Comanagement: a matter of patient choice?

The desire of the patient seems to be the important element in the comanagement debate. Adding fuel to the fire is talk of an FBI investigation into possible kickbacks.

Issue: August 15, 2000

Has the term “comanagement” and the ideas behind it been blown out of proportion, or is it really as bad as the rap it has been getting lately? The linchpin to the whole argument, pro or con, appears to be patient choice. The only gray area seems to be whether or not it is a matter of regular practice or an option used when absolutely necessary.

At the annual American Society of Cataract and Refractive Surgery (ASCRS) meeting in Boston, it was a major part of one of the symposia. It also has been one of the major topics of conversation during interviews done by Ocular Surgery News. Comanagement appears to be a hot topic, but it generally results in the same answer — patient choice.

In a response to our articles regarding comanagement in the May 15, 2000 issue, H. Dunbar Hoskins, MD, executive vice president of the American Academy of Ophthalmology (AAO), and David Karcher, executive director of ASCRS, sent a letter to Ocular Surgery News restating that the joint paper the organizations approved in February never ignored patient choice, but reiterated that patient choice was one of the primary factors in comanagement.

In their letter, they stated that “a voluntary, complete, informed consent must be obtained from the patient agreeing to a comanagement relationship following a properly performed, honest and thorough discussion between the surgeon and the patient. This represents the ultimate patient choice and respects the patient’s decision.”

The letter also stated that the joint paper was not a legal or regulatory document, but a guideline that was advisory and voluntary. The letter listed four “musts” an ophthalmologist must live by, in reference to the joint paper. An ophthalmologist: 1) must inform the patient and the patient must voluntarily consent; 2) must only transfer care if it is clinically appropriate and in the patient’s best interest; 3) must not comanage on a routine basis; and 4) must be sure the fees reflect an appropriate fair market value for services performed.

In an interview with Ocular Surgery News, Mr. Karcher explained that the point of the paper was quite simple. “In our mind, informed consent is nothing but patient choice documented.” One of the suggestions by the joint paper is to make sure that ophthalmologists document their comanagement and inform the patient of why comanagement is an option.

In response to a question regarding a similar comanagement policy put out by the Society for Excellence in Eyecare, Mr. Karcher said that it was fine, “we’re just saying document, as well.”

He reiterated that the patient is the primary focus of any physician and should be in comanagement, as well.

His major concern was that ophthalmologists were being coerced into comanagement through unscrupulous optometrists who could ruin an ophthalmologist’s practice by refusing to refer to him or her. “An MD who refuses partnerships with an OD could result in poor patient flow,” Mr. Karcher said.

“There are times when comanagement is appropriate, but it should never be routine,” Mr. Karcher said.

In a similar interview, Dr. Hoskins explained he was worried that surgeons would be seen, or may begin thinking of themselves, as nothing more than surgical technicians. He said that it was very important for ophthalmologists to realize their duty to the welfare of the entire surgical patient and not just to make sure a good refractive surgery is performed. Dr. Hoskins said that physicians must remember that they are responsible for the preop and postop care of the patient. He pointed out that doctor responsibility would likely be the first fact brought up in a malpractice suit.

Dr. Hoskins also pointed out that the fees being extracted for refractive surgery in comanagement situations were dangerously high. He said that while ASCRS and AAO could not do anything to stop improper agreements and practices between eye care professionals, the federal government could, and would if they became aware of illegal practices.

During the annual ASCRS meeting, ASCRS held a Hallway Controversies panel discussion regarding comanagement. During the debate, J. Trevor Woodhams, MD, explained his contention that splitting of fees during comanagement does not accurately reflect the services rendered for follow-up.

By his calculations, Dr. Woodhams figured out that optometrists are getting fees grossly in excess of the service provided. He said he believed the fees should reflect a simple eye exam, done perhaps three times over the course of a year, totaling no more than $280. It was his impression that the fees charged now reflect a 20/80 split that would allow an optometrist an $800 follow-up fee on a $4,000 bilateral procedure.

While there are several entities that could force a change in the comanagement situation, in regard to fees, Dr. Hoskins felt that the marketplace might be the harshest definer of rules. He explained that as prices for refractive laser surgery continue to fall, “all aspects of refractive surgery and everyone associated with it will have less absolute dollars, which means less absolute dollars to spread around.”

When asked what he would like to see happen because of the joint paper, Dr. Hoskins simply stated, “I think we’d like to see the behavior [of surgeons] reflect the position paper.”

Comanagement consent form

To make it easier and less precarious, ASCRS has created a model comanagement consent form as a service to its members. Its purpose is to assist ASCRS members in providing patients with the information necessary to give informed consent to comanagement arrangements. Use of this form is consistent with the voluntary guidelines set forth in the Joint Position Paper on Ophthalmic Postoperative Care issued by ASCRS and AAO.

ASCRS has advised its members to use the model form in conjunction with other information regarding the surgical procedure, such as pamphlets, videos or interactive software. The organization warns, however, that the model should not be viewed as a substitute for personal physician-patient discussions. This form is intended for use in addition to a broader informed consent process and form.

The model form reads: “I understand and consent that Dr. (co-manager), a licensed (ophthalmologist/optometrist) will provide my postoperative care following my eye surgery, for the following reason: _________. Dr. (the surgeon) has discussed with me the possible benefits or risks of the arrangement and Dr. (co-manager’s) qualifications. I understand my payment obligations to Dr. (surgeon) and Dr. (co-manager) and all of the other information that has been presented to me about my postoperative care, and voluntarily consent to this co-management arrangement. I further authorize Dr. (surgeon), Dr. (co-manager), and other health care personnel involved in performing this procedure and providing care, to share with one another information relating to my health, vision, or this procedure that they deem relevant to providing me with appropriate care.”

The model form then provides places for the date and the names and signatures of the patient, a witness, the surgeon, the comanager and the patient’s guardian, if necessary.

In its description for the use of this form, ASCRS explained that the model form is for informational purposes only. The form limits indicate “it is designed for use as a reference document and a basis for comparison, not as something that should be handed directly to the patient without prior review. The document is not intended to be treated as legal advice. Physicians are encouraged to consult with experienced attorneys to assist them in drafting their own informed consent forms.”

The form also warns that a doctor must be aware of his or her own state’s guidelines when drafting a comanagement consent form.

Patient choice not an option

According to I. Howard Fine, MD, one of the members of ASCRS and AAO who drafted the joint paper, said that patient choice was at one time a specified line in the first drafts of the joint paper by AAO and ASCRS, stating that patient choice was an option for comanagement. However, after lengthy discussions, the line was taken out.

He explained that the reason why patient choice was not a specified routine option for comanagement was because patients were not the best judges of their situation and their symptoms. Simply put, a doctor can tell far more by following his or her own patient than an optometrist can or the patient on his or her own, and because of that, it is a surgeon’s responsibility to follow the patient, regardless of choice.

“The rules made by the government have artificially changed how patients are cared for, but that’s not necessarily the best for the patient,” Dr. Fine said, implying that just because an optometrist is allowed by law to do postoperative care, it does not mean an optometrist is the best choice to do it. Practice acts in each state are unlimited, but hospitals allow very few MDs to perform neurosurgery in their operating rooms even though the state practice act allows for all of them to do it.

Even a 1-day delay could be the difference in correcting a mistake or an unanticipated negative event more easily. If the patient sees a comanaging optometrist first, it is very likely he or she will not see the ophthalmologist who performed the surgery for at least 24 hours, or maybe longer.

Dr. Fine explained that surgical follow-up should be done by the surgeon for his or her own benefit as well as the patient’s. He believes it puts the surgeon in a better position to have a close personal relationship with patients, especially regarding refractive surgery.

“Refractive surgery is really a quality of life issue, not treatment of pathology. It’s a matter of happiness,” Dr. Fine said. He pointed to a case in his own past where a patient traveled from Fairbanks, Alaska, to his office in Oregon for refractive surgery. The results were not up to Dr. Fine’s level of standards, but the patient was thrilled with the results. She was just happy to finally be able to wake up in the dark and not fumble for her glasses, but able to go about her business without difficulty. “You need to know the patient’s goals and the full impact of the surgery,” he explained “and you learn the best by following patients postoperatively.”

And as Dr. Fine put it, following patients advances the art and science of the surgery. By following patients, a surgeon begins to see the subtle individual responses of the eye and to augment and change a nomogram or several to make the surgeon’s practice and responses even better. In addition, most advances in the medical world have resulted in seeing what happens after surgery and how that surgery or some facet of it can be improved.

FBI investigating referrals

According to William A. Sarraille, JD, the Federal Bureau of Investigation (FBI) was, as recently as 4 months ago, investigating referrals between optometrists and ophthalmologists regarding Medicare and non-Medicare referrals, an investigation that extended to refractive referrals, as well.

The question the FBI is apparently looking into is whether or not referral payments between the physician could be considered inducements. According to Mr. Sarraille, the FBI investigation has been an active field investigation.

Mr. Sarraille pointed out that while there are no federal statutes regulating the non-federally subsidized refractive industry, the active investigation should be a red flag to physicians and lawyers in this industry. He feels the investigation points to a rising interest by the federal government in this physician arrangement.

“This investigation shows a federal link is possible, and it is something that needs to be calculated into any risk when deciding how to enter this kind of [comanagement] relationship,” Mr. Sarraille said.

For Your Information:

David Karcher can be reached at 4000 Legato Road, Ste. 850, Fairfax, VA 22033-4055; (703) 591-2220; fax: (703) 591-0614; e-mail: ascrs@ascrs.org; Web site: www.ascrs.org. Mr. Karcher has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

H. Dunbar Hoskins, MD, can be reached at P.O. Box 7424, San Francisco, CA 94120-7427; (415) 561-8500; fax: (415) 561-8533; Web site: www.eyenet.org.

I. Howard Fine, MD, can be reached at 1550 Oak St., Ste. 5, Eugene, OR 97401; (541) 687-2110; fax: (541) 484-3883.

William A. Sarraille, JD, can be reached at 1050 Connecticut Ave. NW, Washington, DC 20036; (202) 857-6359; fax: (202) 857-6395; e-mail: sarrailw@arentfox.com.