COMANAGEMENT Q&A

Don't Hesitate to Communicate

Edited by Paul C. Ajamian, O.D.

Question: How can I make sure my comanagement relationships with other doctors provide the best possible outcomes for patients and make my own job more rewarding?

Answer: The golden rule for successful comanagement: Don't hesitate to communicate. Communicate with the patient, communicate with the doctor to whom you're referring the patient, communicate with insurance carriers.

Referral center director Robert Vandervort, O.D., of the Omaha Eye Institute in Nebraska, offers these tips on how you can get more gratification and fewer hassles out of the care you provide for cataract, refractive surgery and glaucoma patients.

First, always remember to reach out to the patient. It's a rather basic rule, but one that many colleagues often overlook. During your preoperative examination, tell the patient that you can provide his or her postoperative care. Don't count on the surgeon to convince the patient to return to you after surgery. Remember, the patient has the right to choose who provides his or her care after surgery. So, you must lay the groundwork from the beginning to avoid confusing the patient.

Here's a closer look at the big three of O.D.-M.D. comanagement:

• Cataract. Preoperatively, if the cataract is borderline in terms of meeting Medicare's standard visual acuity guideline, document the patient's complaints. Note the results of any testing that supports the patient's complaint. Put all this in a letter to the surgeon requesting a "cataract consultation." Make sure you include data on the patient's last refraction and acuity findings. Results from these two tests often determine whether or not cataract surgery is indicated. Many times colleagues emphasize disease-related information and don't thoroughly address issues about visual complaints, which are often more pertinent to the cataract surgery than slit lamp or tonometry findings.

Establish in writing the date the surgeon will release the patient to your postoperative care. The insurance carrier won't pay claims for services that you and the secondary provider perform on the same day. The surgeon should also mail you a letter that formally transfers care of the patient to you. Preferably, the patient's signature will be on this letter, too.

After each post-op visit send the surgeon a letter that details your objective and subjective exam findings. Many surgeons have a pre-printed form that you can use. Otherwise, your own form or a report on your letterhead, with your signature, will suffice.

• Refractive surgery. When you're setting up your comanagement relationship with a refractive surgeon, determine what pre-op tests are indicated and which of these you'll perform. You play a critical preoperative role in managing each patient's expectations.

Screen out patients who seem to expect too much from their refractive surgery. Often, patients will have a small refractive error postoperatively that might cause some blurring. Make sure they understand this before surgery so they won't be disappointed after. Also before surgery, lay the groundwork that you'll be providing the post-op care too.

Refractive surgery has many of the same documentation requirements as cataract surgery. Before surgery send the surgeon all baseline exam information as part of your referral. Be sure to include results of the cycloplegic refraction. This is especially important if you don't want the patient to go through a second dilation. After each post-op exam, send the surgeon detailed reports. These should document uncorrected and corrected visual acuities, the latest refraction as well as the patient's subjective comments.

Stay actively involved with the patient throughout the postoperative process. If you can, set up your refractive surgery patient schedules so that you can go to surgery with them. This way the patient will see that you're taking an active, personal interest in his or her outcome.

This also sets up in the patient's mind your role as the post-op caregiver, and identifies you as the primary provider of his or her care. You'll get much of the credit for the success of the refractive procedure and benefit from the positive word-of-mouth marketing.

• Glaucoma. From the start, sit down with the secondary provider and agree on general protocols about how glaucoma patients will be managed.

Get answers to these specific questions: Who will do the threshold visual fields? What test patterns and strategies will be used for most cases? Who will do dilated fundus examinations and obtain fundus photos? When would laser or surgical intervention be indicated? What are the typical drugs of first choice for each provider?

This discussion between you and the secondary provider needs to be a two-way street, with lots of mutual respect. If the secondary provider doesn't accord you that respect, the relationship probably won't work for you or the patient.

Communicating the right information to patients and doctors is the key to comanaged care that meets the patient's expectations. By establishing some ground rules with the secondary doctor beforehand and through detailed report letters, you'll be able to improve outcomes for your patients who need referrals, and you'll rest easier at night. 

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