Practice of refractive surgery comanagement experiences changes

Issue: June 2006

ByBob Kronemyer

Increased consumer awareness of refractive surgery procedures is prompting many patients to directly contact refractive centers or surgeons without a referral from a primary eye care provider. As a result, some say comanagement seems to be waning. However, others feel the benefits of comanagement will allow it to grow.

Louis J. Phillips, OD, FAAO [photo]
Louis J. Phillips

“After awhile, patients start to self-refer into the surgical facility, thus bypassing the original referring doctor,” said Louis J. Phillips, OD, FAAO, owner of SightLine Laser Eye Center in Sewickley, Pa. “The patient is not necessarily a patient of the referring doctor. It may be that the patient’s friend was a patient of the referring doctor. If that center is willing to see those people directly off the street, then the center starts seeing many people directly. As a result, the center’s percentage of referred patients begins to drop.”

Dr. Phillips believes nearly all refractive centers have seen a decrease in the percentage of doctor referred patients. “Referral sources are not quite as valuable to the surgery centers as they were when the centers first started,” he told Primary Care Optometry News in an interview. These referral sources, however, are who gave the centers the original patients that have become the basis of the word of mouth referral. “I also think some of these centers have become very cavalier. They aggressively market to the public. I think this dilutes or diminishes comanagement.”

Referring the patient out

If a patient contacts Sightline Laser Eye Center without a referral, the patient is “questioned over the phone about who his or her doctor is and where he or she is coming from,” Dr. Phillips said. “We do everything we can to refer the patient out before they come. However, this is a very dangerous approach, because the patient can be lost. But we have to do this so we are sure we are not competing with our referring in the market place.”

Robert D. Belajic, OD, who is in private practice in Auburn, Calif., is one of the founding doctors of Pacific Laser Eye Center, which has four locations in Northern California. “During the past 5 years, optometrists have referred a greater number of cases,” Dr. Belajic said in an interview. “I also believe they are starting to wake up and choose to refer to optometrically owned and run – or certainly optometrically supported – laser centers and surgeons.”

At Pacific Laser Eye Center, “we require ODs to do as much as possible. Short of actually performing the surgery themselves, they are expected to do it all, including before- and after-care,” Dr. Belajic said.

In the case of a patient who shows up without a referral, the center tries to select an OD near the patient’s home, work or recreational area who is affiliated with the center. “But if a patient already has an OD, we will call that OD and ask if he or she is interested in comanaging the patient,” Dr. Belajic said. “The idea is for the patient to come through an OD before entering our center.”

Dr. Belajic believes that optometrists will have an opportunity to participate in refractive surgery comanagement “as long as they are willing to become educated and accept the responsibilities associated with it. But if they don’t want to be very active in return for their comanagement fees, I don’t see a bright future,” he said. “For me, comanagement has been one of the most rewarding areas of my practice. Patients have become extremely loyal. Comanagement is fun and exciting. In addition, the source of referral for building your personal practice is outstanding.”

Comanagement at TLC centers

John W. Potter, OD, FAAO [photo]
John W. Potter

TLC Laser Eye Centers represent the quintessential comanagement model, according to John W. Potter, OD, FAAO, vice president for clinical services at TLC and a Primary Care Optometry News Editorial Board member. “We have gone to great lengths to make the patient’s desires and needs first and foremost in everything we do,” Dr. Potter told PCON. “Consequently, we have spent a lot of time developing and training all of our surgeons and all of our optometrists about refractive surgery and how to work together to best serve their patients. We have also gone to great lengths to ensure that we respect both professions.”

Comanagement is as strong today as it was in 1999, Dr. Potter said. “It still represents the bulk of our patient care,” he said. “The majority of our patients are referred to us by optometrists. We comanage not only with optometrists, but with ophthalmologists as well.”

However, Dr. Potter has observed an increasing trend of patient self-referral overall. “This is an unavoidable trend,” he said. “It is the way eye care has developed. Today, a consumer becomes a patient for contact lenses. Similarly, in refractive surgery, we have evolved to the point now where informed consumers are going to their doctors or to a laser center and saying ‘I want to have refractive surgery.’ These consumers are no longer in the mode where it is all brand-new and mysterious. The business of refractive surgery has matured.”

Because refractive surgery “is a pretty intimate experience for patients, they want to be cared for by their doctors,” Dr. Potter said. “But if a patient says that he or she desires to be cared for at our center, regardless of his or her relationship with a personal doctor, we honor that request. Overall, though, I predict that comanagement will continue to play a very significant role in refractive surgery forever.”

Direct marketing, increased awareness

Richard L. Lindstrom, MD [photo]
Richard L. Lindstrom

Richard L. Lindstrom, MD, a Primary Care Optometry News Editorial Board member and chief medical editor of Ocular Surgery News, concurred that the outlook for comanagement is not quite as rosy as before. “The percentage of cases that are classically comanaged has declined some,” he said. “More patients are going directly to a laser center or individual practice, based on external marketing. Many laser centers and ophthalmology practices now do direct marketing. Not as many patients go through their optometrists as before.

“There is a lot of patient awareness about laser refractive surgery,” he continued. “The Sunday newspaper and the radio are used by several laser clinics to market directly to the public. Even though patients may have used the services of an optometrist for years, they don’t necessarily go through that optometrist for refractive surgery.”

Dwindling referrals to MD practice for laser surgery

At Dr. Lindstrom’s practice in Minneapolis, approximately 70% of refractive surgery patients now contact the office directly through word-of-mouth or direct marketing. This compares to approximately 50% in 1999 and 2000. “We usually take care of that self-referred patient ourselves,” Dr. Lindstrom said. “However, in our practice, we have a large number of referring doctors, both MD and OD. Many times, if we can, we will refer the patient back out to another local eye doctor once the patient is healed and stable.”

Dr. Lindstrom believes the future of comanagement is “still robust, but it is not growing in percentage of total cases,” he said. “The typical comanaged patient is what I would call a premium patient. These patients tend to be looking for the very highest quality of care and are willing to pay a higher price for that care.”

Cataract surgery comanagement stable

Comanagement of cataract surgery over the years “has certainly become more acceptable,” said Robert T. Crotty, OD, clinical director at Wallace Eye Surgery in Alexandria, La. “Both parties are working closer together. There is a lot more correspondence between surgeon and referring doctor, whether by mail or phone.

“Patients are really receptive, too,” he continued. “They like staying with their doctors in an environment to which they are accustomed. It is also easier to comanage today than in years past, but our percentage of OD referrals has remained fairly stable over the years.”

Increased role of primary eye care

If a patient contacts Wallace Eye Surgery without a referral, that patient is still seen by the office. “But as people become more educated through the media, they are more accepting of optometrists playing an increasing role in their primary eye care,” Dr. Crotty told Primary Care Optometry News. “I think comanagement will continue to exist, unless laws are enacted that prohibit it. Comanagement certainly makes sense for patients who live 60 to 90 miles away.”

R. Bruce Wallace, III, MD [photo]
R. Bruce Wallace

“Although the comanagement relationship has not changed in our practice during the past 5 years, I think it has changed in the country,” said R. Bruce Wallace III, MD, medical director at Wallace Eye Center, in an interview. “I have heard from various sources that there is now less comanagement. For example, the percentage of LASIK patients being comanaged appears to have diminished. I think part of this is due to the marketing efforts of LASIK practices, which drives patients away from primary care optometrists to the surgeon.”

Patients who contact Wallace Eye Surgery directly for refractive lens exchange “are handled as if they did not have an optometrist working with them,” Dr. Wallace said. “However, if the patient prefers glasses or contact lenses instead of surgery, we might refer the patient to a local optometrist.

“As for the future of comanagement, I think it is still healthy,” he said. “After all, there are twice as many optometrists as ophthalmologists in the country, so more of these patients are under the care of an optometrist. Furthermore, patients who are likely to need refractive procedures start out wearing glasses or contact lenses — mostly through optometrists. It seems logical that these patients would ask their optometrists what they think of various refractive procedures. It also helps if optometrists have established programs with surgeons, so the next step can be taken more easily by the referring doctor to the surgeon.”

For more information:

Louis J. Phillips, OD, FAAO, can be reached at SightLine Laser Eye Center, 2591 Wexford-Bayne Road, Ste. 104, Sewickley, PA 15143; (724) 933-5588; fax: (724) 933-6051; e-mail: lp@sightlinelaser.com.

Robert D. Belajic, OD, can be reached at 3211 Fortune Court, Ste. A, Auburn, CA 95602; (530) 885-6241; fax: (530) 885-0144; e-mail: aeca@auburneyedocs.com.

John W. Potter, OD, FAAO, is a Primary Care Optometry News Editorial Board member and vice president for clinical services at TLC Laser Eye Centers. He can be reached at 18352 Dallas Pkwy., Ste. 136, Dallas, TX 75287; (972) 818-1239; fax: (972) 818-1240; e-mail: john.potter@tlcvision.com.

Richard L. Lindstrom, MD, is a Primary Care Optometry News Editorial Board member and chief medical editor of Ocular Surgery News. He can be reached at Park Ave. Medical Office Bldg., Ste. 106, 710 East 24 St., Minneapolis, MN 55404; (612) 813-3633; fax: (612) 813-3660; e-mail: rllindstrom@mneye.com.

Robert T. Crotty, OD, can be reached at Wallace Eye Surgery, 4110 Parliament Dr., Alexandria, LA 71303; (318) 448-4488; fax: (318) 448-9731; e-mail: rcrotty@wallaceeyesurgery.com.

R. Bruce Wallace III, MD, can be reached at Wallace Eye Surgery, 4110 Parliament Dr., Alexandria, LA 71303; (318) 448-4488; fax: (318) 448-9731; e-mail: rbw123@aol.com.