AMA resolution on comanagement likely to change few OD-MD relationships

Issue: November 1999

WASHINGTON — Next month at its annual meeting, the American Medical Association (AMA) will consider a resolution aimed at eliminating financial inducements from comanagement relationships. The resolution was introduced last December by the American Academy of Ophthalomogy (AAO) and was supported by the American Society of Cataract and Refractive Surgery (ASCRS). Almost a year later, there is still much confusion over what significance the resolution has for ophthalmologist-optometrist relations.

The AAO resolution, which was referred to the AMA Council on Ethical and Judicial Affairs at the 1998 House of Delegates meeting, calls on the AMA to “support limitation of surgical comanagement to circumstances that focus on the well-being of the patient and not the financial relationship between the providers.”

In presenting this resolution, the AAO called on the AMA to take a leadership position on this “issue of ‘legalized’ fee-splitting” and to look at “the broader ethical implications of surgical comanagement.”

Competing for comanagement?

The AAO’s actions were prompted by reports that some optometrists were referring only to surgeons who would allow them to comanage patients, Ruth Williams, MD, chair of the Ophthalmology Section Council in the AMA House of Delegates, told Primary Care Optometry News.

“In certain communities where comanagement is strongly practiced, ophthalmologists feel like they have to comanage to compete for cataracts, and they felt that was onerous,” she said.

The AMA resolution does not question the competence of optometrists to comanage cataract surgery patients, Dr. Williams said, but merely reflects the desire to remove financial inducement from comanaging relationships.

No standards for refractive surgery

The ASCRS, which does not have an official position on comanagement, worked with the AAO to draft a resolution that the organization could support, Nancey McCann, ASCRS director of government relations, told Primary Care Optometry News.

While cataract surgery comanagement has been a longstanding issue of contention, Ms. McCann said that the dramatic increase in refractive surgery, where there are no set federal guidelines on comanaging fees, has helped bring this issue back to the forefront.

“Since refractive surgery is elective and not covered by insurance, there’s no set standard as to what to do in that situation,” she said. “With Medicare and cataract surgery, you put a modifier on it and the comanager gets 20% and the surgeon gets 80%. There’s no set rule with refractive surgery. I know that’s a perceived problem, and that’s why we’re taking a closer look at the issue.”

Refractive surgery comanagement is also becoming a legal matter. Ellis Eye and Medical Center and William Ellis, MD, filed suit Sept. 14 in San Francisco Superior Court claiming that local ophthalmologists have competed unfairly to recruit refractive surgery patients. The lawsuit alleges that two Bay-Area refractive surgeons “have regularly engaged and presently engage in the practice of paying secret rebates and fee-splits to ODs.” The lawsuit did not mention any optometrist by name.

The lawsuit asks the court to order the defendants to cease this practice and turn over the money that has been generated. In the suit, Dr. Ellis claims losses to his practice in excess of $200,000 per month.

Comanagement in Connecticut

While the issue is debated by the AMA, practitioners are looking to Connecticut as a harbinger of comanagement’s future.

Last year, after receiving complaints that a certain group of optometrists was referring cataract patients only to ophthalmology practices that would comanage postoperatively, United HealthCare Medicare of Connecticut revised its surgical comanagement policy. The policy, which went into effect Jan. 1, said that comanagement would be allowed when the surgery was performed by an itinerant surgeon or by a surgeon who would be taking a leave of absence after the surgery or when the patient could not return to the surgeon’s office for postop care.

However, the policy also allows patients to “knowingly and willingly” request to have postoperative care performed by the referring practitioner. This request is intended to come after the surgeon discusses the risks and benefits of the surgery with the patient, and the policy explicitly states that “In this instance the surgeon must have the patient sign an informed waiver.”

Confusion among optometrists

Mark Chasse, OD, past-president of the Connecticut Optometric Association, told Primary Care Optometry News that there was still quite a bit of confusion among Connecticut optometrists about what the new rules required. The original problem, he said, is that many ophthalmologists were refusing patients’ requests to be returned to their optometrists.

“The patient is being told by the optometrist that they can comanage and the patient is given a form to fill out,” Dr. Chasse said. “The ophthalmologist is supposed to sign off on that same form, but they are not signing off on it.”

Patient should have choice

According to Arif Toor, MD, medical director for United HealthCare Medicare in Connecticut, the situation described by Dr. Chasse is not how the policy was intended to work.

“It is a beneficiary’s right, not a physician’s or optometrist’s, but a patient’s right of choice,” Dr. Toor told Primary Care Optometry News. “It is the operating surgeon’s job to get a patient’s informed consent. When a patient walks in from an optometrist’s office to a surgeon’s office before even the decision for surgery has been made and before the patient has been informed of all the risks of surgery, and he has a form already signed, that goes against the spirit of the policy. It means that the coercion that we wanted to get rid of still exists,” he said.

Dr. Toor said that he has not received any complaints from optometrists who said they were not being allowed to comanage, but one surgeon did report that patients had brought previously completed waiver forms to his office.

Elwin Schwartz, MD, president-elect of the Connecticut Society of Eye Physicians, said that it is the operating surgeon’s responsibility to explain the risks, benefits and alternatives to surgery to the patient. This cannot be delegated to a member of the staff, nor can anyone outside the surgeon’s office intervene.

Dr. Schwartz handles few comanaged patients, but when patients are referred to his office from an OD, he does not sell them glasses from his practice’s optical shop or continue seeing the patient after he feels that the eye has stabilized postoperatively. “The people I have spoken with haven’t had any problems with the guidelines,” he said. “No one likes to talk about it, but I do think some people felt there was financial pressure for comanagement. If there were not financial pressure, this would be a non-issue.”

For Your Information:

Ruth Williams, MD, can be contacted at 205 N. Main St., Wheaton, IL 60187; (630) 668-8250; fax: (630) 668-3914.

Nancey McCann, can be contacted at 4000 Legato Rd., Suite 850, Fairfax, VA 22033-4055; (703) 591-2220; fax: (703) 591-0614; e-mail: mccann@ascrs.org; Web site: www.ascrs.org.

Mark Chasse, OD, can be contacted at 160 West St., Cromwell, CT 06416; (860) 635-6149; fax: (860) 632-1401.

Arif Toor, MD, can be contacted at 538 Preston Ave., Meriden, CT 06450; (203) 639-3134; fax: (203) 639-3018.

Elwin Schwartz, MD, can be contacted at 195 S. Main St., Middletown, CT 06457; (860) 567-3787; fax: (860) 347-9621.