ODs so far successful in fight to keep their role in surgical comanagement

Issue: April 1999

Optometrists have been participating in successful surgical comanagement partnerships for a number of years. Recently, groups in certain states have challenged this concept and optometrists have had to fight to maintain the comanagement privilege.

“The local Medicare carriers have tried to modify and, in some cases, abolish patients’ rights to have their postsurgical care provided by an optometrist,” said David Mills, OD, chairman of the Federal Relations Committee for the American Optometric Association. “Since the Medicare statute is very clear that the local carriers cannot do this, we’ve been able to get this policy clarified to make sure that the proper protocol for comanagement is followed in each of these regions.”

Revised policy for Connecticut

In Connecticut, the issue recently came under scrutiny when a local Medicare carrier questioned whether or not surgical comanagement is a necessary part of patient care. In response, the U.S. Health Care Financing Administration (HCFA), both locally and nationally, participated in the development of a new medical review policy for Medicare, which took effect Jan. 1. The policy lists situations in which comanagement is allowed and those in which comanagement rules are violated.

J. James Thimons, OD, executive director of TLC The Laser Center in Connecticut, said that he is pleased with the outcome. “They’ve reviewed the need for this, they’ve reviewed the quality of care rendered and all of the dynamics of the process and found that it is a viable alternative in how care can be delivered in the eye care field,” he said. “So in Connecticut, we have language now that specifically describes the ability of the patient and the primary care practitioner to participate in this process. There was an assumed privilege of practice, and ophthalmology questioned that assumed privilege. I’m very happy with the fact that there is now written documentation of the viability of this process and it is no longer something that’s subject to question or interpretation.”

Kansas carrier withdraws policy

Blue Cross/Blue Shield of Kansas, the Medicare carrier for Kansas, Nebraska and part of western Missouri, has withdrawn a payment policy that could have extensively restricted optometric comanagement of cataract patients in those areas. The policy, which was originally proposed last fall, appeared to conflict with the reimbursement policy for optometric comanagement put in place by HCFA.

New Jersey optometrists await ruling

In New Jersey, the state academy of ophthalmology filed a petition for rulemaking, which is “asking the state board of medical examiners to develop a regulation that would prohibit ophthalmologists from delegating postoperative care to optometrists,” said Christopher Quinn, OD, of Iselin, N.J. “Organized ophthalmology has been on this bandwagon before, and now with refractive surgery, there is a small group of relatively right-wing ophthalmologists pushing this agenda. However, clearly, we’ve seen in the last 10 years a significantly increased acceptance of comanagement as a model for delivering efficient patient care.”

In January, after careful review and discussion, a subcommittee of the New Jersey State Board of Medical Examiners recommended that the board deny the petition for five reasons:

there was “insufficient evidence presented to the board to document harm or adverse effects to New Jersey patients by virtue of comanagement;”
the medical literature presented lacks sufficient research “to demonstrate whether or not there exists a lack of recognition of complications by optometrists involved in comanagement;”
“current regulations already make the operating surgeon responsible for all patient care;”
although there is concern regarding fee splitting arrangements, an existing body of federal and state law already prohibits such arrangements; and
“the jurisdiction of the board does not extend to defining scope of practice of optometry.”

At the subsequent board meeting, the board voted to table the denial pending additional input from the New Jersey Academy of Ophthalmology (NJAO).

Reni Erdos, executive director of the NJAO, does not agree that comanagement equals efficiency in patient care. “What we observe is that optometry is essentially creating the situation where the optometrists determine the surgery,” she said. “The optometrist then refers the patient to this ‘technician-surgeon,’ and the surgeon, after performing the surgery, refers the patient back to the optometrist. That is not acceptable practice of medicine, and we believe that it is not in the patient’s best interest.”

Ms. Erdos said that the patient’s best interest, which is the catalyst behind the NJAO filing the petition in the first place, is being compromised by the comanagement policy currently in place. “What is really created in the comanagement model is a kickback scheme, where the optometrist doesn’t refer the patient to an ophthalmologist who would not refer the patient back,” she said. “We believe that patients are paying more, being inconvenienced, being sent distances that are unnecessary. Comanagement had been a valid concept in those circumstances where, in rural areas for example, there weren’t enough ophthalmologists or there was a traveling surgeon. In those situations, maybe the concept had merit. But in most places, there are more than enough ophthalmologists. It isn’t necessary to refer the patient back for after-care.”

Dr. Quinn said that should the board of medicine develop a regulation prohibiting the delegation of postoperative care, many optometrists would be willing to take further action. “We always have the prerogative to introduce legislation to prevent them from doing that,” he said. “I think if the outcome were unfavorable to us, optometrists in the state would be willing to explore that avenue.” However, Dr. Quinn said that such an action does not seem necessary. “In the many years that comanagement has existed, I don’t believe there have been any complaints to the board of medicine about either a problem with quality of care or any complaint relating to this issue,” he said. “Why are we going through this if there’s no problem except in the minds of these radical right-wing old-timers?”

The decision process of the petition for rulemaking comes on the heels of the American Medical Association (AMA) House of Delegates’ decision to adopt a surgical comanagement resolution. The resolution, which was introduced by the American Academy of Ophthalmology at the Dec. 8, 1998, AMA House of Delegates meeting in Hawaii, is directly related to the flurry of state activity, Ms. Erdos said. “This is going on all over the country,” she affirmed.

Dr. Thimons said that his objection was not being questioned about the validity of optometrists participating in surgical comanagement, but rather the exclusivity of the investigation. “My only concern is that optometrists are the only ones being questioned,” he said. “It shouldn’t just be optometry being questioned by ophthalmology. If we’re going to question this issue, we need to look at the whole issue of how health care is being provided and with each of these multidelivered aspects of care. For instance, should internists actually see patients after cardiology surgery? I think they would tell you ‘yes,’ just as I would tell you that I see patients after eye surgery, too. If the overall issue of comanagement – internists, podiatrists, orthopedists, cardiologists – is gone, and it doesn’t have validity in the next century, then we all drop out.”

Policy reviews likely to continue

Dr. Mills said that although the issue has been resolved in certain states, it is likely to continue to turn up around the country. “We’ll just continue to make sure, from our standpoint, that Medicare fulfills what the statute says it has to,” he said. “The carrier medical directors can’t re-write federal statutes. I’m sure we haven’t seen the last of it – we’ll see it continue to crop up – but I think it’s become quite clear to them now what they can and can’t do.”

For Your Information:

J. James Thimons, OD, is the executive director of TLC Connecticut and the medical director of a referral, secondary and tertiary level surgical practice. He can be reached at Ophthalmic Consultants of Connecticut, 165 Stella Lane, Fairfield, CT 06432; (203) 255-6196; fax: (203) 265-1467.

David Mills, OD, is chairman of the American Optometric Association Federal Relations Committee and can be contacted at 1050 Centerville Rd., Warwick, RI 02886; fax: (401) 828-3202.

Christopher Quinn, OD, can be reached at Omni Eye Services, 485 Rte. 1, Ste. A, Iselin, NJ 08830; (732) 750-0400; fax: (732) 750-1507; e-mail: cqod@home.com.

Reni Erdos is the executive director of the New Jersey Academy of Ophthalmology. She can be reached at the NJAO, 1114 Raritan Rd., #8, Clark, NJ 07006; (732) 388-7130; fax: (732) 388-7138; e-mail: NJAO@aol.com.