The Lone Dog: Co-Management in Laser Vision Correction

Note: for Brits, the situation is not quite the same. The LD has yet to figure out what exactly a British optician (as opposed to an American optometrist) does and doesn't do.

How do optometrists make a living? They (1) charge professional fees when they provide general eye care to the vast majority of the public, (2) sell glasses, and (3) sell contact lenses. It is economically impractical for ophthalmologists to provide general eye care to the populace at large, because an ophthalmologist represents a societal investment in the care of serious eye disease and the production of eye surgery, not eye glasses or annual eye health exams. Optometrists are ideally situated to identify older people who need cataract surgery, and younger people who want laser vision correction (LVC). The cataract connection is what first started co-management.

Cataract surgery underwent some serious and valuable innovation in the late 1980s and through much of the 1990s. Besides the admirable professional desire to make a good thing better, Medicare in the USA paid really well for cataract surgery for quite a while, so ophthalmologists could suddenly afford $100,000 microscopes. Nature hates a vacuum, thus the manufacturers of microscopes and other increasingly sophisticated equipment for cataract surgery stepped right into the void. Over time additional pressures emerged. First, as cataract surgery became increasingly reliable and problem-free, some ophthalmologists decided they were wasting their professional time doing uncomplicated post-operative care when they could be in the operating room actually operating. They began to sub-contract post-op care to optometrists, and what simpler or more agreeable arrangement than to send the patient back to the optometrist who sent the patient to you originally? Second, Medicare gradually began reducing its payment for cataract surgery, so that meeting the bottom line for high-dollar, high-volume cataract surgeons pretty much required that they sub out post-op care and spend all their time in the operating theatre.

Since Sam the Optom couldn't be expected to do this work for free, initially "referral" or "finder" fees of various sorts came into existence. The legislation on the legality of this type of incentive was murky for awhile, but eventually some pretty clear, and strong, anti-kickback legislation came into being. Being clever folk, MDs and optoms used Medicare's own fee structure to negotiate the crevasse. Payment for surgical procedures is divided into what you get for your time and effort in the OR, and what you get for care during the "global" period after surgery, which is 90 days for cataract surgery. So it was possible to simply slice the piece of pie one more time, have each provider bill separately and legally (MD = surgery, optom = global period care), and everyone enjoyed the weekend.

Why did this fly? First, a lot of it was under the radar of government payers and various professional licensing bodies for a long time. Second, ask 100 people the difference between an ophthalmologist and an optometrist and 99 of them won't know. Granny is very unlikely to be the one soul who does know. So patients were not concerned about receiving care right after surgery from someone other than a surgeon, because they didn't really understand it was happening. Patient "convenience" was often cited as a legitimizing reason. This is a legit reason if Granny lives 200 miles from an ophthalmologist and 10 minutes from her family optometrist, and the optometrist is (1) qualified to recognize an uncomplicated post-operative course and manage it appropriately, and (2) qualified to recognize complications or impending complications and get Granny back in the car to the surgeon pronto.

Eventually the Medicare payment for cataract became so paltry that the pie piece was almost too small to slice, unless the ophthalmologist was a high-volume guy, operating on "easy" cases, and generating patient after patient with good outcomes requiring very little post-operative care. Right about the same time, LVC began to climb the hill of respectability, reliability, and uncomplicated post-operative healing. Are you following the scent? However, it is not quite a no-brainer, because there is a funny balance of pros and cons to LVC for optometrists.

Your ordinary nearsighted person will come in annually for an exam and a new pair of glasses and/or contact lenses. This might go on for 20-30 years. Although Wal-Mart and the Web have driven down the markup on contacts recently, the markup on better quality frames and lenses is still astronomical. Over five years, an optometrist with an upscale clientele could net an easy $1000 from one patient who gets one pair of new glasses annually. So if he is going to refer that person for LVC, there is a reasonable likelihood that the $1000 goes poof. How does an optometrist turn LVC to his advantage? Since the LVC slice of pie is still good-sized (although dwindling thanks to Canada), of course he gets part of that slice. If he does the recruitment and post-op care, he may get the part with the whipped cream on it. He may or may not net $1000 or more per patient, but the difference is that this is captured money that he has now, not something that will come in over 5 years depending on the eyewear shopping whims of Lou Schmo. Also, the population of nearsighted adults is continually replenished from below by school kids, so there is no real end to the business. Best of all, since this is a cash service, the optometrist and the ophthalmologist can make any arrangements they want over payment without interference from the suits at the Office of the Inspector General.

So now you know how the RSI and co-management met, danced, and married. Since you are concerned primarily about yourself, your corneas, your vision, your GASH potential, etc., it's time for the LD to reframe co-management in terms you, Lou, can use to make decisions. The questions are basic.

If one or both parties to your LVC screw up, you and your lawyer will quickly discover that the professional relationship between them is nearly incomprehensible. There is little case law yet as to who catches what share of the blame when an intensely co-managed case goes wrong. By "intensely" I mean that the optometrist recruited you, screened you, performed the pre-operative assessment, gave the bulk of the informed consent, and did most or all of the post-op care. You probably did not meet Joe Surgeon before the day of surgery, or if you did it was on one previous occasion only. Joe examined you immediately after the surgery (primarily to be sure your LASIK flap wasn't dangling), but possibly not even one more time after that. He may or may not have repeated any of the necessary testing.

So if your pre-op measurements (prescription, pupil size, corneal thickness, tear production) are wrong and that leads to a bad outcome, who ya gonna sue? [Translation for Brits: from whom might you seek legal recompense?] Should the surgeon have rechecked? What if he did and he's wrong too?

If you are fine 10 minutes after surgery, but two days later get infection or inflammation that your optometrist attempts to treat on his own with a bad outcome, who ya gonna sue?

The LD doesn't know the answer to these questions. They can only be answered (in the USA, anyway) by repeated experimentation in medical malpractice trials. But in the meanwhile, he can wax philosophical.

What might we deduce about ophthalmologists who co-manage intensively? First, they don't really know you and don't care to. Second, they are generally in it for the money, because if there are any legitimate professional reasons not to personally provide a decent level of pre-op and post-op treatment, the LD isn't aware of them. I'm not saying every single visit, especially if you and Joe live 3 hours apart. But Joe should care enough about you as a human to want to do the right thing (pre-op assessment), and to want to know that you are doing well afterwards (post-op care). Modern LVC is indeed quite reliable and uncomplicated for the majority of people who undergo the procedure, and if you are flying high and telling the world about it 10 days after surgery, in your case it may be entirely reasonable to have your straightforward post-operative care with Sam the Optom. If you agree to an intensive co-management arrangement which reduces the ophthalmologist to the level of a flap-and-zap LVC-technician, that's your business. If things are going wrong and you call Joe's office, don't be surprised to be told to call Sam instead. If you have already seen Sam 4 times in 4 days and your vision is terrifyingly bad, you might get the same answer (call Joe). Don't forget you live 3 hours away from Joe.

One further point. Joe needs to keep tabs on laser performance, and your visual acuity, residual prescription, and professed satisfaction are terrible ways to do it. He needs to check your topographies (more on this from the LD soon). He might also like to keep tabs on his own performance by looking at your LASIK flap size, location, and healing. If you have LVC via the intensely co-managed route, there's a fair bet that Joe is getting essentially no quality control feedback on his long-term results. It is the ultimate open-loop system.

In the USA there is a lot of bad feeling between the EyeMDs (i.e., ophthalmologists — people who went to medical school) and the optometrists (or optometric doctors, ODs, who did not). It's a long, complex story with legitimate grievances on both sides. It's politics, money, power, prestige, snobbery, money, politics, etc. A smart, well-trained, caring OD can detect more disease and provide better care than a lazy, badly-trained, indifferent MD.

Can an optometrist provide appropriate pre-operative patient selection and testing for LVC? Can he provide appropriate post-operative care from day one on out? Is LVC co-management a symbiosis that provides a net benefit to the LVC patient?

Let's ditch the first two questions and look at this from a long perspective (out near Haley's Comet would be good). Why would you, Lou, prefer to undergo a surgery involving decisions down to microns, a very elaborate razor blade, a half-million-dollar laser, and the potential to turn you from an ordinary happy person into a miserable wreck of an LVC casualty . . . by someone you know so little you can't remember his name one year later?

You don't believe me? The LD has made it a point over the past year to ask lots of people who have had LVC who their surgeons were. In well over half the cases, the answer is either (1) Dr. Sam (whom the LD later determines is an optom, not an MD), or (2) "a guy in Bigcity, I can't remember his name". Would you not know or forget the name of your heart surgeon? You say, "but LVC can't kill me, it's not the same thing!" The LD replies, "bad LVC can make your life very hard to live."

Co-management in the RSI is generally successful only because (1) many people are, in fact, reasonably good candidates for LVC, (2) the procedure is effective if it is planned and conducted properly by the surgeon, and the laser performs correctly, and (3) if 1 and 2 apply, post-operative care is usually uncomplicated and has little influence on the final outcome. Supposing that either 1 or 2 do not apply to you, you enter a whole new category of risk.

That being said, should you have a well-established relationship with a local optom whom you like and trust, it is reasonable to inquire of him as to whether he would be willing to perform the required pre-op measurements to see if you are a good candidate, and some of the post-op check-ups. This would be a symbiosis with value to the patient. It is particularly helpful if you wear contact lenses, because Sam probably has a good feeling for your level of tear production, seasonal eye allergies, tendency towards irritation or infection, and other issues of substantial importance in assessing your LVC risks. Also, it is far better to be carefully followed after surgery by a qualified local OD than to just skip the appointments because you see fine, feel fine, and Joe is too far away.

If you are considering symbiotic co-management, the LD politely suggests that you:

The LD is pretty sure he has just infuriated 2/3 of the optoms and refractive surgeons on the North American continent. Maybe all of them. So what. This isn't heart surgery. Unlike heart disease, if you don't have LVC you will not risk permanent bad things like sudden cardiac death. If you do have LVC you do risk permanent bad things that may ruin your life as you currently live it.

In the LD's opinion, a substantial number of LVC casualties could be prevented at the screening phase through careful examination and a little honesty about what the lasers do well and don't do so well. Patient selection has been tainted by money because neither the MD nor the OD makes any if a patient is told he is a poor candidate. Patient selection has been tainted by ego because if an MD rechecks referred patients and turns down a lot of them from one optom, the OD might get peeved and start sending those referrals elsewhere. This qualifies as a money taint too. Patient selection has been tainted by a false sense of security on the part of both MDs and ODs about "whose fault" it will be if Lou has a preventable poor outcome. This is also a money taint because each doc assumes the other one will pay. Patient selection has been tainted by the big-volume economics of the procedure, which will tolerate a surprisingly high bad-outcome rate because those patients typically take their corneas elsewhere, don't talk much about it, and don't sue.

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