Co-Management: Finding Common Ground
Here's a look at the current
co-management climate from O.D. experts - and what it means to you.
By Karen Rodemich, Senior Associate Editor
Co-management has come a long way since its
beginnings in the mid-to-late 1980s when the first co-management model emerged
in the form of Omni Centers. Before these centers were formed, O.D.s often
encountered variable relationships between themselves and M.D.s.
So how has co-management changed over the past 20
years and what�s the status of optometric referral centers? Your colleagues
will provide their thoughts on this and other issues in this article.
But first, let�s take a look at recent
legislative efforts regarding co-management.
Recent co-management bills
There�ve been legislative battles in three
states recently, two of which have attempted to stifle and repeal co-management,
the other, to better define and regulate co-management.
A big post-op care debate between ophthalmology
and optometry took hold in Florida this past spring. Bills in the state
legislature sought to ban optometrists from providing follow-up care to ocular
surgery patients. Fortunately, for the time being, the bill died and optometry
is still free to co-manage.
Around the same time as the Florida bill, the
Missouri Society of Eye Physicians & Surgeons attempted to legally regulate
co-management in Missouri, but that bill didn�t pass either.
Nevada just passed and signed a co-management
bill in June that outlines how co-management is to be handled by optometry and
ophthalmology. The bill, which is a joint effort by the Nevada Optometric
Association and the state ophthalmology society, goes into law October 1. It
outlines the circumstances under which an O.D. may collaborate with an M.D. for
the provision of care to a patient. In short, the bill requires total disclosure
to the patient in the form of a written document including both the O.D.�s and
M.D.�s names, addresses and phone numbers, as well as those of the state board
of optometry and the board of medical examiners, the amount of the fixed fee and
the proportion of that fee to be received by each collaborating party.
The patient and a witness who isn�t one of the
collaborating parties needs to sign a statement that the patient under- stands
Matters of discussion
This past February, Chief Optometric Editor Neil
B. Gailmard, O.D., M.B.A., F.A.A.O., moderated a discussion about co-management
among a group of prestigious optometrists who are recognized as some of the
premier experts in medical and surgical eyecare. These O.D.s discussed the
origins of co-management, the current standing of this arrangement and where
they think it�s headed.
The original model
The O.D.s who participated in this discussion
represent individual practices that adhere to a certain philosophy of
co-management with various ownerships and interests.
Offering more detail to this history lesson,
Chris Quinn, O.D., center director for Omni Eye Services in New Jersey,
explained, "All of us were part of some of the original Omni Centers, which
were under a single entity control.
"Obviously O.D.s had few choices in
referring patients. They were pretty much stuck referring to the local M.D., who
didn�t always treat them with any type of respect. So the original company and
these centers sprung up throughout the country in response to that. This group,
which we now call the Keystone Group, came together through our original
association with the original Omni centers.
"When that entity broke up, we still wanted
to get together. So we first met about 10 or 11 years ago in Keystone, Colo.,
for our first meeting. Now, we meet twice a year to discuss clinical and
Robert Pinkert, O.D., who�s part of a
multi-doctor practice in Phoenix, agreed. "We share common challenges and
it�s good to meet with people in similar situations to find out how they�ve
solved the problem with O.D./ M.D. relationships," he offered.
Omni Eye Services of Atlanta Center Director,
Paul Ajamian, O.D., said, "This group of O.D.s got together and decided
that a center should be run by O.D.s who work with M.D.s who are only interested
in doing what they were trained to do, and that�s the surgical
Daryl Mann, O.D., of Chattanooga, started the
optometric co-management consultative center Southeast Eye Specialists in 1999
with his partner. He�s also the past president of the Tennessee Optometric
Association. "I think the principle that we started back in 1980 is still
in play today, and some of our practices are still very much exclusive to
optometry referrals. They�re not patient referrals or direct access."
Said Dennis Mathews, O.D., founder of Omni Eye
Services of Memphis and part-time associate professor at the Southern College of
Optometry, "This general concept of when we all began is still alive after
20 years. I like to think that we had some input in passing many of the laws
throughout the country that have helped expand the clinical privilege of
Past owner of Omni Eye Services in Miami, Steve
Holbrook, O.D., is now in a multi-specialty group practice, The Eye Center of
Southern Indiana in Bloomington. "When the centers first started out, it
was really the first time that O.D.s had direct involvement in patient care
post-operatively. And that raised the bar overnight because the O.D.s�
expectations of the surgical outcome made the surgeon perform at a higher
level," he explained.
"And this is one of the things I think that
drove the quality and the outcomes that we see now. It was a key and a
fundamental change in what was acceptable versus what could be achieved. And
what could be achieved started changing, which is one of the reasons why these
centers have flourished � because the outcomes at the time were better than
anything else out there."
Why is co-management so important?
While we�re devoting this whole article to the
topic of co-management, it makes sense to ask the basic question of why it�s
so important to optometry.
Dr. Ajamian responded, "I think the reasons
today are the same as those 20 years ago. Optometry was left out of the loop;
O.D.s had long-standing patients and families of patients but because of the
laws at that time, when the O.D. sent out a patient for a red eye or a cataract,
it was rare for the M.D. to ever send back the patient." He continued,
"Even rarer was for the O.D. and patient to get a letter and for the
patient to gain some kind of educational experience from the referral."
Dr. Mann offered his response, "I think the
thing that�s really important here is patient care. We�ve brought optometry
and ophthalmology together, and in doing so, the quality of patient care has
been elevated in many areas throughout the country."
Next, Dr. Gailmard asked the doctors how they
felt about the current status of co-management between private O.D.s and M.D.s
who don�t have a nearby referral center. "Is that still another type of
co-management today?" he asked.
Dr. Ajamian began, "Not everybody in every
city and small town could have a co-management center." He
continued,"It�s just not practical. But I think our concept spread rather
rapidly around the country to the point where individual M.D.s saw that if they
wanted to enhance their practice, that working with optometry made sense."
He went on to state that he firmly believes that the Omni Centers were a model
for ophthalmology to follow in how to interact with O.D.s and that they still
are a model today in some cases.
Robert Vandervort, O.D., center director of the
Omaha Eye Institute and in practice at a co-management center, revealed a
different sentiment. "In terms of impacting Midwest and rural practices,
our model has been copied to a degree," he said.
"But, the farther away you get from a true
co-management center or an entrepreneurial M.D., the less cooperation you see
from the M.D.s in that rural area. It�s still not where it needs to be,"
Dr. Vandervort concluded.
Jim Powers, O.D., from Fairfax, Va., practices at
Capital Eye Consultants. Regarding O.D. and M.D. relationships in co-management,
he said, "The economic force behind the early co-management practices was
really cataract surgery."
LASIK co-management is today�s high-profit
center, said Dr. Powers. "O.D.s provide a vital role in patient education
and pre-op and post-op care for which we deserve fair compensation.
"You see many surgeons copying what they saw
a decade ago in the co-management model for cataract surgery, but with a twist
because they�re also doing direct advertising," he said.
Interjecting another point, Dr. Ajamian said,
"We have great relationships between individual O.D.s and M.D.s, and yet
terrible relationships still exist. Ophthalmologists who take an active role in
fighting scope expansion make the profession feel like it did 20 or 30 years
O.D. surgery in the future?
"At what point will O.D.s perform
surgery?" asked Dr. Gailmard. "Do you think that�s the best
direction in which the profession should move?" Here�s what these O.D.s
had to say about this delicate topic and about the future of laser vision
"I think O.D.s are already performing
surgery," said Dr. Mathews. "In Tennessee, our law allows surgery
under specific guidelines. But no one�s doing cataract surgery at this
Brian Den Beste, O.D., private practitioner in
Orlando at Laser View, stepped in with his comments. "LASIK is a complex
operation. I think that the only way you get good at the procedure is if you do
a lot of it, and not many private practitioners are going to have the ability to
do a lot of it. It�s a wonderful procedure and it has a lot to offer, but it
doesn�t take much to get a bad outcome either."
Dr. Mathews added, "O.D.s have been
performing laser procedures [PRK, not LASIK] in Oklahoma for a long time and
with good outcomes. I think it�ll develop in other states, too."
Said Dr. Pinkert, "Probably all the eye
surgery that�s performed in this country could be done by 3,500 M.D.s �
maybe 2,000 cataract surgeons, 1,000 retina guys and 500 glaucoma guys. The rest
of the M.D.s would provide primary medical eye care or primary eye care. So in
some ways, it�s counterintuitive to try and spread that surgical
responsibility. Certainly, there�s no doubt that O.D.s are capable of this,
but does it really make sense from a manpower standpoint?"
On the topic of optometry and surgery, Dr. Quinn
said, "I think O.D.s should be able to do what they�re trained to do. The
biggest hurdles we face are the artificial restrictions placed on us. It�s a
completely arbitrary decision to say that because you�re an O.D. you can�t
learn how to do a type of surgical procedure."
Dr. Quinn said he doesn�t see why surgery
wouldn�t appear in optometry school curricula. "In some schools, it�s
The joint position on co-management
As you may remember from February 2000, the
American Academy of Ophthalmology (AAO) and the American Society of Cataract and
Refractive Surgery (ASCRS) released a joint position paper, "Ophthalmic
Post-operative Care," which contains guidelines for co-managing ophthalmic
surgical patients. The paper has a disclaimer stating that the guidelines are
voluntary, but it states, "Although [postoperative care] may be ethically
ceded to another healthcare provider, it is anticipated that this will be an
exceptional, rather than a routine, occurrence." Suitable reasons for
co-management include surgeon unavailability because of illness, travel, leave,
etc., and patient inability to travel to the surgeon�s office.
Dr. Gailmard asked the group if they�d observed
any impact from the co-management position paper.
"I think a lot of the paper alludes to
patient choice," said Ed Wasloski, O.D., of Baltimore. "And a lot of
it�s about not understanding what we do to make sure patients are
well-informed. Nothing really changed. I think it was a good thing for
co-management because it reaffirms and enhances the communications."
Dr. Ajamian added, "I think the AAO�s
paper raised a significant red flag because I�ve spoken to colleagues who
think that they can treat what they want in their primary care practice and send
out patients whose cases they can�t handle to the ophthalmologist. But the
M.D.s aren�t going to send back those patients without a co-management center
there. And most of them have primary care practices of their own anyway. So some
of our colleagues think that with the success we�ve had on the TPA front, we
really don�t need the co-management situation. I think these centers that are
optometrically managed and driven are critical."
Howell Findley, O.D., is in group practice in
Lexington, Ky. He says he hasn�t seen any affect on his practice from the
joint position paper. "I think part of that is because we do true
co-management, which includes patient education, patient choice and a high level
of communication between surgeon and the co-managing doctor," he explained.
"I�ve heard some ophthalmologists say,
�Well, now we can�t co-manage� because of the paper. I think they just
used the paper as an excuse to cut out co-management when they never really
practiced it in the first place."
In Dr. Mathews� opinion, the regulations
relative to the position paper are pretty clear. "Number one, O.D.s
aren�t doing anything they�re not licensed to do. Number two, the patient
makes the choice of who does his post-op. As long as we�re doing it that way,
I don�t see problems. These guidelines are designed to make sure no illegal
financial relationships exist."
Dr. Mann thought the paper raised more questions
than anything. "The AAO�s paper probably confused a lot of its member-
ship because the code of ethics of the AAO specifically talks about working with
O.D.s and co-managing patients. The Federal Register uses that as an example of
ophthalmology and optometry working together to care for patients. It�s just a
On a more serious note, Dr. Quinn said,
"It�s important for optometry to realize that one of the significant
impacts of the position paper has been to give political ophthalmology some
momentum in trying to restrict co-management both through Medicare carriers and
through state legislative efforts in which they cite this position paper for
reasons why co-management isn�t a good thing."
Dr. Holbrook asserted, "If you revert back
to a time when there wasn�t a model for co-management, quality of care was
affected. With co-management, we�ll continue to raise standards of care."
Dr. Vandervort offered his view. "It all
gets down to the dichotomy between M.D.s who are willing to work with optometry
and recognize that O.D.s are well-trained and conservative in what they
do." He proposed that some people are just going to look for excuses to
stop the co-managing relationship.
Pre-op: How much and whose responsibility?
"In a perfect world, what level of pre-op
testing should the referring O.D. be involved in? Do you find that M.D.s redo
these tests anyway, even if the O.D. performed them and sent them in?"
asked Dr. Gailmard of the group.
"A couple of the O.D.s in our area have
their own topographers and one has a pachym-eter," responded Dr. Findley.
"They use them mainly for screening and when
the patient comes in to see us for a LASIK evaluation, we use the Orbscan II
diagnostic system to re-evaluate the patient." He said he�s not sure
it�s in an O.D.�s best interest or worth the time and financial investment
to have this expensive instrument in his office."
Dr. Holbrook has seen a dip in activity here.
"Back in the early 1990s there was a little bit of a push where O.D.s were
starting to do a little more in-office A-scans and so forth. And that
disappeared. There�s an art to it and it�s volume-dependent."
Dr. Pinkert had a different viewpoint. "We
have several surgery centers in rural areas around Arizona where our surgeons
travel to O.D.s� offices and perform surgery either in that facility or one in
town. Those O.D.s have done volumes of A-scans," he remarked. "Our
surgeons regularly use the O.D.s� A-scans. Technically, it�s not a difficult
test with experience."
Dr. Vandervort agreed with Dr. Pinkert�s view
"When it comes to pachyme-try and
topography," he said, "it would be nice if optometry got more
involved. It�s simple and can be easily done with minimal training."
Dr. Den Beste remarked, "It goes back to
patient choice. We screen patients pretty carefully, and ask who their eye
doctor is. In most cases, if we work with their O.D. and are comfortable with
that O.D.�s co-management skills, then we tell the patient that his primary
care eye doctor is perfect for providing pre-op and post-op care � and that
it�s more convenient for the patient.
"Ultimately, the patient decides if he wants
to be co-managed. If not, then our center performs his pre- and post-op care.
Patients should have a lot of input; they�re in control."
Dr. Holbrook offered his thoughts, "We have
some primary entry into our practice at this point, and when a patient contacts
us about LASIK we always ask who her O.D. is. If she feels more comfortable
dealing with us post-op, we take care of her. But the majority of patients
travel back to their current O.D. post-op."
Dr. Powers stated that the real problem with this
for the co-management centers is that LASIK is a primary care entry procedure.
"LASIK has potential to tear apart co-management centers. In our market,
we�ve had success by being referral-only for LASIK. And we make the best
effort we can to send those patients back to the referring doctor."
Still ground to cover
The testimonies of these O.D. experts� comments
are evidence that co-management has covered much ground. And from an O.D.�s
standpoint, it�s headed in the right direction, despite some minor legislative
bumps. Just think of what the co-management climate will be like 20 years from
now! Could O.D.s and M.D.s possibly co-manage in harmony in the future? Only
time will tell.
Optometric Management, Issue: September 2001