This article is more than 5 years old. Information may no longer be current.
Comanagement: the intuitive choice and the right choice
Click Here to Manage Email Alerts
Overall, I consider myself a fairly rational person. Whether consulting with a patient, evaluating a new technology in clinical practice or reviewing articles for publication in Primary Care Optometry News, I generally like to consider all the facts before making a recommendation. In the final analysis, I often find that the most reasonable solution is a rather intuitive one.
It’s for precisely this reason that I often grapple with the comanagement debate. Try as I might, I cannot understand why comanagement is such a controversy. For me, given all the facts, comanagement seems intuitive.
Granted, as a strong comanagement proponent for many years, I’m inherently biased. I believe, however, that I can disregard my intuition and objectively arbitrate the issue of patient comanagement. To this end, let’s consider the relative merit of those arguments refuting comanagement.
Quality care
Comanagement is bad medicine, because only the surgeon is capable of providing quality postoperative care. Undoubtedly, the ophthalmic surgeon is eminently qualified to provide all aspects of postoperative care. But is this a skill set conferred only upon surgeons? In other medical specialties the surgeon judiciously delegates postoperative patient care to other physicians, residents, nurses and physician assistants. Furthermore, two decades of Medicare-sanctioned optometry comanagement of cataract surgery has not proven detrimental to patient well being. Finally, in no way does comanagement require that the surgeon abandon patient care. Rather, the very essence of comanagement assures “shared care,” during which patients receive the complementary skills of both providers.
Comanagement is bad medicine because the surgeon is unaware of the patient’s postoperative course, thereby compromising outcome analysis and quality of care. Granted, every ophthalmic surgeon strives for improved quality of care through outcome analysis. Fortunately, many ophthalmic surgeons are able to build outcome analysis databases from within their patient base. Furthermore, all optometry comanagement models provide the surgeon with an inherent quality assurance check, prompt reporting of postoperative complications and determination of final outcome. In its simplest form, if the surgical outcomes are poor the referrals cease.
Comanagement is inappropriate because it fosters the development of surgical “mills.” Unfortunately, certain high-volume ophthalmic surgical practices have probably grown from overly aggressive comanagement models. However, the vast majority of optometrist referrals are made with the patient’s best interest in mind. It’s not merely coincidental that the best patient results are often at the hands of experienced, high-volume surgeons. Will mandating that the surgeon provide all postoperative care result in a more equitable distribution of cases? In theory, maybe. In reality, probably not. As the optometrist and patient are primarily interested in a successful outcome, certain surgeons will remain in high demand. The only difference is that patients are inconvenienced by a greater surgical wait time — unless, of course, the surgeon delegates postoperative care visits.
Financial implications
Comanagement is inappropriate, because it’s really just a form of kickback. Unfortunately, financial improprieties occur in every aspect of society including eye care. However, the majority of referrals do not appear to be financially motivated. Given the modest reimbursement for cataract surgery comanagement today, it’s fairly apparent that clinicians are not in it for the money. Considering the required chair time, assumed liability and limited eye wear needs of today’s cataract surgery patient, it’s obvious that practitioners could easily improve their practice’s bottom line by devoting this time to other — more lucrative — patient endeavors. Similarly, the extremely competitive nature of refractive surgery has required that both surgeons and comanaging practitioners become increasingly efficient and cost effective. Simply put, the underlying motivation for comanagement is to better serve patient needs and not to make a quick dollar.
Indeed, even as I attempt to defend the anti-comanagement sentiment, the more intuitive the right choice becomes. This is not to say that every patient should be comanaged. However, in many cases it’s in the patient’s best interest as well as his or her personal choice.