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Discussion in 'Ophthalmology: Eye Physicians & Surgeons' started by Richard_Hom, Oct 23, 2004.
Never should see post op cat patients?
Cataract post-op checks should be done by the surgeon on Day 0 and perhaps Day 7. If all is well, then the optometrist can see the patient at one month for the final refraction and glasses.
Some surgeons see the patient on Day 0, and if the surgery went well, then will call the patient on Day 7. If the vision is good without pain/redness/discharge, then the patient returns for a refraction and DFE 4-6 weeks post-op.
Optometrists should not only handle the day 1 post-ops, they should do the entire Phaco/IOL procedure---its not that difficult.
Please don't dignify this with a response anyone.
For those of you who don't know about co-management, it's all about the money when optometrists want to see the patient sooner. They are not satisfied with selling glasses after cataract surgery but want to manage the patient post-operatively ASAP.
This is how it works. The physician's fee for cataract surgery is ~$650 in Iowa. For any surgery, the patient cannot be billed more for surgery follow-up for 90 days. Included in the above fee, 20% of this fee (about $130) is to pay the surgeon for post-operative follow-ups. In co-management, the optometrist will receive more compensation if s/he takes over the post-operative management on Day 0 (optometrist gets $130 and surgeon gets $520). If the patient care was transferred after 1 month, the optometrist will receive about 2/3 of the $130. After 2 months, the optometrist's reimbursement is 1/3.
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. Economically, after 1 month, the optometrist receives ~$85 and profits from the sales of glasses. Considering that glasses frames cost less than $30 wholesale, the optometrist makes over $150 from the sale of glasses. In the end, the optometrist makes over $200 for referring a patient for cataract surgery and following-up with the patient after 1 month.
I see no reason for optometrists to see post-operative patients on Day 0 or within 2 weeks of surgery.
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
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.
Doctor, I politely disagree with your assessment. I too believe that the surgeon should see that patient on day 1, but assuming all is well and the surgeon and referring doctor have a good working relationship I see no reason why the referring doctor cannot resume the primary care of his or her patient. If complications develop then absolutely the surgeon needs to get involved ASAP, and if the referring doc doesnt know what too look for then they should go back to school. Saying that the referring doc should only see their patient 4-6 wks po for a refraction is preposterous. As for the reimbursement, you should be happy you can collect as much. It is only about 1/2 that in my local. My point is to continue the care of my patient as soon as possible and do not put any unnecessary burden on patients.
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.
They are my patients too when I operate on them.
That's the spirit. Ps I said our patients and I hope we can deliver the best to them at all time.
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.
How long will it be before optometrists "comanaging" surgical cases argue that they have gained insight and experience in postoperative management not available yet in schools of optometry and that refractive surgery is so automated that they should be allowed to do it as well? State legislators and the public will have great difficulty distinguishing the difference between ophthalmologists and optometrists. When this happens, we will have no one to blame but ourselves.
The ophthalmologist's duties concerning postoperative care are succinctly outlined in Academy Policy Statements and the Code of Ethics. Whether you participate in comanagement or shared-management of patients with another ophthalmologist or a nonophthalmologist these documents are well worth reading. As physicians, our guiding principle must always be to do what is in the best interest of patients.
This article is so full of misinformation, I don't even know where to begin.
I know of 4 ODs personally who have been sued for their involvement in refractive surgery that went south. In 3 out of the 4 cases, the OD NEVER SAW THE PATIENT FOR POST OP CARE. The surgery went poorly and the surgeon AND the OD were sued. As is common in malpractice cases, attorneys sue anyone and everyone who was even remotely involved in the patients care. Simply visit surgicaleyes.org for discussions on how many ODs and OMDs have been sued for poor LASIK outcomes.
Co-management fees should never be higher than 20%. Though there is no strict law stipulating this amount, that is the medicare guidline and variations on this percentage have been viewed as a "kickback."
$400 is disproportionately high for LASIK comanagement? You have to be kidding. If I do the one day, one week, one month, three month, 6 month and 1 year visits, that's not worth $400? Even if I don't do the one day and one week visit, I essentially do 4 comprehensive eye exams at a MINIMUM for the $400. Never mind all the followups needed for dry eye patients and all the additional followups needed if the patient has an enhancement. I charge $125 in my office for a comprehensive exam. I could actually make MORE money just seeing non-surgical patients. This is the main reason why I rarely comanage ANY surgical patients any more outside of the VA where I work one day per week.
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.
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.
It's odd that you are arguing that ODs get sued less and I'm arguing that they get sued more.
You are right. Just because a patient complains to me does not mean that their surgeon blew them off but many patients have TOLD me that their surgeon blew them off. This is why they are complaining to me and is often times what they are complaining ABOUT.
I am not implying that ODs are sued frequently, but I'm implying that they are sued alot more than what that article you posted claimed. It claimed that there were NO malpractice cases, and that's just not true. And in fact, the claim was made that there were NO lawsuits arising from comanagement which seems to me like a pretty STRONG argument for MORE comanagement.
With respect to surgical comanagement, if there is a complication you can guarantee that the OD will be named in the lawsuit as well. We all know that lawyers will sue anyone who was even remotely involved in the patients care. I recall seeing a story on 60 minutes where a doctor in a hospital was sued and actually had a judgement entered against him when he was sued by a patient that HE NEVER EVEN SAW.
ODs malpractice is low because ODs practice conservatively. In many cases, it's almost to a fault. ODs also don't engage in many high risk procedures. That may change as time goes on. A collegue of mine told me that he was paying only $800 per year for malpractice but it went up to $3800 when he admitted to his insurance company that he participates in LASIK comanagement. You are right. Insurance economics will dictate what rates are going to be, but you can rest assured that if there is malpractice arising from comanagement, the lawyers are not going to say "Ok, Dr. Jenny. Since you're just an OD, we're gonna let you go despite your 2000000/4000000 coverage and we're just going to sue the surgeon."
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.
I agree with you Dr. Doan. There is a lot of hearsay on the internet. I guess that's it's greatest drawback. But I contend that the original article you posted was loaded with it. The author claimes that no malpractice cases arised from comanagement, but he references OMIC which is an organization that does not insure ODs unless they are directly employed by OMDs. He also sights "numerous letters" that he's received. Cmon. He also claims that OMDs receive "nearly the same fee" as ODs for surgical comanagement. That implies a 50/50 splitting of fees. I have NEVER heard of that kind of arrangement, and it certainly is unheard of in the area that I practice in. Where in the USA are ODs and OMDs splitting fees 50/50??
I also disagree with the notion that it takes years for insurance companies to alter rates. I just got my homeowners policy for 2005. It's WAY up. When I called to ask why, the response was "Hurricane Charlie and Ivan" And I live in New York state. I firmly believe that insurance companies have it down to a science, and if there is even a SLIGHT justification for raising rates, they will do it. It might take years for rates to go DOWN, but to go up, they don't need much excuse, and in fact are always on the lookout for excuses to raise rates. They're worse than credit card companies.
I don't happen to know anything about who gets sued how much, but I just had a quick thought. Obviously, part of co-managment is the money (captalistic society and all) but were I an OD my biggest reason to favor co-managing patients would simply be this: if you co-manage, you will get your patient back. I am by no means saying that all OMDs steal the patients away after cataract or LASIK, but I think we can all agree that sometimes patients can just slip through the cracks and end up staying with their surgeon for primary eye care. That seems to me the biggest reason to co-manage. Sure the ~20% fee is nice, but getting the patient back to the OD as a regular patient overshadows that (1 or 2 yearly DFE's tops that 20% pretty easily). Just my 2 cents.
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.
Playing by the rules
When do you generally consider a catarct patient "stable" after cataract surgery?
What is your standard follow up regime for an uncomplicated cataract extraction?
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
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?"
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.
The "greed" you refer to is not the desire to get a portion of the pitifully low comanagement fee. Even if I were to get 20% of the fee (I think medicare pays just under $800 in my area) I would collect about $160. What good is that for doing one day, one week, and 1 month exams? And those are for UNcomplicated cases. God forbid there's inflammation that doesn't quite calm down that quickly or any other problems that require MORE visits. I could make a lot more money just seeing 3 different patients. The goal is to maintain control of our patients. You sound like you would be decent to deal with, and if I wear near you I would refer you my patients but far too many of your collegues are not like you, I regret to say.
I'm sure someone will post that THEIR patients INSIST on staying with them because THEY'RE so wonderful and the OD is so useless, but far too often the surgeon does nothing to encourage the patient to return to their primary eye care provider and in many cases actually discourages this.
I had a young OMD take me out for lunch once about 5 years ago. He was new to the area and wanted me to refer him my patients. He seemed nice enough and he agreed to let me observe some of his surgeries which were efficient and proficient. Patients seemed pleased with the outcomes. So I agreed to send him some of my cataract patients.
So, over the course of about a year I sent him about a dozen patients of which I saw NONE of them back. All but one were patients that I had seen for years. One day, I was examining one of the daughters of a woman I sent to him and asked her how her mom was doing. "Great! She's doing really well with the cataract." I told her daughter that we would see her anytime she needed, and the daughter got a puzzled look on her face. She said that the surgeon told her mother that since she had had surgery, that she could NEVER see an OD again. She had to see an OMD. The daughter said her mom was disappinted that she wouldn't be able to come back to my office.
Soooooooooo. I called up two of the other patients that I sent over there and they said the EXACT SAME THING! I didn't even bother with the rest of them. What a load of crap. I called up this dingus surgeon, and told him to never expect another from me or any of my collegues.
I'm sure our refusal to send him patients didn't have anything to do with this, but I'm glad to say that he no longer practices in our area.
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.
JennyW's anecdote is far too common and I believe has spurred much of the "militancy" in optometry. I have the luxury of being in practice for many years and have seen this far too many times.
I can only wish more of your collegues were like yourself Dr. Doan. Too bad you are not close to me. I would gladly send you my patients.