If you could hire an assistant who did all the parts of your job that you consider to be a tedious drain on your productivity, how much would you be willing to pay? If this boosted your billings and kept you intellectually challenged, probably a decent amount. Now, what if that person worked for free?

That’s a no-brainer right there.

This is the proposition optometry offers to ophthalmic surgeons when seeking comanagement arrangements. You don’t work for free, of course, but since your reimbursement doesn’t come from the ophthalmologists (except for those employed by one), it’s essentially “free” to them. They get to spend more time in surgery, where they earn considerably more and find the work more professionally stimulating anyway.

Frankly, it’s an offer they can’t refuse.

The need for greater optometric involvement in cataract surgery is pretty much inevitable, given recent trends. In January, the Medicare surgical reimbursement—which surgeons already felt was too low—was cut by 13%. In a classic case of “no good deed goes unpunished,” CMS justified the cut with data showing that the average cataract procedure time has dropped from 35 to 21 minutes in recent years. Surgeons who improved the predictability, efficiency and safety of cataract surgery were rewarded for their ingenuity with a pay cut.

But that’s only half the problem for surgeons. The newest innovation—using a femto laser to replace some manually performed aspects of the procedure—adds about $500,000 to the capital equipment needs of a surgical center, and a usage fee of about $400 per procedure. Oh, and it increases procedure time. (But no surgeon is naive enough to expect the Medicare fee to be revised upward as a result).

Squeezed by fee cuts on one end and rising costs on the other, cataract surgeons have attempted to charge patients out-of-pocket for refractive correction and premium IOLs at the time of surgery, a promising idea that has had lukewarm results thus far. It’s less a strategy than a Hail Mary play.

Closing the Gap
A better way to keep surgeons solvent while also meeting the runaway demand for cataract extraction is to bring ODs more fully into the fold, with stronger comanagement relationships or even direct employment at a surgical center, a career path that new optometrists in particular might find attractive if private practice optometry isn’t hiring and corporate optometry is uninspiring.

In this month’s special comanagement-themed issue, Kim Calnan-Holt, OD, of Pacific Cataract and Laser Institute gives us a glimpse of life at a surgical center and the many responsibilities entrusted to the optometrists there who comanage cataract surgery. In a well-run multidisciplinary facility, ODs empowered to their fullest capability can do (or at least oversee) everything but the surgery itself, freeing up the surgeons to increase their procedure volume to make up for that nasty 13% fee cut.

Independent ODs who refer their cataract patients to surgery centers—certainly the more common method of comanagement—have less direct control over the process than those employed at a center, and that’s probably holding back progress in this area. According to a recent AOA survey, optometrists diagnose an average of 13 cataract cases per month, but only comanage about half of them (six/month on average).

The only realistic way to perform five million cataract cases per year—as the demand is expected to reach in just a few years—is through tighter integration between ODs, MDs and an array of support staff. Many hands make light work, said the English playwright John Heywood way back in 1546.

Surgeons will need to trust their comanaging ODs with more clinical responsibilities, and optometrists should make it a priority to earn that trust.

Surgical comanagement should be front and center in educational curricula and at national conferences—in both professions.

The AOA survey reported a comanagement participation rate of 78% among optometrists. That’s impressive. But let’s close the gap between cases diagnosed and cases (co)managed by an OD. The opportunity, and the need, is too big to ignore.