Ethical Comanagement: an Oxymoron

As you peruse this edition of Cataract & Refractive Surgery Today and evaluate the responses and opinions of the AAO leadership and individual ophthalmologists and optometrists with respect to optometric surgical initiatives, the Oklahoma legislation, and the Department of Veterans Affairs (VA) situation, it becomes immediately apparent that optometry is changing from an allied health profession to a group that will soon be listing itself in a newly created section of the Yellow Pages, called Optometric Physicians and Surgeons.

You may also notice a curious term, ethical comanagement. Like the term comanagement, I fear that ethical comanagement may become cleverly woven into the literature as a way to legitimize the behavior of individuals who choose to skirt the guidelines established by the American College of Surgeons, AAO, ASCRS, and Association of University of Professors of Ophthalmology.

COMANAGEMENT

Abandoning Postoperative Care
During the several years leading up to the AAO/ASCRS Comanagement policy's creation in 2000, the Council of the AAO repeatedly requested that the Board of Trustees address the issue that was plaguing state leadership: comanagement's erosion of the underpinnings of ophthalmic care. Ophthalmologists were abdicating postoperative care for future referrals and avoiding political advocacy as an associated phenomenon.

The AAO's Board of Trustees responded, and a nonbinding voluntary policy became a reality. The federal government, likewise, became concerned about the risks of financially induced kickbacks and established, through Stark Legislation (42 USCA 1395 NN and proposed 42 CFR 411 et seq.) and the Federal Fraud Abuse/Anti-Kickback Statutes (42 USCA 1320 A-7B), its definition of what it felt to be “high-risk behavior” and that “anything in cash or kind as an inducement to refer” is fraud. Intuitively, ophthalmologists knew that the agreement not to execute postoperative care themselves was “the inducement to refer” (as long as it is unspoken, the coercion is unproven). Numerous articles appeared in the ophthalmic literature, including titles such as “Comanagement Is Really No Management,”1 “Comanagement, a Word Used to Hide Collusion,”2 “Comanagement or Coercion,”3 and a thorough and exhaustive treatise by the Chairman of the AAO's Ethics Committee, Samuel Packer, MD, entitled “Ethics of Comanagement.”4

Who Takes Care of Whom and When?
The Centers for Medicare & Medicaid Services wrestled with establishing a uniform policy for the transfer of care. One of the most carefully written was the Kansas/Nebraska/Missouri Medicare Carriers payment policy for preoperative management, which states, “Transfer of global surgical care will be allowed only to protect the legitimate interests of the beneficiaries in the following circumstances.” Legitimate indications were stated in the policy with no wiggle room. The term patient choice never appeared in the policy. Patrick Price, MD, from Kansas City, Missouri, author of the policy then restated the American College of Surgeons' position in Principles of Perioperative Responsibilities. It is based on and extracted from the AAO's ethics policy, which asserts that the patient's welfare and rights are placed above all other considerations.

No one has stated the issue more eloquently than one of the senior authors of the AAO comanagement position paper,5 Paul Orloff, MD, in his presentation to the Council following the unveiling of the policy at the Mid-Year Forum in 2000. Dr. Orloff said, “I have never had a patient say to me, ‘Dr. Orloff, you are a great surgeon, and I really like you, but after you do the surgery, I want to be taken care of by someone who is maybe a little less trained and [has] a little less experience, and I'd like to pay them a lot of money.' ”

Are we to believe that all of us can establish our own rules for the transfer of care for what we think is ethical? Is “I've trained the optometrist, so I feel comfortable with his skill level” an acceptable defense for ethical comanagement? Who will judge whether an optometrist is adequately trained to handle the postoperative course? Sadly, the public has no idea that there is no uniform standard for this homemade observation, for we all know that, if there is any true management, it will be performed by the surgeons.

ODs IN THE va SYSTEM
The Executive Vice President of the American Board of Medical Specialties, Stephen H. Miller, MD, MPh, recently wrote a comprehensive letter6 to the Under Secretary for Health Policy Coordination at the VA that referred to the optometric privileging there. It stated, “The Veterans Hospital Affairs directive is confusing, potentially initiates a two-tier system of eye care and may jeopardize the safety of patients undergoing laser surgery within the Veterans Hospital Affairs system. This was not an issue of professional turf, but an issue related to standards of educations, training, and quality of care provided by health professionals to patients.” He further stated, “following completion of this training [ophthalmology residency], a candidate desiring to be a board certified ophthalmologist will be evaluated by an independent American Board of Medical Specialties member board according to generally accepted peer-reviewed standards and criteria. Thus, when an ophthalmologist performs laser eye surgery, the patient is assured that the person performing the surgery is not only technically capable of performing the procedure, but is also capable of judging which patients are appropriate candidates for the surgery [preoperative care], which patients have medical conditions that might contraindicate the surgery and is capable of independently dealing with any complications that may result from the surgery. Unless optometrists have undergone similar training and peer-reviewed evaluation, the patient cannot have the same assurance.” The point is the surgeon's job is the surgeon's job, only to be abdicated in unusual situations and only when it is clinically appropriate and in the patient's best interest.

CONCLUSION
Why all the hubbub about comanagement now? If you listen to legislators who are sponsoring optometric surgical scope bills (which include laser surgery, incisional surgery, narcotics, oral medicines, and parenteral routes of administration), surgery is a natural evolution, considering the flagrant and cavalier transfer of pre- and postoperative care, also known as comanagement, to optometrists.

If you have to rationalize ethical decisions, they are probably unethical. As Michel de Montaigne said, “Easily doth the world deceive itself, in things it desireth or fain would have come to pass.”

Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533; rclanciano@comcast.net.
1. Weingeist T. How Comanagement Is Really no Management. EyeNet. 2000;4:1:11-12.
2. Spaeth GL. “Comanagement”: a word used to hide collusion. Ophthalmic Surg Lasers. 1997;28:449-51.
3. Hoskins HD. Comanagement: Does the “Co:” Stand for “Cooperation” or “Coercion”? EyeNet. 1999;3:8:14-15.
4. Packer S, Lynch J. Ethics of comanagement. Arch Ophthalmol. 2002;120(suppl 1):71-76.
5. Orloff P. AAO/ASCRS Joint Guidelines. Paper presented at: The AAO Mid-Year Forum; April 18, 2000; Chicago, IL.
6. Quoted from letter dated September 7, 2004, to Frances M. Murphy, MD, MPH, Deputy Under Secretary for Health for Health Policy Coordination, Department of Veteran Affairs, 810 Vermont Avenue NW (10H), Washington, DC 20420.