Missouri attempts to legislate comanagement

Missouri eye surgeons introduced the bill into state legislature. Organized optometry opposes the measure.

Issue: May 1, 2001

JEFFERSON CITY, Mo. — Eye surgeons in Missouri are attempting to do what has not been possible on the national level: create a law regulating comanagement between ophthalmologists and optometrists.

Missouri House Bill No. 785 and Senate Bill No. 552 would create the first law to mandate what protocols eye care providers must create and follow when deciding to comanage. The bill’s protocol is very similar to recommendations in the American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) joint position paper on comanagement that was released in spring 2000.

The bill is the handiwork of the Missouri Society of Eye Physicians and Surgeons (MoSEPS), who asked state Rep. Harry Kennedy to introduce the bill on Feb. 14. A Senate version of the bill was introduced by Sen. Betty Sims on Feb. 26.

ODs input and putout

Unlike the position papers and similar policies that have been created around the country in the past year, MoSEPS actually asked the Missouri Optometric Association (MOA) for input regarding the bill.

According to the executive director of MoSEPS, Rich Paul, the negotiations between the two associations went very well in the short term. The bill that is currently in the legislature is actually a substitute bill that was drafted as a result of MOA and MoSEPS negotiations.

“We went to the optometric association and told them we were proposing this bill and gave them a draft on February 5 or so. We asked them if they had any changes, but there was no response,” said Mr. Paul.

The MOA did not say anything publicly about the bill until their lobbyist went to the bill sponsor and asked him to not introduce the bill. He entered it onto the house floor anyway.

The MOA and MoSEPS met for negotiations a few weeks after the bill’s introduction and when House and Senate hearing were scheduled to hammer out changes to the bill.

“The president of the MOA [LeeAnn W. Barrett, OD] was very reasonable with how she conducted herself in the negotiations,” Mr. Paul said. “But they have some aggressive members on their board who don’t want regulation of comanagement. Three days after our president [John B. Holds, MD] and their president shook hands on the deal, the OD association backed out of the deal.”

The substitute bill stayed in the House anyway, and the first committee hearings on the matter took place on March 14.

The hearings were no picnic either, according to Mr. Paul. Optometrists testified during the hearing and tried to gut the bill. The ophthalmologists are now preparing to return to the committee and address the optometrists’ remarks. Mr. Paul characterized much of the OD testimony as untrue.

Nuts and bolts

The major points dealt with in the bill are kickbacks, protocol, patient consent, communication and “indiscriminate” comanagement. Unlike the national policy of AAO/ASCRS, the bill clarifies that patients have the right, ultimately, to participate in a comanagement arrangement or refuse it.

“We’ve always maintained that a significant number of eye MDs don’t approve of comanagement but that it may be appropriate in other surgeons’ circumstances,” said Mr. Paul. “This bill puts reasonable regulations on comanagement.”

He used the example of coercion on either the surgeon’s or optometrist’s part as reasons why comanagement can be dangerous. He said it was important that neither eye care providers use referrals as an enticement to be held out in return for comanagement.

“There’s been an undercurrent of doctors for a long time who feel like they’re being pressed to comanage. Those strings make them uncomfortable. Some rationalize it. Others who are more interested in making money comanage everyone so they can boost their volume. Then there are others who don’t do it at all because of their conscience,” Mr. Paul said.

With this bill, patients will be told in advance about fee arrangements, and they can choose to participate or not. “Patients are not aware enough of the situation to know that comanagement is the exception, not the rule. This bill defines comanagement for MDs and ODs in an equitable manner,” said Mr. Paul.

Among the other integral parts of the bill is the creation of written protocols to govern the manner in which care will be provided and the stipulation that communication between the providers must occur regularly in a timely manner consistent with the surgical procedure protocol. According to Mr. Paul, some surgeons have said they do not hear back from optometrists enough regarding their comanaged patients.

Mr. Paul was quick to point out that the AAO, ASCRS and other physician organizations are not the only ones who have put forth policies very close in wording to the Missouri bills. He noted the March 15, 2001, edition of Review of Optometry, in which appeared an article on “Six Tips for Proper Comanagement,” laying out similar guidelines.

A representative from the Missouri Optometric Association was unable to comment on this topic.

For Your Information:

Rich Paul can be reached at 10 W. Phillip Rd., Ste. 120, Vernon Hills, IL 60061-1730; (800) 575-6674; fax: (847) 680-1682; e-mail: EyeOrg@aol.com; Web site: www.MidwestEyeMD.org.

Senate Bill No. 552 can be found in its original format at www.senate.state.mo.us/01info/billtext/intro/sb552.htm.

House Bill No. 785 can be found it its original format at www.house.state.mo.us/bills01/biltxt01/intro01/hb0 785I.htm.