Article Date: 9/1/2001

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 the document.

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 political topics."

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 specialty."

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 optometry."

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."

O.D./M.D. relationships

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 ago."

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 correction.

"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 point."

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 already there."

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."

Making excuses

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."

Causing confusion

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 position paper."

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 on A-scans.

"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