November 2013

 

NEWS & OPINION

 

Ethical dimensions of co-management


 

John Banja, PhD Bridget Sundell, MD

Richard Lindstrom, MD

 

An interview with Bridget Sundell, MD, and Richard Lindstrom, MD

John Banja, PhD, professor and medical ethicist at Emory University, Atlanta, interviewed ophthalmologists Bridget Sundell, MD, and Richard Lindstrom, MD, on the sometimes-controversial issue of co-management. Dr. Sundell is the founder of Sundell Eye Associates, Virginia, Minn. Dr. Lindstrom is the founder and attending surgeon of Minnesota Eye Consultants.

Dr. Banja: “Co-management” is sometimes characterized as an independent optometrist seeing a patient preoperatively and then providing that patient’s postoperative care. The principal ethical (and legal) worry that attaches to it is that co-management can become an “I’ll scratch your back if you scratch mine” referral arrangement between optometrists and ophthalmologists. On the other hand, and in many practices, co-management is extremely familiar if not inevitable. What’s your present-day experience with co-management? Do you see a good deal of it?

Dr. Sundell: Presently, I co-manage a lot of cataract surgery patients. Co-management relationships were already in place when I joined the practice, so I have basically continued what was already established. Up until recently, I did surgery at two smaller hospitals, one two hours away from my main office and one an hour away from my main office. In these two areas, I co-manage about 50% of my surgeries with local ODs. Many of these patients are very elderly and economically challenged so being able to have their surgery and postoperative care close to home is ideal. Many of these patients would not otherwise be willing to have surgery due to transportation barriers.

Dr. Lindstrom: At Minnesota Eye Consultants we co-manage several thousand surgical patients every year with more than 400 referring ophthalmologists and another 400 or so referring optometrists. Some are local while others practice as far away as the Middle East and India. Although we always do what we believe is in the patient’s best interests, we’re significantly influenced by the patient’s personal desires, as that is to me the basis of patient-centered care. I have had anxious patients return weekly from 1,000 miles away for every postoperative visit, in spite of my suggesting that their local referring doctor could provide appropriate care. And I have had others who strongly desire to return to their referring doctor for postoperative care even though I’m only 10 miles from their home.

Dr. Banja: Do you have any formal, written agreements with referring optometrists?

Dr. Sundell: No, and in the rare event that a patient has a complication, I do not allow ODs to co-manage them. These are special circumstances, and I send a letter or call the referring OD and explain the situation. Most of them do not want to co-manage any type of complex surgical patient and are grateful to be relieved of this responsibility. In the recent past, as I have started using the Crystalens (Bausch + Lomb, Rochester, N.Y.), I have told the referring ODs and the patient that they will not be co-managed. These patients will require more attention, a suture removal, and careful gathering of postoperative refractive data to maximize their use and my learning curve early on. I have not had one OD or patient have a problem with this so far. If they object, I can always refer them to someone else.   

Dr. Lindstrom: I will not have a written or implied contractual agreement with optometrists. The optometrist is free to send any patient to me or to any other consultative ophthalmologist of his/her choice. Once the patient’s care is transferred to me, I will care for the patient as the patient’s care plan dictates, but also as the patient desires. I firmly believe that care should be patient-centered, and if the patient wants to come back to me, that is his or her choice. This is a rare situation, and when it occurs, tactful communication with the referring doctor is required. But I believe it remains a patient’s right in most health plans to choose his or her caregiver, and in my opinion the highest quality patient-centered care requires patient choice regarding the doctor and the clinic.

Dr. Banja: In cataract cases, do you feel that liability issues will generally rest with the surgeon?

Dr. Lindstrom: Any healthcare professional must do what is in the patient’s best interest, so if patients need to return to see me, I am firm in requiring that they do so. If they strongly desire to see the referring doctor for a routine postoperative visit and I am comfortable that the referring doctor has the training and skills to perform that task, I honor the request. We never promise a referring doctor that we will routinely return any surgical patient at any specific postoperative visit or even for any of the postoperative visits. If the patient wants us to do all the postoperative care, we do it, including optical correction. Once we discharge the patient to the referring doctor, we communicate that and expect the referring doctor to provide the care and bill for it.

Dr. Sundell: I feel I’m ultimately responsible for what happens to patients and that I must be available to them during the global period and beyond. I just don’t get paid for it. Of course, when the referring OD “isn’t available” to a co-managed patient, he or she calls me and I end up seeing the patient at no charge. A lot of private OD practices are closed on Fridays and weekends so, in my opinion, they shouldn’t be co-managing surgery patients if they aren’t available at all times.  

Dr. Banja: When an optometrist sends you a patient for surgery and requests that he or she co-manage the case, what do you do?

Dr. Sundell: If an OD sends a patient to me for surgery for the first time requesting to co-manage the patient, I have a packet that I send with what I require. This includes the OMIC (Ophthalmic Mutual Insurance Company) consent form* and my standard preoperative and postoperative management guidelines with drops and visit schedule. That at least gives the OD some idea of how I manage surgical patients. There are no written agreements between me and referring ODs. 

In the rare event that a patient has a complication, I do not allow ODs to co-manage them.  

Dr. Lindstrom: Once the patient’s care is transferred to me, I will care for the patient as the patient’s care plan dictates and as the patient desires. I have some patients who never return to the referring doctor for one reason or another, and in some cases it is simply a patient preference issue. I strongly believe in the patient being involved in all decision making including who provides what care and where. The compensation issue to me is straightforward: The individual who does the work should get paid an appropriate fee for his or her efforts. We can argue about the fairness of our compensation system in the U.S., and whether an inexperienced ophthalmologist should be paid the same for a unit of work, such as a postop visit, as an experienced ophthalmologist, and of course, whether an optometrist should be paid the same as an ophthalmologist. But state and federal laws, regulations, and licensing boards are where these standards are set, and they are usually set in stone regardless of how any of us individually feels about their fairness.

Dr. Sundell: Patient-centeredness and transparency are central in any co-managing I do. Patients definitely have a right to choose who provides their care. And if you are not truthful with them, they will eventually find out. I think it is better for them to have a clear understanding of any co-management arrangement before surgery.

Dr. Banja: You mentioned that you like to use the OMIC consent form with patients.

Dr. Sundell: Yes. I ask that the referring ODs have patients sign a consent form that states they have chosen to have their postoperative care with their referring OD, and they have to list a reason. This is usually stated as due to travel distance. I always refer to that form when I consent patients for surgery and make sure that they are comfortable going back to their referring OD. The OMIC consent form has been helpful to me to make the co-management arrangement more transparent, and it clearly states that patients are free to call me, the operating surgeon, for any problems or questions, even if they choose to return to the co-managing OD.  

Dr. Banja: Any final thoughts?

Dr. Lindstrom: In my practice, patient-centered co-management of surgical patients occurs on a daily basis with both referring optometrists and ophthalmologists. In fact, I might not have a single patient who I do not cooperatively co-manage with several other caregivers. Our co-management must be patient-centered and transparent, however, and the doctor who does the work should get paid for the work.

Dr. Sundell: So often when this topic comes up, I hear providers agonizing about feeling trapped if they don’t co-manage patients with ODs because then they won’t get the referrals. I have to admit that I’m fortunate to live in a more remote area. There aren’t as many ophthalmologists in my geographical area as opposed to very saturated markets like California. Nevertheless, while it can be a real challenge to remain ethical in many co-management type situations, failing to do so can be very problematic.

*The OMIC consent form is available online at www.omic.com/comanagement-after-eye-surgery.

Contact information

Banja: jbanja@emory.edu
Lindstrom: rllindstrom@mneye.com
Sundell: bsundell@sundelleye.com

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