The recent proliferation of co-management relationships in connection with refractive surgery has prompted both government agencies (the Office of the Inspector General and several Medicare carriers) as well as professional societies (the Academy and ASCRS) to issue restrictive statements concerning co-management relationships where post-operative care is performed by an eye care professional other than the operating surgeon. According to these statements, co-management should be a rare exception, occurring only when the operating physician was unavailable to perform post-operative care, or when it was virtually impossible for the patient to return to the operating surgeon.
SEE believes that these policy statements are an unwarranted and overreaching reaction to certain extreme, and exceptional, conduct undertaken by a small number of ophthalmologists who have put economic considerations ahead of the interests of their patients. While SEE does not condone such practices, SEE believes that the response of the agencies and professional societies is misdirected. Instead, SEE believes that any policy statement relating to co-management must recognize the right of the patient to decide whether to participate in such a program subject to agreement by the operating surgeon that such decision does not compromise the patient’s best medical interest. At the same time, SEE recognizes that the patient’s decision to obtain post-operative care from an optometrist must be made only when the patient is fully informed about co-management and that there may be instances where the patient’s medical condition does not support a co-management arrangement.
[For the purposes of this document, “eye care professional” is limited to licensed ophthalmologists and optometrists.]
Ever since the Social Security Act Amendments of 1986 expanded the definition of physician to include optometrists, co-management has generated controversy in the ophthalmic community. Accusations of improper referral arrangements between ophthalmologists and optometrists triggered investigations by the Office of the Inspector General and Congressional hearings on the propriety of co-management. No widespread abuse was identified, and as a result, no further action was taken. Co-management became a common practice in the profession.
The explosion of refractive surgery, however, has once again put co-management in the spotlight. Because refractive surgery is not covered under Federal or state health care programs, it is viewed as largely unregulated, and co-management arrangements between ophthalmologists and optometrists for refractive procedures have become far more aggressive than those arrangements when cataract surgery is involved. As a result, once again accusations have been made about the propriety of these arrangements.
In response to these concerns, there have been a number of recent policy statements issued relating to standards for co-management. Most significantly, in February the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery issued a Joint Position Paper entitled “Ophthalmic Post-Operative Care.” The Joint Position Paper focuses principally on the concern that co-management arrangements may be based upon economic considerations rather than clinical appropriateness. The Joint Position Paper articulates standards which should be followed when the surgeon concludes that the delegation of post-operative care is in the patient’s best interest. Further, the Joint Position Paper condemns the routine use of co-management, expressing the view that co-management should be the exception rather than the rule, and should be utilized only for “justifiable circumstances.” “Justifiable circumstances” for these purposes do not include the patient’s convenience or preference.
The position articulated by the Academy and ASCRS, although well intentioned, misses the mark. SEE agrees with and supports unequivocally the Academy’s and ASCRS’s position that co-management arrangements should not be driven by financial considerations, and that ophthalmologists should not enter into agreements for the routine referral of patients. SEE is concerned, however, that the Joint Position Paper is inappropriately restrictive in presenting the circumstances where co-management is appropriate. More specifically, SEE believes that the key consideration in any co-management program is that the decision to co-manage must be made by the patient, not by the operating surgeon or other eye care professional. At the same time, SEE recognizes that any decision concerning patient care must be made with the patient’s best medical interest in mind. As a result, SEE has developed the following policy which tries to balance a patient’s freedom of choice with the patient’s best medical interest.
Co-management is a cooperative interaction between health care providers to coordinate medical and surgical services in order to enhance both the efficiency, quality, and convenience of a patient’s care. The decision for co-management must be made by the patient. Physicians who participate in a co-management arrangement must assure that the patient is adequately informed about the choice for co-management and that the patient’s choice will be honored. The patient’s decision to participate in a co-management program must be balanced by the particular medical needs or condition of the patient.
Principles for Co-management
Expanding further on the policies set forth above, the following principles of co-management should be followed at all times:
- Considerations for co-management are patient choice and care which is in the patient’s best medical interest. In no event should financial considerations affect a co-management arrangement.
- There may not be an agreement between the operating surgeon and another eye care professional for the routine referral of patients.
- The final decision for co-management must be made by the patient, subject to agreement by the operating surgeon that it will not compromise the patient=s best medical interest. If the patient decides to obtain post-operative care from an eye care professional other than the operating surgeon, the patient should sign a statement confirming that decision.
- Prior to surgery, the patient must be provided with information about post-operative care requirements, the eye care professionals who are capable of providing the post-operative care, and the credentials of those individuals.
- The patient must be given the option to return to the operating surgeon for post-operative care and the patient’s decision must be honored.
- Co-management is not appropriate if a complication arises following surgery or if the medical condition of a particular patient requires continued treatment by the operating surgeon.
- If the patient elects to be co-managed by another eye care professional, the operating surgeon (or another surgeon designated to cover in the absence of the operating surgeon) must be available during the post-operative period for any complications that may arise.
Co-management arrangements in connection with services covered under the Medicare program must follow Medicare requirements relating to who may bill for what services and the appropriate amount to be apportioned between the surgery and the post-operative care. Because refractive procedures are not covered under Medicare or Medicaid, the federal requirements do not apply. As a result, there have been a wide range of financial arrangements in connection with refractive procedure co-management. SEE acknowledges that practices among medical professionals may vary, and that there is no hard and fast method which should be applied to all refractive procedures. Nevertheless, recognizing that co-management should be driven by the patient’s best interest and not by financial considerations, the following operational principles apply in connection with refractive procedure co-management, in addition to the principles articulated above:
- The amount paid to each provider of services must reflect the appropriate proportional value and intensity of the services provided.
- If the patient does not make a payment to each individual provider of services (as in the Medicare model), but instead makes a global payment to a single provider or entity, the patient must be informed in writing of the amount attributable to each of the providers of services.
Coordination of Care
SEE believes that participation in a co-management arrangement does not remove the responsibility from the operating surgeon. A number of SEE’s members have developed programs to enhance the coordination of care between the surgeon and the provider of post-operative services in order to assure that the best quality of care is provided to their patients. While the following do not represent standards required to be followed in order to comply with SEE’s co-management policy, they are presented for consideration by each surgeon as additional steps which may be taken to implement an effective co-management program.
- Development of a co-management protocol
The operating surgeon must recognize that he or she continues to be responsible for the care of the patient during the post-operative period. If another eye care professional is to provide services during the post-operative period, the operating surgeon may develop a protocol to be followed by that eye care professional. The protocol may set forth the number of visits, the timing of the visits, the scope of the examination, and any indications for which the co-managing eye care professional must contact the operating surgeon. This protocol generally is in writing and provided to all co-managing eye care professionals.
- Coordination of patient record
A number of operating surgeons require that a co-managing optometrist provide the ophthalmologist with a copy of the office visit notes when the patient returns for a co-management visit. In this way, should there be any need to examine the patient in the case of a complication, a complete set of records will be in the ophthalmologist’s file.
- CME program for co-managing optometrists
A number of surgical practices provide periodic medical education courses for co-managing optometrists. The courses focus particularly on complications following surgery.
- Co-management training program
Some practices have developed a training program which requires the optometrist to attend surgery, participate in “grand rounds,” and generally demonstrate a capability and understanding of the medical issues facing the surgical patient. Only when this process has been completed will the surgeon agree to co-manage with the optometrist.
SEE believes that the principles articulated in this Policy Statement provide the foundation for a co-management program which assures patient freedom of choice balanced with the patient’s best medical interest. One of the principal missions of SEE is to serve as the patient’s advocate. SEE believes that we, as physicians, must respect the dignity of our patients and provide them with appropriate information to allow them to make an informed decision in selecting their caregiver.