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Day 1?
Day 3?
Week 1?
Month1?
>Month 1?
Never should see post op cat patients?
Day 3?
Week 1?
Month1?
>Month 1?
Never should see post op cat patients?
OD. said:Optometrists should not only handle the day 1 post-ops, they should do the entire Phaco/IOL procedure---its not that difficult.
Andrew_Doan said:"...I see no reason for optometrists to see post-operative patients on Day 0 or within 2 weeks of surgery.
Richard_Hom said:Dr. Doan,
I'm curious about your first post and this one. Is this a change in viewpoint between the two?
Richard Hom, OD,FAAO
San Mateo, CA
Andrew_Doan said:Like I said, if the vision is good without pain/redness/discharge, then the patient returns for a refraction and DFE 4-6 weeks post-op (for the optometrist) or ophthalmologist.
Funny, to me this battle is not about how we can provide the patient with better medical care, but rather, it is all about how much we stand to make from the patient. What I see is that one day in court you guys are going to lie about professional competence, but really by that time the patient in question would be blind. Let try and honour the 'interprofessional' protcols and manage our ppatients giving them the best medical care their money can buy.Andrew_Doan said:Like I said, if the vision is good without pain/redness/discharge, then the patient returns for a refraction and DFE 4-6 weeks post-op (for the optometrist) or ophthalmologist.
packerhater said:My point is to continue the care of my patient as soon as possible and do not put any unnecessary burden on patients.
That's the spirit. Ps I said our patients and I hope we can deliver the best to them at all time.Andrew_Doan said:They are my patients too when I operate on them.
Andrew_Doan said:How Comanagement Is Really No Management
By Thomas Weingeist, MD, PhD
Optometrists often receive a fee of several hundred dollars. Ophthalmologists receive nearly the same. In the past, it was called fee splitting and was frowned on by the American Medical Association and individual physicians. It was against our code of ethics. Now it is called comanagement.
Comanagement with nonphysicians has become more common following cataract and refractive surgery. You don't have to be a rocket scientist-or an ophthalmologist, for that matter-to determine whether something has gone horribly wrong with either of these procedures. The eye lets you know. We are told one of the reasons comanagement, especially following cataract and refractive surgery, is popular is that complications from these procedures are comparatively uncommon. In effect most of the time the "patient finder fee" or fee-splitting arrangement called comanagement is associated with little or "no management." It is a consequence of the trivialization of highly successful and technologically advanced surgical procedures.
The optometrist following the patient seldom needs to do more than identify disasters. Sadly many are unable to recognize the rare and subtler early signs of endophthalmitis, which if treated effectively would be a great service. When disaster strikes, the patient is returned to the surgeon.
Rarely, if ever, does a malpractice suit involve the optometrist. According to the Ophthalmic Mutual Insurance Company (OMIC), no suits have arisen among its members because of comanagement. Nevertheless, it recommends using explicit forms confirming in writing the postoperative shared- management arrangement for each patient.
The comanagement fee for optometrists of $400 to $950 for LASIK is disproportionately high considering the service rendered. Is it any wonder that many regard the fee as a "pay back" for the referral? Nor is it any wonder that ophthalmologists who refuse to participate in this form of legalized fee splitting are ostracized by referring optometrists? What value do patients derive from the fee they pay?
Except in emergency situations when the physician is indisposed patients should be informed prior to surgery who will be responsible for their care and what his or her qualifications are. Furthermore, according to Rule 8 of the American Academy of Ophthalmology Code of Ethics, the patient must be informed beforehand of the effect of the postoperative care arrangements on the fees for services.
This isn't to say there aren't appropriate circumstances for shared- management. This sort of arrangement works brilliantly in underserved areas- for instance, rural communities. In this setting, local practitioners can team with out-of-town colleagues to extend care.
In recent years, in a minority of practices, an associate may only be involved in the pre- and postoperative management of patients. It is argued that this offers patients the best technical and medical care while providing the most efficient use of practice resources.
During the past year, I have received a number of letters decrying a new practice, the establishment of comanagement refractive surgery in academic ophthalmology programs with local optometrists. Academic centers faced with Physician At Teaching Hospital audits, so-called PATH audits, tighter regulations and increased competition, are fighting for survival like other ophthalmologists. Some have hired optometrists to foster referrals from outside optometrists. In some instances, comanagement occurs within the institution not only among ophthalmologists, but among ophthalmologists and optometrists who screen patients, perform preoperative evaluations and follow patients postoperatively. This causes many members grave disappointment because they view academic centers as our "moral compass." For others it is viewed when performed within state-supported institutions to be unfair competition.
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JennyW said:What value do patients derive? They get their eyes examined by an actual doctor at their follow up visits who takes the time to answer any questions that they may have and provides reassurance rather then an exam in which 99% of the work is done by a technician and 2 seconds are spent with the surgeon who's solution to everything is to just throw a sample of artificial tears at the patient. That's the value that most of my patients perceive and they have told me so.
Andrew_Doan said:It's funny how the otherside can be so biased in one extreme.
Dry eyes are a possible risk with refractive surgery. Either the surgeon didn't explain, or the patient didn't listen. In our clinic, we commonly explain before the surgery that this can be a problem after surgery. However, do you know how many patients remember what the surgeon tells them? About half of the patients will remember everything that was discussed during the consent and preoperative visit. Even if the patient has dry eyes after refractive surgery, does it really require a 1 hour work-up? It does not. You're wasting time. It requires a reminder of the risks of refractive surgery and a minute to decide what to do: artificial tears, doxycycline if there if MGD, restasis, and then plugs.
We also provide printed information about the risks and complications that can occur with refractive surgery.
Furthermore, we look for signs that may indicate higher risks for dry eyes. Just because the patient complains to you, does not indicate that the surgeon blew them off or didn't explain. Patients will tend to complain to anyone who will listen. I'm sure you're more willing to listen when your patients complain about their ophthalmologists...
The majority of the time Jenny, optometrists are NOT sued. This is why your malpractice is $400/year and ophthalmologists pay over $10,000/year. Insurance economics will reflect who and who are not sued. It's simple math because the insurance companies will not let optometrists pay $400/year if your profession is sued as frequently as you imply.
Andrew_Doan said:Jenny,
You're right. Malpractice will rise for ODs who comanage and decide to pursue surgery (e.g. Oklahoma). Insurance premiums, however, take years to reflect the higher risks associated with complex cases and surgeries.
BTW, discontent patients may perceive their care differently than what occurred in reality. I'll reiterate, just because your patients claim that the surgeon "blew them off", does not necessarily reflect what truly happened. This is all hearsay.
Playing by the rulesAndrew_Doan said:Without co-management, OD's can still get their patients back. If this is the concern, then let the consulting physician know. At Iowa, we make it clear that we're sending the patients back to the referring physician after the patient is stable.
In fact, if you refer a patient for cataract surgery, then I always let the referring doctor prescribe the glasses. That's a refraction and pair of glasses sold for the referring optometrist.
Andrew_Doan said:Without co-management, OD's can still get their patients back. If this is the concern, then let the consulting physician know. At Iowa, we make it clear that we're sending the patients back to the referring physician after the patient is stable.
In fact, if you refer a patient for cataract surgery, then I always let the referring doctor prescribe the glasses. That's a refraction and pair of glasses sold for the referring optometrist.
JennyW said:When do you generally consider a catarct patient "stable" after cataract surgery?
Jenny
Andrew_Doan said:I strongly feel that surgeons should follow-up with all their patients until they are stable. After cataract surgery, this is usually 1 month and a minimum of 2 weeks.
Andrew_Doan said:Jenny,
JennyW said:What is your standard follow up regime for an uncomplicated cataract extraction?
Jenny
Andrew_Doan said:Same day or Day 1 post-op
1 week post-op
4-6 weeks post-op (Can start seeing optometrist now.)
6 months post-op
JennyW said:So, for the 4-6 week visit, and the 6 month visit, should the optometrist not get some sort of the global fee? Correct me if I'm wrong, but doesn't the surgical fee include all the post operative care?
Is that not the definition of "co-management?"
Jenny
Andrew_Doan said:Dear Jenny,
Please read my comments above. I'm not against co-management all together if done right. I agree that the optometrists should receive a portion of the post-operative care starting at 4-6 weeks post-op check!
Also, the post-operative period is only 90 days, so the 6 month follow-up can be billed as a full exam by the optometrist.
However, this is not what optometrists are arguing for. Some want to see the patient at Day 1 to collect all of the post-operative fee (i.e., 20% of the surgeon's fee). This is driven by greed because the later the optometrist sees the patient, the less s/he will receive in the co-management fee. At 1 month, the post-operative fee is cut by 1/3.
Andrew_Doan said:I understand your concerns, and I agree with you that ophthalmologists should send back patients to the referring optometrists after they are stable.
Similarly, I also think ophthalmologists should give up optical shops unless they work with optometrists who are allowed some ownership of the optical business.
Andrew_Doan said:I understand your concerns, and I agree with you that ophthalmologists should send back patients to the referring optometrists after they are stable.
Similarly, I also think ophthalmologists should give up optical shops unless they work with optometrists who are allowed some ownership of the optical business.