this whole concept. In larger-scale practices such as ours, where we have a lot of doctors to manage, a big part of what we do is aggressive education with our doctors; it is also part of my job within our center to ensure that anyone we agree to comanage with—and we don’t comanage with everyone—is certified and to ensure that we are protecting our end from our practice standpoint.
Walter O. Whitley, OD, MBA:
What Derek said is key. The certification process is one of the things that Liz and I and the rest of our surgeons do. Before we will share in the care of any patient, we want to meet with the comanaging doctor to discuss our respective roles either at their office or ours. We have a 2-hour course that comanaging doctors must go through as well so that they understand the various nuances that we are all looking for at each of the visits. It is important that everyone is on the same page. Whether via fax, phone calls, secure texts, etc., constant communication is imperative.
Michael S. Cooper, OD:
I echo both Derek’s and Walt’s sentiments. I am relatively new to the game when it comes to comanaging with the ODs in my area, and I am starting to reach out to the community. We really need to harness the ability to get all of the eye care providers on the same page, which is difficult sometimes. To facilitate, we also bring comanaging optometrists into our practice to show them how our surgeons do things.
Steve, Rob—what have you done within your practice that was successful in garnering the support and the confidence of your community?
Robert J. Weinstock, MD:
We hold quarterly OD seminars for CE credit. We bring in an optometrist who is an expert at comanaging and who can speak to optometrists in their own terms and provide a different perspective from the surgeon. I also make a point to visit local optometrists’ offices. If I am on the way from one office to another, I will sometimes drop in on the practice. I then work on building a relationship with the optometrists by inviting them into the OR, letting them see my technology portfolio, and demonstrating how I interact with patients. Showing the optometrists how much you care about your patients will help them establish confidence that you are going to take good care of their patients.
In addition, we hired an optometrist who is very business-minded. Her full-time position in our practice is outreach to the medical community, specifically to optometrists. She even helps optometrists find jobs or fill in spots if they need to pick up an extra day. She has become a tremendous asset to them and is a great liaison and a direct point of contact. We also have a special phone hotline just for optometrists so that they do not have to call the main number and instead can immediately speak with someone and get what they need.
We will all face uncomfortable situations out there because it is competitive. You may run across some doctors who are not taking the high road in their relationships with comanaging doctors—maybe they are not paying them on a standard 80/20 split, or they are reimbursing doctors when there are no services being performed. I would urge you not to get caught in that trap. Get the right infrastructure in place with the appropriate documentation. Make sure you receive communication from the optometrist about how patients are doing at their follow-up visits. That way, if there is ever any legal scrutiny, you have a paper trail showing you did the proper thing and that the optometrist truly gave care that justifies splitting the fee.
If you comanage, you may run into ophthalmologists who frown upon what you do. Stick to your guns. I personally am a big supporter of working with optometrists and see a great need for a team-based approach.
Not everybody wants to comanage. A lot of ODs are referring from more commercial centers, so they simply do not have the practice setup to be able to comanage. In one specific lawsuit, a patient complained that she did not know, after having a problem, that she could have access again to her surgeon; she thought that the surgeon was just a surgical extender of the OD who provided her primary care. That lack of communication between the surgeon and optometrist was a major concern. I tell my patients at every visit that if everything goes well, the optometrist will primarily be the one continuing their care, but if they have any questions or issues related to the surgery, they will be sent back to me. I make it a point to emphasize that the optometrist and I work together all the time in managing our surgical patients.
Steven J. Dell, MD:
That approach is perfect, Liz. It seems to me that there has been a reduction in the interest of ODs in comanaging cataract surgery. Some of that may just be related to the fact that the fees have ratcheted down and optometry is doing well in terms of optical sales. But do you sense that there is less interest in comanagement?
We are starting to see that more and more. We have about 125 ODs who refer to our practice, but only about 30% of them actively comanage. I have had several ODs recently tell me that they prefer for us to take care of everything because chair time is an issue and they prefer to focus more on the rest of their practice.
Keep in mind, when these high-volume optometric power practices start sending patients and they do the metrics, $120 for four office visits for cataract comanagement is just not feasible. It’s a business decision for a lot of them. These are practices that have OCTs, are well versed in disease practice, and may even have a large glaucoma setting within their patient base. Based on the numbers, they would prefer the patients just be sent back when they are ready for routine eye care and glasses.
Maybe it is because I am newer, but I actually turn them onto more ocular surface disease. That has been a very strong uptake. So, instead of just downstream, I am going upstream and finding that it gets them linked back into the discussion about cataract surgery.
The scope of optometry is often the elephant in the room when it comes to discussions about comanagement. I am curious as to how my colleagues feel about optometrists expanding the scope. What about operating under surgeon supervision in the OR?
That type of setup is common and well established with many allied health professions within the medical community. A physician assistant (PA) will perform a procedure, and then the MD comes in afterward.
There are PAs across the country injecting Botox (Allergan) and performing intense pulsed light therapy treatments and laser skin resurfacing. If a PA can legally do a femtosecond laser treatment on an eye while the surgeon sits in the OR and then performs the intraocular portion, why shouldn’t an optometrist, who knows a lot more than a PA about eye care and eye disease, be allowed to fire a femtosecond laser?
I think it is our job as the next generation of ophthalmologists to break out of some patterns of behavior that were indoctrinated into us over the years. We have talked extensively about the growth of baby boomers, and we are supposedly not going to be able to handle the volume of patients coming forward. Further, LASIK is also supposed to continue to grow. According to statistics, there won’t be enough ophthalmologists to serve the needs of the population. So, in theory, don’t we need the help of other trained eye care providers?
It is important that we continue this conversation and constantly evaluate our practice models. It is the only way to ensure that the future of eye care moves in the best possible direction for the ultimate benefit of all our patients.