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What is our real role in comanagement?
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Yes, comanagement is under fire. Again. Not so much in a global sense, but rather comanagement between optometry and ophthalmology. There are, of course, numerous theories as to why. Some contend the sheer number of cataract surgeries performed annually place OD-MD comanagement under intense scrutiny.
Certainly, Medicare is closely monitoring the use of procedure code modifiers to properly allocate postoperative compensation and identify erroneous billing. The solution? Eliminate comanagement. Others feel that cataract surgery reimbursement reductions make it less financially feasible for surgeons to share the global fee. The answer? Eliminate comanagement. Still others question ethics, maintaining that certain surgeons comanage as an inducement for referrals. What to do? Eliminate comanagement. Finally, some still feel that optometrists lack the knowledge and skill to comanage surgical patients. The easy thing to do? You guessed it, eliminate comanagement.
The argument for comanagement
While condemning comanagement appears to be the topical — if not mindless — solution, equally compelling arguments support OD-MD comanagement. Arguments that are well-rooted in comanagement’s long, successful history. First, in this age of managed care, MD and OD practices have become increasingly adept at proper coding and billing. I am confident the majority of comanaging practices have adapted systems to assure that each practice bills appropriately.
Furthermore, as cataract compensation diminishes, both the surgical and postoperative components are adjusted accordingly. In short, all providers are equally impacted and comanagement does not cost the system more. With respect to ethics, I cannot imagine an optometrist referring to an inadequately skilled surgeon or a surgeon discharging patients to an incompetent optometrist, all in the name of a few dollars. The stakes — and patient expectations — are too high, and neither party can afford to take such risks.
Finally, with respect to practitioner competency, there are numerous avenues through which one becomes proficient in providing postsurgical care. Continuing education seminars, professional literature and didactic experiences all provide optometrists with the core competencies required for effective comanagement.
As I see it, we could argue the evils and virtues of OD-MD comanagement to a virtual stalemate (... maybe we already have). In actuality, the issue is easily arbitrated by asking one simple question: Is the optometrist’s role in comanagement in the patient’s best interest? Unequivocally, yes. First, consider that these patients have been with their optometrist for years. They are comfortable with the optometrist’s chair side etiquette, clinical skills and decision making. In short, patients entrust their optometrist with every aspect of their care, surgical referrals notwithstanding.
Secondly, who better understands the needs, complexities and appropriate solutions for a given patient than his or her optometrist does? As a patient advocate, the optometrist often makes the appropriate referral predicated on each patient’s specific needs. As cataract surgery is increasingly a refractive procedure, the optometrist’s advice is invaluable in guiding patients through the selection of — and adaptation to — binocular distance, monovision or multifocal IOL correction.
Finally, very practical issues surround comanagement. Patients often select an optometrist because they provide prompt, courteous, professional care in a conveniently located and pleasant office environment. For many senior patients the prospect of cataract surgery is frightening enough and they readily welcome the opportunity to return to their optometrist for postoperative care. Of course, this trend is familiar to all of medicine, as evidenced by decentralizing many hospital services to community-based facilities.
What can we say for certain about OD-MD comanagement? It will always have its proponents… and opponents. As nothing in health care is sacred, it will continue to be challenged and evaluated. But as long as quality and convenient patient care are at the heart of this issue, OD-MD comanagement is essential.