THE COMANAGEMENT CONTROVERSY CONTINUES

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by Lisa B. Samalonis Contributing Editor

Two major issues arise with comanagement, one involving the surgeon and the other involving patient consent, said Priscilla E. Perry, MD, associate clinical professor at Louisiana State University School of Medicine, Shreveport. She helped draft the American Society of Cataract and Refractive Surgery's position paper on comanagement that was released last year.

"Under comanagement, there is an inherently increased burden of responsibility in a situation in which a surgeon delegates the postoperative care and decision making for a patient to another caregiver. That burden is increased if the caregiver does not have the same level of training or knowledge as the surgeon ...," said Perry, who is also ASCRS' primary delegate to the American Medical Associations.

In addition, it is necessary that the patient understand and agree to the transfer of care, and that the patient be aware of the comanager's level of expertise and training, she said.

Leon D. Solomon, MD, associate professor, McGill University, in practice in Montreal, said that optometric comanagement and "assembly-line" laser in-situ keratomileusis practiced by large corporate centers are dangerous.

Solomon, who spoke at ASCRS, said patients have to be aware that comanagement is occurring and that a fee will be paid to each individual. "Essentially, it is health professionals getting together in association to better serve a population they already serve, and they're performing only their own specialties ...," he said.

In this situation, the optometrist typically finds the patients and presents the goals, problems, limitations, risks, and costs of refractive surgery, he said. The optometrist also does the preoperative medical and psychological assessment and refers to the ophthalmologist. The ophthalmologist repeats the medical and psychological assessment, explains the surgical technique, the goals, and the limitations, and then makes the final decision about refractive surgery. "The final decision must rest with the ophthalmologist, in spite of what the optometrist wants," Solomon said.

In the optometric comanagement situation, the ophthalmologist does the surgery and provides the first 24-hour postoperative care (longer if there are complications).

Then the optometrist takes over, prescribes any glasses for residual needs, and maintains contact with the ophthalmologist so he or she can address any questions or offer comments.

"Each of them maintains a complete record and a periodic chart review, and they do their continuing medical education," he said.

Solomon referred to the second type of comanagement as assembly-line LASIK, where often a public corporation is selling a product. "Surgery is the commodity and the medical doctor has very little to say in the business plan, and the business plan is what drives the corporation. This is a business; this is not a practice of medicine ...," he said.

This type of LASIK service can be impersonal, because the doctor is hired and big promotions and low costs attract the patients. Patients may travel long distances to get the lowest refractive surgery price and then must return to the center or pay extra for more local care. A lifetime guarantee of enhancements may be offered; however, several companies have already gone bankrupt. Also, surgeons often work at multiple locations at per-diem rates, so they may be overworked and underpaid, he said.

Partnering with optometrists

Jeffrey J. Machat, MD, national medical director, TLC Laser Eye Centers, Toronto, said that optometry's role in educating patients is going to increase dramatically in the next 5 years, because more patients are going to have refractive surgery. In addition, there will be more refractive options, more technologies, and more price confusion.

"Seventy percent of the patients who are good candidates for refractive surgery fall within an optometric practice. Optometrists are trusted by their patients, and they are the ones who actually present the vision care options to their patients," he said.

Optometrists can identify good candidates and educate patients about refractive surgery, not during one visit or two visits, but over years, Machat said.

In addition, optometry provides a vital link for most patients in high-volume practices. Under comanagement, Machat receives candidates who are well-educated about the procedure and who understand the risks. "I get to perform more surgery, have more time for research, more time to help complex or difficult cases," he said.

Machat acknowledged that low-priced corporate centers have not stood the test of time. "High-quality patient experience is what I have seen working with optometry and that always stands the test of time," he said. "People are now looking, not just for value, but for confidence and reassurance, and they are going back to their optometrists. We have seen a huge resurgence, just in the past few months in Canada." Machat noted that patients are also responding favorably to new technologies, such as wavefront-guided LASIK.

 

? Does the patient understand who will be delivering care and know their qualifications?

? Does the patient give consent? Would the patient choose this course of action voluntarily?

? Is the postoperative status stable?

? Does the comanager possess the expertise and the legal license to care for this patient?

? Is there a reason comanagement is necessary or desirable?