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    5 features of successful comanagement

    An ophthalmologist outlines his ideal relationships with referring ODs

    James C. Loden, MD, is in practice in Nashville, TN.In my Nashville practice, my colleagues and I successfully comanage surgical patients with a large network of referring optometrists. Over the years, I have learned what steps ophthalmologists and optometrists should take to set their relationships up for success. The underlying theme is the setting of realistic expectations.

    Preframe the relationship

    “Preframing” is a way of setting patients up so that they know exactly what to expect from their preoperative exams and procedures. As a part of setting these expectations, ODs and MDs explain where patients will be seen for their follow-up examinations. Having a specific conversation in advance is a much more effective method of communication, rather than having to “reframe” the patient’s expectations later.

    Related: Cataract Co-management—an OD’s perspective

    For example, the patient’s optometrist might have a conversation like this: “I am sending you to see Dr. Loden. I am confident he will do a great job and give you the outcome you are looking for. When you go to the clinic, he and his staff will perform several tests, he will discuss laser surgery, and he will make a recommendation based on what is best for you. I know you have worn monovision contact lenses for years, and monovision can work well with cataract surgery. I will recommend to Dr. Loden that you proceed with monovision cataract surgery, but he will discuss that more after he has the results of the preoperative testing. After the surgery, I will see you back here for the one-day postoperative exam.”

    With that as background, here are five key characteristics to successful comanagement.

    1. It is legal and ethical

    According to the Medicare guidelines, payments cannot be made for referrals. True comanagement requires that care transfer from the optometrist to the surgeon and from the surgeon back to the optometrist, with both parties participating in the care.

    For premium intraocular lens (IOL) surgery, which typically involves higher fees for both the surgeon and the optometrist, additional services must be provided to justify the additional fees. For example, for potential premium IOL patients, I like to see more preoperative tests performed during their prior care.

    I perform laser arcuate incisions for patients with >0.50 D of corneal astigmatism, and I choose a toric IOL for those with >1.25 D of cylinder. Therefore, my network of optometrists referring patients for refractive cataract surgery must be able to determine how much corneal astigmatism they have via corneal topography. Topography is also useful for evaluating the position of a toric lens postoperatively. If a lens appears to be >5° off axis after surgery, I want to know. A slit-lamp with a rotating axis beam is the bare minimum to perform this function.


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