ISRS embraces comanagement, AAO hosts point/counterpoint debate

DALLAS — In October 2000, the annual meetings of both the International Society of Refractive Surgery (ISRS) and the American Academy of Ophthalmology (AAO) were held here, and both groups — just a few miles apart — recognized the resurgence in the comanagement debate with special sessions devoted to it.

The ISRS session, “Under pressure: the revitalized attack on comanagement,” featured presentations that covered the historical perspective of comanagement; the legal, regulatory and practice implications of the joint position paper issued by the AAO and the American Society of Cataract and Refractive Surgery (ASCRS); the new ISRS position; international issues; and the American Optometric Association (AOA) position. The overall tone of the session was collegial and generally supportive of ethical, proper surgical comanagement among MDs and ODs.

John D. Hunkeler, MD, a former ASCRS president, reviewed how optometry has expanded its scope of practice since the early 1970s by obtaining the right to use and prescribe diagnostic and therapeutic pharmaceutical agents. He cited a “landmark decision” made in 1986 by the Department of Health and Human Services to recognize optometry as “a profession qualified to provide a broad range of services beyond the refraction and provision of glasses.” Dr. Hunkeler said, “This was specifically meant to include management of cataract and aphakic patients and the appropriate reimbursement for such services.”

Dr. Hunkeler stressed that ophthalmologists and optometrists must focus on the patient’s best interest, first and foremost, and that they must respect each other as health care providers. “From a historical perspective, the ophthalmologist who has offered that respect to his ophthalmic and optometric colleagues has enjoyed the benefits of receiving ongoing referral of patients, a true way to win for the patient and the provider,” he concluded.

Legislative review

Alan Reider, JD, reviewed the legislative history of comanagement. “From my perspective, it’s fairly clear to me that the ophthalmology profession has created many of its own problems in this area,” he said. “And the controversy continues.”

He said that the “true genesis of comanagement” was the Omnibus Budget Reconciliation Act of 1986, where Congress expanded the definition of physician under the Medicare program to include optometrists with respect to those services for which an optometrist is licensed under state law. This allowed ODs to obtain Medicare reimbursement.

He reviewed the history of involvement at the federal level with the Office of the Inspector General (OIG) and the Health Care Financing Administration, which occurred primarily in response to concerns expressed by the AAO, and he reviewed concerns raised at the state level and by state boards of medical examiners.

While Medicare carriers have published guidelines saying that routine comanagement would not be reimbursed, all have been withdrawn. In November 1999 the OIG declined to grant comanagement safe harbor protection. Because it recognized that abuses may exist, “we will not protect every comanagement relationship that is out there,” the group stated.

Comanagement would be considered on a case-by-case basis. “There’s no blanket protection, there never was and there probably shouldn’t be,” said Mr. Reider.

He then referred to a portion of the AAO/ASCRS position paper: “If the reason for sharing postoperative care with another provider — however well trained — is economic, specifically as an inducement for surgical referrals or the result of coercion by the referring practitioner, it is patently unethical and in many jurisdictions illegal.”

“That is an absolutely true statement,” Mr. Reider said. “That is the position taken by the Academy and ASCRS. That is the foundation. What they also use as their foundation is the position of Medicare carriers and the Office of the Inspector General, and that would be incorrect, because those positions of the carriers have been changed and, with respect to the Inspector General’s office, it did not take a position of anti-comanagement, it simply took a position that said we have to look at each individual relationship.”

Routine comanagement

“If a physician comanages in 100% of his or her cases, it seems that would violate this position paper, and I’m not sure the Academy and ASCRS can say that,” he continued. Mr. Reider stated that a fundamental problem with the position paper is that it does not address the patient. He asked: If every one of a surgeon’s patients requests to be returned to the referring optometrist or ophthalmologist for postop care, that is appropriate, but would that constitute routine comanagement and violate this policy?

The AAO and ASCRS have said that these are only guidelines, but Mr. Reider cautioned that these guidelines are looked at very carefully by the government, medical boards and malpractice lawyers.

After the AAO/ASCRS paper was released, other organizations followed, and all disagreed with these two organizations. “We clearly have a developing rift among the professional societies in ophthalmology,” Mr. Reider said.

After the formal presentations and during a panel discussion, Mr. Reider predicted that the issue of comanagement will get more public attention, and he expects the government to issue more formal statements in early 2001.

Global perspective

Michael Lawless, MD, of Australia, incoming president of the ISRS, opened his presentation by stating: “Comanagement is a global issue with different emphases in different countries. The United States is not the only country struggling with comanagement issues; it is the focus, however, partly because of the size and importance of the market, but also because of the American way of embracing change and new ways of dealing with problems in a way that sometimes shocks the rest of the world.”

Comanagement is an accepted, cooperative interaction between health care providers in many fields and an accepted method of coordinating medical and surgical services, he said.

“Comanagement is here to stay,” said Dr. Lawless. “This recent controversy in the United States will be helpful in clarifying the guidelines. If professionals breach acceptable guidelines, they should be dealt with appropriately by the profession or by external authorities. The market itself will solve any financial irregularities. Consumers will not tolerate financial extravagance within refractive surgery, just as they don’t within cataract surgery.”

ISRS perspective

Jeffrey B. Robin, MD, ISRS executive vice president, said the ISRS has become involved in comanagement issues because, “We are the world’s largest and oldest professional society devoted to the field of refractive surgery. As such, we have a unique perspective and can recognize the realities of refractive surgery, both medical and nonmedical, and we are committed to the advancement of refractive surgery care. We have, for our entire history, educated all professionals involved in this field who are willing to come to ISRS.

“Perhaps most importantly,” he continued, “we’re not encumbered by past cataract comanagement battles or the recent struggles for the control of primary eye care in the managed care world. We have, perhaps, a little cleaner perspective and viewpoint than our sister organizations.”

The ISRS was surprised by the release of the AAO/ASCRS position paper and the fact that the issue of patient choice was ignored. “Those two words are not mentioned in the document,” Dr. Robin said. “From the standpoint of clinical care, it offered no clinical evidence to support the strong expressions of concern. There has been no published evidence that patients who are comanaged in refractive surgery do worse than similar patients who are under the care of the operating surgeon throughout the entire course.”

The ISRS surveyed its U.S. membership and 75% of the respondents said they actively comanage or would do so if the opportunity presented itself. Based on the survey results, the organization issued its own comanagement position paper.

ISRS position

The paper recognizes the successful history of comanagement and the AMA Council on Ethical and Judicial Affairs, which said services must be properly allocated based on expertise; patient care must be coordinated among the providers; financially based conflict of interest must be avoided; and patient confidentiality must be respected. The ISRS paper also recognizes the American College of Surgeon’s statement on principles, which specifies that it is not inappropriate for the surgeon to transfer postoperative care to another physician.

The basic principles of the ISRS position are listed in the accompanying chart. Dr. Robin read the official ISRS position: “Responsible and ethical comanagement, either between the surgeon and optometrist or the surgeon and another ophthalmologist is appropriate for refractive surgery. The key, in addition to the necessities of patient care, is informed patient choice, and we strongly believe that patients are capable of making decisions affecting their care and that they have the right to make these decisions. Financial considerations should not be a determining factor.”

He said a task force will now approve a comanagement guidance document, which they hope to have in circulation by next July’s meeting.

Optometric position

Howard J. Braverman, OD, AOA president, told the audience that — with a few suggestions — the AOA agrees with much of the AAO/ASCRS position paper on comanagement. He read the AOA’s position:

“The AOA believes that referrals for specialty services should be based on achieving the best possible outcome for the patient and not on financial relationships between providers. All health care professionals have an ethical obligation to patients for whom they are responsible to ensure that medical and surgical conditions are appropriately evaluated and treated. Decisions to comanage should be made on an individual basis and should always include proper and complete documentation and communication between providers. Comanagement should occur only when these basic principles are followed.”

Dr. Braverman said the AOA’s exceptions to the AAO/ASCRS document are the absence of any recognition of the patient’s right to choose his or her provider of care and the reference to comanagement being an exceptional — rather than a routine — occurrence requiring justifiable circumstances.

“With all due respect to my colleagues in these two organizations, they just, frankly, made up this last point,” Dr. Braverman said. “It is not supportable by either law or regulation or scientific evidence or, perhaps most importantly, the academy’s own code of ethics. Taken together, these two major shortcomings expose the joint paper for what I believe is its real purpose: to disrupt legitimate comanagement situations through misrepresentation or intimidation.”

Dr. Braverman said he believes that the fear of “patients being bought and sold … alone cannot explain the ferocity of these latest attacks. There are at least two other factors involved: greed and jealousy,” he continued. “This is really an ophthalmology/ophthalmology issue with optometry being caught in the middle.”

He said that the refractive surgery “pie” grew more quickly than expected, and that a relatively small number of surgeons have a larger interest in it. “Many of their colleagues are professionally jealous and looking to take some of this pie back,” Dr. Braverman said. “Ironically, even if these latest attacks were successful in eliminating comanagement in the rarest of circumstances, I do not believe referral patterns will be substantially altered. Optometrists will still refer to those surgeons who consistently get the best results and respect the skills, training and expertise of the referring optometrists — the very same surgeons who currently get the lion’s share of referrals anyway.”

Dr. Braverman concluded by saying the AOA is telling its members that there are no legal or ethical barriers to providing comanaged care as long as proper protocols are followed, and is advising them to follow those proper protocols in all referral relationships.

Meanwhile, across town

The next day, over at the academy meeting, presenters used the point/counterpoint format in the refractive surgery program to debate the issue: Is the AAO/ASCRS joint position paper on comanagement too stringent? The overall tone of this session differed greatly than that of the ISRS session the previous day. After the presentations, when the issue was presented to audience members, an estimated 65% of respondents agreed that the position paper was reasonable.

Paper is too stringent

Mark G. Speaker, MD, PhD, supported the stance that the paper is too stringent. In his practice, his objectives are the patient’s best interest and patient choice. Dr. Speaker said that, preoperatively, patients should see whoever has the best knowledge of their refraction and history. He feels that postoperatively a comanager can better assess the success of the surgery and determine if an enhancement is necessary.

“I don’t think the [position paper] respects the patient’s right to choose their doctor,” he said. “I also don’t think it respects the traditional role of comanagement in medicine.”

Daniel S. Durrie, MD, a board member of the AAO’s Refractive Surgery Interest Group and secretary of the ISRS, has been comanaging surgery since the 1980s. He said his lifetime goal is to improve the quality and safety of refractive surgery.

He believes the “pendulum theory” can be applied to comanagement: The pendulum usually swings beyond the ideal point before it moves — making a correction — and swings back, as with the stock market, technology and politics. He maintained that anyone who is “buying care” should be taken care of by the appropriate state licensing groups due to illegal practices.

Paper is reasonable

In defense of the AAO/ASCRS position statement, Paul N. Arnold, MD, FACS, said, “There’s been tremendous pressure within the organization to come up with such a statement and comanagement guidelines.” An AAO Practice Management Committee member and past chair of the ASCRS Government Relations Committee, Arnold said ASCRS worked to modify a radical stance that was opposed to all comanagement.

The position paper states that comanagement may not be routine or coerced or induced. Dr. Arnold said the paper’s critics contend that the guidelines are voluntary — which is true — and that the position is unwarranted and over-reaching — which is not true.

The most common criticism indicates that the statement does not consider patient choice. “The statement presupposes patient choice; how else could we get informed consent?” Dr. Arnold responded.

Priscilla E. Perry, MD, agreed that the position paper is reasonable. She cited the American College of Surgeons’ code of ethics, which states that the surgeon is responsible for postoperative care, that the surgeon should coordinate postoperative care and that there should be no financial considerations.

She referred to the American Medical Association stance that fee splitting is unethical and illegal. She stated that Medicare policy varies by state: one state specifies that comanagement is not allowed if the surgeon is available to provide the care; another state says it is not allowed if demanded by the referring provider.

Dr. Perry said that the AAO was mandated to take action on comanagement, and that 90% of respondents to an ASCRS survey called for limiting the practice. She advised doctors to consider three questions:

1. Is ophthalmic surgery a special case?
2. Would most patients want to be followed by the surgeon?
3. Would a patient consider the guidelines reasonable?

“If comanagement is routine, it’s unethical,” she concluded. “Patient interest must not be compromised.”

During his rebuttal, Dr. Durrie said that the definition of “routine” comanagement was not clarified in the statement. Dr. Perry said she believes routine means the majority of the time, but she agreed it is open to interpretation.

Dr. Durrie said that although proponents maintain that patient choice is implied, it should be clarified as well. He also pointed out that in only one state did a Medicare provider allow comanagement only if the surgeon is not available. “Look at the language of the document and eliminate some of the ambiguities,” he concluded.

Dr. Speaker said he did not believe that requiring informed consent from the patient for comanagement was necessary, but Dr. Perry insisted that patients should be informed of all postoperative management options.

For Your Information:

• John D. Hunkeler, MD, can be reached at 4321 Washington, Ste. 6000, Kansas City, MO 64111; (913) 588-6605; fax: (913) 588-6615.
• Alan Reider, JD, can be reached at Arent Fox, 1050 Connecticut Ave. NW, Washington, DC 20036; (202) 857-6462; fax: (202) 857-6395.
• Michael Lawless, MD, can be reached at The Eye Institute, 270 Victoria Ave., Chatswood, NSW 2067, Australia; (61) 2-9424-999; fax: (61) 2-9410-3000; e-mail: srsc@acay.com.au.
• Jeffery B. Robin, MD, can be reached at NuVista Refractive Surgical Center, 3755 Orange Place, Beachwood, OH 44122; (216) 514-3945; fax: (216) 514-3948.
• Howard J. Braverman, OD, can be reached at 1935 E. Hallandale Beach Blvd., Hallandale, FL 33009-4708; (954) 458-2112; fax: (954) 458-7186; e-mail: AmOptBDHJB@aol.com.
• Mark G. Speaker, MD, PhD, can be reached at Laser & Corneal Surgery Assoc. 115 E. 57th St., 10th Fl., New York, NY 10022; (212) 832-2020; fax: (212) 832-9739; e-mail: lasikspeak@aol.com.
• Daniel S. Durrie, MD, can be reached at Hunkeler Eye Centers, 5520 College Blvd., Overland Park, KS 66211; (913) 491-3737; fax: (913) 491-9650.
• Paul N. Arnold, MD, FACS, can be reached at Arnold Eye Care Center, 1265 East Primrose St., Springfield, MO 65804-4278; (417) 886-3937; fax: (417) 886-1285; e-mail: arnold@dialnet.net.
• Priscilla E. Perry, MD, can be reached at 1310 N. 19th. St., Monroe, LA 71201; (318) 388-2020; fax: (318) 361-0914.