Article

Are Politics Burdening the OD/MD Relationship?

Despite scope of practice expansion, working with optometrists is — and needs to be — on the rise

Are Politics Burdening the OD/MD Relationship?

Despite scope of practice expansion, working with optometrists is — and needs to be — on the rise.

By Samantha Stahl, Assistant Editor

The strained relationship between optometrists and ophthalmologists, always one that ebbs and flows with changing times, seems to be reaching another historic low. With reports about scope of practice legislation hitting the news seemingly every month, it's no wonder MDs can be leery to place trust in their optometric counterparts. But are the worries about optometric overreach warranted, or are sensationalist politics more to blame? Many optometrists have even said they aren't interested in performing surgical procedures and don't support expansion legislation, so is the perception of the power-grabbing OD truly accurate, or just a cliche? Do optometrists and ophthalmologists really need to have such a hard time getting along?

As the one-two punch of health care reform and an aging population inundate MDs with new patients, it may be more important than ever to have strong relationships with ODs. “Thirty percent of an ophthalmologist's day is spent doing things that a technician or optometrist could do,” says practice management consultant John Pinto. With a need for efficiency at an all-time high, optometric support may be just the thing to make an increased workload a little more feasible.

The Scope of Practice Battle

Earlier this year when Kentucky passed a bill expanding optometric scope of practice to include certain surgeries, there was a fierce outcry from ophthalmologists across the country who were justly uncomfortable allowing surgical procedures, even minor ones, to fall in undertrained hands. “Surgical privilege proposals for ODs have an understandably high shock value to most MDs and DOs, and these somewhat radical proposals have made it hard for the two sides to communicate,” says Mr. Pinto. He says it is hard to predict how the scope of care battles will play out state-by-state, calling the situation an “absolute wild card,” that has unfortunately hardened some people's outlook.

Others, such as the Pennsylvania Academy of Ophthalmology (PAO), have approached the issue by advocating legislation to better define ophthalmic surgery, a measure that eliminates ambiguity in current regulations about what optometrists are permitted to do. Kenneth Cheng, MD, immediate past-president of the PAO, has actively promoted House Bill 838, the Definition of Ophthalmic Surgery Bill. He insists the legislation won't have any negative impact on OD/MD relationships since it doesn't change or take away anything from optometrists' current scope of practice.

“Defined levels of education and training are required for safe delivery of health care,” Dr. Cheng says. “Graduation from medical school and completion of internship training are appropriate prerequisites for ophthalmology residency training and are necessary to ensure safety for patients undergoing eye surgery.” Unfortunately, other states are aiming to follow in Kentucky's footsteps, with Nebraska, South Carolina and Texas considering similar scope-expansion legislation, moves that could re-stoke the OD/MD fire.

“A much more gentle and professional approach would have been a coalition of MD/DO/OD providers applying facts and data, doing a better job of education on both sides of the aisle,” Mr. Pinto says, on the poor handling of previous scope of practice issues. But an entirely different set of politics — Obamacare — may mean that closer OD/MD collaboration will be a future inevitability.

The Necessity of Eyecare Teams

Despite the political confrontations, there has been marked expansion of comanagement and integrated management over the last 20 years. The biannual American Academy of Ophthalmology membership survey showed that while only 28% of ophthalmologists reported employing an optometrist in 1994, the number has steadily risen, peaking at 50% this year. The 2011 survey also reported that 58% of young ophthalmologists (those in practice five years or less) employ an optometrist.

Some speculate that expansion of integrated care could eventually ease tensions over optometric scope of practice.

“The more the two ‘Os’ have an opportunity to work together, the more common understanding, common care pathways and mutual respect arise,” says Mr. Pinto. He foresees the combination of higher OD to MD/DO ratios and falling fees, if they ensue, briskly driving a process of labor substitution. ODs and technicians will do more of the work that is currently handled by eye surgeons.

Daniel Briceland, MD, the AAO's secretary of state affairs, is another believer in the integrated eye care model. Besides efficiency and high quality care, the dynamic has another huge benefit: cost savings. “The team approach represents a very good use of scarce healthcare dollars,” he says.

Jean Ramsey, MD, the AAO's board of trustees council chair, agrees, saying that the economic drivers for healthcare reform seem headed in the direction of integrated care. “Recognizing this important trend and being proactive in the development of successful models of care will be critical to meeting our responsibility to transform healthcare.”

The predicted added demands on the eye care delivery system will place a need for technicians, opticians, optometrists and ophthalmologists to work together, says Dr. Cheng, but he emphasizes the need to prioritize patient safety.

“Any patient who has received poor care would be aghast and enraged to think that some perceived, but probably not real, shortage of adequately trained health care providers or cost savings led to their poor care.” To meet the public's needs for eye care in the future without compromising quality of care, a few precautions must be met.

Successful Comanagement

Comanagement, once established to ease the burden of traveling for postoperative care in rural demographics, has seen varying degrees of complications over the years. Unfortunately, CMS's approval of the rural comanagement provision slowly became a revenue sharing proposition, an un intended consequence that further harmed the reputation of a setup that should have solely been a healthy solution to a common problem.

Because of the complex legality issues with comanagement and referrals, Mr. Pinto recommends looking closely at the AAO and ASCRS guidelines (see sidebar, previous page) and getting input from regulatory and billing experts to avoid any risk of being slammed for illegal kickbacks.

“Depending on the type of eye surgery, patient distance from the surgeon and patient condition, comanagement could be an option for the surgeon to consider,” Dr. Briceland says. However, transferring care to a non-surgeon potentially puts the patient at risk for delay in treatment of a serious complication.

The most important component of comanagement is making it clear to the patient that they have a choice of who to see for care. Larry Patterson, MD, of Crossville, Tenn., says that most of his patients return to their optometrist for some or all of their postop care, especially the ones who live in other towns. He warns that physicians shouldn't seem like they're pushing patients to go back to optometrists just so they can get the comanagement fee and future referrals. Additionally, in the event that a patient would prefer to stay with the MD for postop care, he recommends picking up the phone and explaining the situation to the optometrist. “If you build up a relationship over the years, they know you're not trying to steal patients.”

While Dr. Patterson hasn't personally experienced the issue, he notes there are optometrists who avoid referring patients to certain ophthalmologists out of fear of never getting the patient back. While keeping a patient in-office for future care may seem like a smart move at the time, ultimately it can be bad for business. Optometrists pick up on who snags patients, and will stop sending referrals.

Some practices have also taken the initiative to educate optometrists about premium IOLs so that ODs can subsequently educate their patients about the lenses long before consulting with a surgeon. While the additional information for patients may be great, does throwing another chef into the kitchen only complicate the matter? Can surgeons trust that optometrists know enough about the lenses that they'll provide accurate facts without swaying the patient's decision in the wrong direction?

Dr. Patterson tells his optometrists to feel free to introduce the lenses to patients. The practice has information to hand out, which helps patients understand the facts at an early stage. While the ODs generally don't go into in-depth discussions, the initial introduction of lens differences and pricing can also help offset some of the patient's sticker shock before meeting with the surgeon.

Looking Forward

With the significant shortfall anticipated in the ability to meet society's growing ophthalmic needs, a change in the eyecare delivery system is unavoidable. As the discussion of healthcare reform widens, integrated health care team models play an important role in meeting the gap between workforce supply and demand, says Dr. Ramsey.

These cohorts of ophthalmic manpower have the potential to streamline patient care and stay in sync with economic mandates, so long as each member of the integrated model is assigned proper duties. In Dr. Ramsey's opinion, “the delegation of responsibilities in these teams are best not determined by legislative fiat, but by careful, informed decision making and policy changes based on an understanding of the training, credentialing standards and expertise of the diverse health care professionals.”

Dr. Briceland agrees, saying that scope of practice legislation is a “tremendous waste of resources that could be put to better use to help ensure all are provided with better access to high quality care.” Time to put the politics aside and focus on best possible practice. OM

AAO's Guidelines on Comanagement
“Co-management must always be based on the true needs of the patients, not the economic wants of the providers involved,” says Jean Ramsey, MD, the AAO's board of trustees council chair. “Ask: ‘What is in my patient's best interest?’ and use the Academy's policy on comanagement to guide the process.” The statement, published in 2000, provides the following recommendations:

If co-management of surgical patients is being considered, justifiable circumstances should exist such as:

• The surgeon's unavailability (travel, illness, leave, itinerant surgery in a rural area, or surgery performed in a designated physician shortage area).
• The patient cannot travel to the surgeon's office because of distance or the development of another illness. When situations arise in which the surgeon concludes that the delegation of postoperative care is in the patient's best interest, guidelines that should be followed include:
• The surgeon, prior to surgery, must inform the patient if there are any prearranged postoperative management plans, and the patient must voluntarily consent to this in writing. This consent process, which should be documented in the medical record, should include the reason for the transfer of care, the qualifications of the healthcare provider who will render the postoperative care, and any special risks that may result from this arrangement.
• If an unanticipated transfer of postoperative care is required, the patient should be informed and this information documented in the medical record.
• The surgeon should inform the patient of the financial implications resulting from the co-management arrangement, particularly with regard to the patient's payment obligations and the postoperative provider's reimbursement.
• The transfer of care must not occur unless it is clinically appropriate and in the patient's best interest.
• The surgeon should confirm that the co-manager is legally entitled and professionally trained to provide the particular services.
• The co-management must not be done as a matter of routine policy on all patients.
• The surgeon should follow the patient until postoperatively stable, and there is no fixed time when the patient is sent back to the referring provider.
• The patient should be reassured that he/she has access to the surgeon, if necessary, during the postoperative period at no additional cost. (If a Medicare/Medicaid patient returns to the surgeon, both the surgeon and postoperative care provider must file a corrected claim.)
• Any fees must reflect an appropriate fair market value for the services performed
.

The full text of these guidelines are available on the Academy's Web site, under the “Clinical Statements” in the “Practice Guidelines” section. Further comanagement information can be accessed in the “Compendium of all Academy Postoperative Care and Co-Management-Related Publications” section.

We Want to Hear From You!
The experts say working with optometrists more closely is going to be unavoidable — and, in fact, desirable, if ophthalmology practices are to increase patient volumes. What do you think? How comfortable are you relinquishing some of your daily responsibilities over to an OD? If your practice is already using an integrated management model of care, how do you divide the workload?
Scope-of-practice battles are hitting the news every month. Do you think the media is inflating the drama, or is the commotion valid? Has scope-of-practice affected you in any way?
Take a brief survey at http://svy.mk/comangement, and let us know how you feel. We'll report on the results in a future issue.