| Glenn - USAEyes.org 2004-10-05, 7:10 pm |
| >Glenn -- was just wondering if in fact, as has been alleged so
>colorfully by "Splashy", optometrists have financial incentives to
>refer patients to eye doctors for laser surgery. If so, how much of
>an incentive?
The answer is both yes, and no. In the best of circumstances, the
optometrist acts as a knowledgeable gatekeeper, provides advice
specific to that patient's situation, avoids mediocre and poor
surgeons while directing patients only to the best available surgeons.
The optometrist may be much more convenient to the patient (especially
in rural areas) and have been a trusted provider of care for years.
This process can be as simple as a verbal recommendation to a known
surgeon, or fully involved comanagement; one physician provides a
portion of the patient's care and another provides the remainder.
Comanagement is not new, nor is it unique to eye care. Nurses and
doctors are an example of comanangement. Primary care physicians and
cardiologists are another.
The possibility of financial motivation most certainly exists, and can
color a professional decision.
In most circumstances, optometrists have no additional financial
incentive to refer to one comanaging ophthalmologist over another.
For the most part, the amount the optometrist receives for the
preoperative and postoperative care is consistent no matter which
ophthalmologist comanages the patient. If one surgeon is paying
significantly more than the others, then there could be a financial
incentive to use that doctor over those who pay less.
In some cases optometrists have formed associations or corporate
affiliations. The optometrists may purchase the laser equipment,
lease the office space, even handle day-to-day management. In this
environment, it is highly unlikely that an optometrist will refer to a
surgeon outside of the incestuous circle.
Since refractive surgery is by and large highly successful, it is easy
for an optometrist to be convinced that s/he may as well go for the
greatest financial reward, because the results are going to be about
the same no matter who gets what share of the pie. That is an
argument that has a lot of evidence in its support, even if it is a
bit distasteful and unnerving.
The fear is that optometrists are going to be paid for patient
referrals to a poor surgeon. No one argues against every professional
being paid his or her fair share. As long as what the optometrist is
paid reasonably reflects the amount of care provided, then that is an
appropriate and equitable comanagement arrangement. If the
optometrist is paid $1 more than what is reasonable for the work
provided, then that dollar is paying for a patient (capitation and
steering) and is illegal.
It is often difficult to determine exactly what is a fair amount.
There are no guidelines from insurance companies or government.
Refractive surgery comanagement is like the wild west. In Medicare,
20% of the global fee is provided by the government to the comanaging
doctor, but even this percentage is not recognized for refractive
surgery.
We recommend that the patient make separate payment for the
comanagement portion, the surgical portion, and if necessary, the
facility fee. In this manner, the patient knows exactly who is
getting what, and each entity is being paid directly. It is rare that
separate checks are written, but even if only one payment is made the
patient can at least determine how much the optometrist will be paid
of the total fee and if the optometrist has any other financial
arrangement with the surgeon, such as partnership, ownership of the
laser, etc.
As long as the patient knows all the facts and is comfortable with the
situation, then comanagement is just one more elective decision about
an elective surgery.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
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