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Up Front: Chief Medical Editor's Page | Nov/Dec 2019

The Comanagement Debate

Comanagement between ophthalmologists and optometrists continues to be a hot area of debate and discussion. Major organizations such as the AAO and ASCRS have been relatively unsupportive of the comanagement process and have certainly not been proactive in protecting ophthalmologists who practice comanagement and collaborative care in the event of scrutiny, audits, or investigations. The overly litigious and broken legal system jeopardizes a doctor’s ability to care for patients in the best way possible with policies such as the whistleblower policy in place. Some of the draconian rules of Medicare and CMS actually get in the way of quality care.

Ophthalmologists and optometrists who practice collaborative or comanagement care, especially in cataract and refractive surgery, know very well that the patient comes first. Educating optometrists in how to manage cataract and refractive surgery patients is crucial to the success of these models, and many practices do this to ensure the seamless hand-off of patients’ surgical care in the postoperative period. Elaborate infrastructures for communication between the two providers must be established to ensure everyone is on the same page as to how a patient is doing.

Busy practitioners know that it is nearly impossible to continue to see their surgical patients year after year for routine examinations. It is impractical, and it keeps surgeons from operating at the peak of their skill set. At the same time, patients know their optometrist very well, and their optometrist knows them very well. Optometrists often understand their patients’ needs much better than the surgeon would after seeing them for just one visit and a surgical consultation.

The team approach to patient care, in many of our current situations, is better than the surgeon trying to do it all by him or herself. Processes are in place to ensure that the patient is fully informed of the opportunities for comanagement or for continuing their care with the primary surgeon only. If anything, the primary surgeon actually loses money by entering into a comanagement partnership, and it is inaccurate and often a misrepresentation to claim that doctors who comanage are doing so for financial incentives.

Unfortunately, there will always be those few people who ruin things for the rest of us by taking advantage of situations and opportunities. As a result, there have been increased government investigations and whistleblower cases regarding comanagement. Certain state ophthalmology societies tend to alienate doctors who comanage and are notoriously anti-optometry, which is unfair to the surgeons in those particular states who find comanagement an important part of delivering high-quality care to patients. This is especially true in rural areas, where patients have to travel long distances to see an ophthalmologist at a surgical facility; it is not in the patient’s best interest, nor is it practical, for them to be forced to receive their postoperative care with that ophthalmologist.

It would be a step in the right direction for some of the states’ societies, along with the AAO and ASCRS, to generate protective language regarding comanagement and to offer better protection for those doctors who do practice comanagement. We should all understand that, with a growing number of baby boomers and the explosion of the population over the age of 60, surgeons alone cannot take care of the amount of cataract patients who require care in the pre- and postoperative setting. We need the help of our trained colleagues, and we need teamwork in the community.

Robert J. Weinstock, MD | Chief Medical Editor

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