Fear of losing a patient to another doctor. Pressure from managed-care plans to cut corners. Lack of respect from third-party payers.

None of theseaccording to our 2004 Comanagement Surveyis stopping O.D.s from providing the best possible patient care, regardless of pressures to do otherwise. Results represent responses from 193 optometrists, or 19% of our National Panel, Doctors of Optometry. 

Comanagement Numbers
The O.D.s we surveyed comanage an average of 12 patients each month. For 57% of our respondents, that number remained unchanged from last year. It was, however, an increase for 24% of O.D.s and a decrease for the other 18% of participants. O.D.s typically refer an average of 8 patients for surgery each month and 12 patients for nonsurgical treatment.

Our panel was split almost evenly when asked about comanaging patients with other optometrists. Some 53% of your colleagues said they dont comanage with other O.D.s, while 47% said they do.

Only 35% send patients to an optometric referral center. Most of the remaining 65% say that no such center is available where they practice or that the center is too far away for their patients.

Only 18% of O.D.s said that an ophthalmologist regularly schedules hours in their offices.

Most O.D.s surveyed typically treat glaucoma and ocular allergy themselves. The top reasons for referring to ophthalmologists include retinal disorders, refractive surgery, neurological disorders, diabetes, blepharoplasty, cosmetic surgery and fluorescein angiography. The most recommended referrals to other O.D.s were for vision therapy and diabetes. (See table below.)

The Competition
Fear of losing patients to other doctors plays a very little role in the decision to refer. Indeed, 48% of respondents say they are never afraid of losing patients to the other doctor. Another 30% occasionally worry about losing the patient, and 13.78% said they sometimes worry. Only 6% said they frequently worry, and 2% never refer.

 Im never reluctant to refer, says Jeffrey Magun, O.D., of Columbia, S.C. I only refer to top-notch specialists who always send detailed reports and refer the patient back to me.

However, Joseph P. Winberry, O.D., of Camp Hill, Pa., admits some apprehension when referring patients. You cannot always control the decision of a patient to seek care in another office, he says.

Similarly, we asked our panelists whether they are reluctant to refer patients to M.D.s who have dispensaries in their offices. Some 73% said potential competition of another dispensary does not deter them from referring patients. Instead, they consider the M.D.s reputation, clinical skills, expertise and level of care as the most important factors in where they send patients.

There are certain ophthalmologists I use for tertiary care whom I consider the best in my area, says  Michael D. Schall, O.D., of Charleston, S.C. Whether or not they have a dispensary is irrelevant. I want the best care for my patients.
Still, 27% said they would not refer patients to M.D.s with opticals. I try not to refer, states Lower Burrell, Pa., optometrist Dennis A. Zelazowski. They (ophthalmologists) have stolen patients from me after IOL surgery.

Managed Care
Our participants were especially vocal about managed care. Indeed, some 89% feel that third-party payers do not fully recognize optometrists role in comanagement.

Plans do not bother to educate primary-care physicians who are case managers about the availability of O.D. treatment, says Fort Lauderdale, Fla., optometrist Paul Klein.

Optometrist James Hannigan, of Georgetown, Texas, describes third-party payers as notorious for not understanding our scope of practice. If they did, adds a California O.D., it would be less difficult to get authorization and payment.
Some 61% say that managed care has not forced them to refer patients to doctors whom they feel might not provide the best care. Elktown, Md., optometrist Gerald Resnick says he always refers patients to where they will receive the best care. Ditto for Baltimore optometrist Bruce Hyatt, who says, I wont deal with doctors that I feel are inadequate.

However, 39% say they have had to refer to doctors they felt would not provide the best care. Says optometrist Richard Glonek, of Scottsdale, Ariz.: Some of the Medicare HMOs have limited panels with doctors I would prefer the patient not see. An Alabama O.D. bluntly adds that sometimes theres just no choice when the patient doesnt want to pay for a doctor thats not covered in their plan.

Still, some two-thirds of our panelists do not feel that managed-care plans encourage them to cut corners. The 33% who feel that managed-care plans forced them to cut corners cited restrictions on referrals and non-payment of necessary post-op visits among their frustrations with managed care. 

Adequate Care
Slightly more than one-third (35%) of our panelists have indeed found themselves in a comanagement situation in which they did not feel that the other doctor provided adequate care for the patient.

Follow-up with your patient and that other doctor is crucial. Heres what Michael B. Maizel, O.D. of Lansdowne, Pa., does when another doctor misses a patients problem: We attempt gently to make a better recommendation or handle the bulk of the problems in-house.

Those who continually experience conflicts over the patients care often discontinue comanaging with those other doctors. Says one San Diego O.D.: I have a patient that I referred for diabetes but who ended up losing vision in one eye because the surgeon delayed treatment.

Despite managed-care restrictions or the possibility of losing patients to other doctors, most O.D.s surveyed simply refuse to compromise patient care. Even if it means a few more gray hairs in the process.