As the sun sank, 63-year-old Pat Raynor found it hard to focus on the road. The red and white tail-lights of the cars ahead were swimming in a haze. Raynor, a diabetic who lives in Hampton, Va., had long feared that the disease would harm her vision. As her night vision decreased she went to see a local optometrist and was startled by the procedures the optometrist was suggesting. As someone who deals with health policy through her position with the state’s health department, Raynor knew the shared care the doctor was suggesting was unusual.
Her care provided an eye-opening experience of how some optometrists and ophthalmologists collude in a way that, critics charge, can ignore the best interests of patients.
“The optometrist told me I would need cataract surgery,” Raynor said. “She dilated my eyes and then explained to me that she would refer to an ophthalmologist and I would return to her for post-operative care. I would end up paying both her and the surgeon for my care. I had trouble reading the documents but I signed them.”
It bothered her though that she was unable to read the documents clearly while her eyes were dilated. Staff at the eye clinic she said told her the documents were normal. “Everyone signed these, I was told.”
In some ways, she welcomed the surgery. By then she was having trouble seeing even in broad daylight. After having often paid $600 annually for a special kind of eye glasses, she looked forward to having good vision again. It was only the next day she began to wonder about the documents.
“I called and asked my optometrist to see the documents I’d signed. The office assured me that these were normal papers that ‘everybody signs.’ I knew what they were saying, however, it just wasn’t right.”
Still not satisfied with the papers that she was shown; Raynor contacted her diabetes specialist who suggested she still see an optometrist and provided a referral to a recommended ophthalmologist. “I didn’t realize it until I pulled up that day in the parking lot but, it was still the Virginia Eye Care Center, just I was referred to a different doctor. I was told there this time by the ophthalmologist that my optometrist would do the post-operative care if I did the surgery with them. They also suggested I take out a credit card so I could pay for the procedure.”
Raynor’s experience is emblematic of the dark side of patient co-management or share-care, which some of the ophthalmologists and optometrists who spoke to the American Media Institute describe as dangerously inadequate. Rather than just the practice of an optometrist referring a patient to an ophthalmologist for care, co-management is a fee-sharing arrangement where ophthalmologists perform surgeries and optometrists provide post-surgical care.
Co-management means big money for optometrists, who are not medical doctors. “In most places in the U.S, cataract surgery is the most common surgical procedure,” says Jaime Membreno, a Kissimmee-based ophthalmologist. “If you say out of 100,000 cataract surgeries (which cost can cost between $600-$2000), that 20% are co-managed, that’s generating something like $50 million dollars per year.”
The co-management of patients was kickstarted in 1999, through a regulation issued by the U.S Department of Health and Human Services’ Office of Inspector General sanctioning the practice. At the time, regulators warned that if the practice if misused, serious anti-trust issues could emerge.
Proponents of the measure argue that it allows eye patients in rural areas to receive more rapid access to medical care. Since patients often see their optometrists more regularly, this can lead to an increased level of comfort. Critics charge that co-management has degenerated into fee-splitting, a practice which is illegal according to the Stark Laws at the federal level and Florida laws regarding patient self-brokering. The Stark Laws prevent a physician from referring a Medicare or Medicaid patient to another medical professional if a financial arrangement exists between the two parties.
A joint position paper between the American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery is supposed to guide management. While the version of these guidelines published in 2000 stressed that co-management should not be done for financial gain, the version released a year ago had more vague language. An article on the American Optometric Association website called the new policy “a momentous reversal of long-held policy.”
“There are many areas in the state of Florida where there isn’t an ophthalmologist,” says Salvatore DeCanio, a South Florida optometrist who has 32 years of experience in his field and thinks the case for co-management is often under-stated, “And even if there is I think many people would be willing to travel an extra mile to see a premiere ophthalmologist.”
DeCanio thinks it is the best interests of the patient and all health care providers that ophthalmologists don’t focus on surgery.
“If you’re a good surgeon and you want to continue to be a good surgeon you should spend your time doing operations. You shouldn’t be dealing with a general eye exam. The busy surgeons work with good sharp optometrists on post-operative care. Sharecare is a team effort where professionals are operating at their highest skill level.”
Actually, only 22,660 people out of Florida’s 20 million residents live more than 40 miles from an ophthalmologist, according to FloridaPolitics.com.
“Physicians should engage in co-management arrangements only to assure the highest quality of care,” says an official policy of the American Medical Association. “those who participate in surgical co-management arrangements must avoid such financial arrangements as fee splitting, which are both unethical and illegal.”
While referrals are commonplace across medicine, giving a fee to a professional making a referral (co-management) is not common outside of eye care. The practice is largely confined to post-operative cataract care, where optometrists refer patients to eye surgeons in return for getting a fee for supervising the patient’s recovery. The problem is that non-doctors, such as optometrists, often cannot treat surgical complications as doctors can.
Optometrists and ophthalmologists who spoke to the American Media Institute said that due to Florida’s large elderly population co-management is rampant — and the fee-splitting is usually not disclosed to patients.
Brad Oren was a young ophthalmologist, happy to be practicing after eight years of medical school and residency. Just three weeks into his practice, he was told about co-management. “I walked into my waiting room in West Palm Beach, and there was a stranger who turned out to be an optometrist. He was friendly at first, and he wanted to speak to me about co-management; he wanted to talk about percentages,” he said. “I soon realized that this was a practice not in the best interest of the patients.”
The optometrist made what Dr. Oren now knows is a very common pitch for co-management: If I refer patients to you, you will send them back to me for post-surgical care and I will collect 20% of the overall surgical fee. If you don’t agree, no optometrist will refer any patients to you. Since most patients come through optometrists, they have real leverage over licensed surgeons. These arrangements can be bad for patients.
“In my former practice area, patients would come from hours away to see a surgeon when there was already was one, as good or often better, in their hometown,” Oren said. Why were patients with poor eyesight driving hours out of their way? He said it was because the distant doctor had agreed to share his fee with the referring optometrist.
Other problems with co-management include the inability of non-doctors, such as optometrists, to correctly diagnose and treat surgical complications or spot emerging diseases. A missed or wrong diagnosis could lead to permanent blindness.
A Florida native, Oren now practices in New England. “I left Florida and moved to the Northeast to get away from co-management. I was tired of being pressured to get into these commercial relationships, which don’t benefit patients.”
Chip Richardson has struggles with co-management at his ophthalmology practice in Eastern Kentucky. “In rural areas of Kentucky, seniors are being traded around like commodities and ophthalmologist in the countryside won’t survive unless he goes along with it.”
Richardson was so troubled that he traveled to Washington D.C. in 2013 to explain to Federal Trade Commission officials that co-management violated the anti-trust laws. Having prepared for months for the meeting, he was shocked by the cold reception he received.
“The FTC told me what the optometrists are doing is just good businesses sense,”he said, “but the collusion is leading to over-diagnosis of cataract surgery and we are seeing people getting this surgery earlier than they should.”
Alone and on the long trip back to coal country, he kept turning over the meeting in his mind. “From the federal government’s standpoint, there is cost-benefit to [people being treated before it is medically necessary]. If an individual gets the surgery done on private insurance before they are Medicaid or Medicare eligible, that is one less individual for whom the U.S. government has to foot the bill down the road.”
How many optometrists are using co-management is unclear — no law requires the practice to be disclosed and no state or federal agencies track to practice.
But Pat Raynor thinks even one is too many. She eventually traveled to Florida for cataract surgery from a specialist and stayed an extra week to receive post-surgical care from the surgeon who operated on her. She now drives at night without fear.
“I hope that other people don’t go through what I had to go through,” she said, “just because some people are trying to line their pocket instead of helping people.”
This feature is the second in a series.