Optometric Perioperative Care

This paper discusses the proper role and responsibilities of providers in co-managing patients, consistent with federal regulations and ethical standards. For purposes of the paper, co-management is defined as two or more independently licensed health care professionals sharing responsibility for the diagnosis, treatment, and management of a patient's medical or surgical condition. (To download a PDF version of this paper, click here.)

Background

Doctors of optometry are committed to achieving the best possible outcome for their patients. Doctors of optometry have a long history of successfully managing patients in coordination with various medical specialties and primary care physicians in the perioperative care models.

The federal government has long recognized the role of optometrists in providing postoperative co-management. Since Congress amended the Medicare statute in 1980 to allow payment to doctors of optometry for postoperative care, optometrists have been successfully co-managing patients with ophthalmologists. 1,2

The American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) issued a joint position paper on this issue in 2000 and again in 2015. At the time of the 2000 paper release, in regards to the American Academy of Ophthalmology's Code of Ethics Rules 7 and 8, the Federal Trade Commission (FTC) stated that "the rule would not prevent ophthalmologists from arranging for optometrists to provide postoperative care services consistent with state law." The FTC further concluded, "Serious antitrust concerns would, of course, be raised by an ethical rule that unreasonably interfered with legitimate competition by ophthalmologists working in conjunction with non-physician health care professionals, or prevented optometrists or others from providing services they are legally and professionally qualified to provide."

The more recently released position paper from the AAO-ASCRS demonstrates a shift from the initial position in 2000. The most notable difference between the two position papers is that "Patient Prerogative" is now listed as a circumstance under which co-management and transfer of care is deemed appropriate.

Government Activity

The Anti-Kickback Statue (AKS) and Physician Self-Referral Law (Stark Law) are two of the federal laws governing Medicare fraud and abuse.3 In 2011, the Office of the Inspector General of the U.S. Department of Health and Human Services gave an advisory opinion that a specific arrangement between co-managing ophthalmologists and optometrists using premium intraocular lenses would not necessarily violate the AKS.4 In a footnote to the opinion, the OIG reiterated its view, published in 1999, that splitting global fees between optometrist and ophthalmologist must be examined on a case-by-case basis to determine compliance with the AKS. Health care providers should be well versed in these and any other state and federal laws and regulations to ensure appropriate co-management practices and operations.

Suggested Recommendations

Co-managed care should always adhere to the basic tenets of good patient care, the ethical responsibilities of providers, and governmental rules. The following suggested recommendations are offered to help providers meet these objectives.

  • The selection of an operating surgeon for patient referral should be based on providing the best potential outcomes for that patient. Financial relationships between providers must not be a factor.
  • The patient's autonomy to choose the method of postoperative care should be recognized consistent with informed consent and the best medical interest of the patient. Co-management of postoperative care should be determined on a case-by-case basis and not prearranged. The patient should be advised prior to surgery of potential postoperative management options, with considerations to include distance and travel time for follow up care , availability of the doctor during the post-operative period, the patient's preference of which doctor to see for follow up care, and potential complications which may change the patient's postoperative course of treatment.
  • The transfer of postoperative care must be clinically appropriate and depend on the particular facts and circumstances of the surgical event.
  • Following surgery, transfer of care from the operating surgeon to an optometrist should occur when clinically appropriate at a mutually agreed upon time or circumstance (patient's choice of provider and doctors' willingness to transfer and accept the patient); and such time should be clearly documented via correspondence and be included in the patient's medical record.
  • The operating surgeon and the co-managing optometrist should communicate during the postoperative period to assure the best possible outcome for the patient.
  • Compensation for care should be commensurate with the services provided. Cases involving care for Medicare beneficiaries should reflect proper use of modifiers and other Medicare billing instructions.


Conclusion

The American Optometric Association believes that referrals for specialty services should be based on achieving the best possible outcome for the patient and not on financial relationships between providers. All health care professionals have an ethical obligation to patients for whom they are responsible to ensure that medical and surgical conditions are appropriately evaluated and treated. Decisions to co-manage should be made on an individual basis and should always include proper and complete documentation and communication between providers and patients. Co-management should occur only when these basic principles are followed.

  1. Omnibus Reconciliation Act of 1980. (Section 937 of Public Law 96-499). https://www.govtrack.us/congress/bills/96/hr7765/text
  2. http://www.aging.senate.gov/imo/media/doc/publications/5231988.pdf
  3. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
  4. http://oig.hhs.gov/fraud/docs/advisoryopinions/2011/AdvOpn11-14.pdf