David I. Geffen, OD, FAAO
When done well, co-management of the cataract patient is a true practice builder. The OD’s care is an essential component of the anxiety-producing experience of a patient going through cataract surgery. The key to making this a success–and solidifying a patient’s continued loyalty–is educating the patient in options and referring them with a firm message that you will continue to care for them during this process and beyond.
Cataracts are a condition that affects nearly all senior citizens. It is the most common surgical procedure in the US. With our aging population, ODs can take advantage of a practice-building opportunity by co-managing these patients with eye surgeons by providing pre- and post-operative care.
Co-managing cataract patients by providing pre- and post-operative care is a practice-builder. Tap into this revenue stream and provide a needed service to our aging population.
CALCULATE REVENUE POTENTIAL. ODs typically receive approximately 20 percent of the cataract surgical fee.
NO ADDED INSTRUMENTATION INVESTMENT NEEDED. The same equipment you use to conduct comprehensive examinations is enough for cataract co-management.
ESTABLISH RELATIONSHIPS WITH EYE SURGEONS. Visit surgeon at their offices and observe cataract consultations. Establish a good working relationship with surgeons and key staff persons.
Compute Practice-Building and Revenue-Generating Opportunity
There is a great advantage for the OD to handle the pre- and post-operative care of the cataract patient.
–OD is best equipped to provide pre- and post-op care (which is not cost effective for MD)
–OD provides continuity of care (MD specialist is not equipped for that).
If you just refer the patient and let the surgery center do all the pre- and post-ops, the patient assumes that you have relinquished their care to the surgical center. They often feel no need to go back to the OD’s office. They will refer their friends directly to the surgery center. By participating in the pre- and post-op care, the OD shows the patient that they are the patient’s primary eyecare doctor. It is similar to an internist referring a patient for heart surgery. The internist refers the patient for the heart treatment but fully expects to manage the patient’s overall health in the future and participate in the patient’s ongoing care. When it works this way, the patient keeps their confidence in their OD and will continue to have that long-term bond, as will the patient’s family. They will refer their friends and family to their eye doctor, the OD.
The Medicare standard is that the pre- and post-op care is 20 percent of the global fee. When dealing with advanced technology IOL’s there is a fee the patient pays, in addition to the insurance covered amount, and therefore, the OD will participate in a percentage of this fee, too. As insurance reimbursement has fallen, the global Medicare fee is quite low for an OD to participate in, however, with the higher fees generated with the advanced technology lenses, this allows the OD to be better compensated for the time necessary for follow-up care.
Create Plan to Provide Typical Cataract Patient Needs
Prior to the procedure, the referring OD is seeing the patient to do their general eyecare and monitor the development of the cataract. This may be one visit and then a referral, or the OD may see the patient every few months to monitor the growth of the cataract and evaluate the change in vision. After the procedure, the patient will typically see the surgeon for the one-day post-op and then is referred back to the OD. I see the patient at one week, three weeks, six weeks, three months, and if using an advanced technology lens, we see the patient for a six-month check. For standard cataract surgery, the post-op period is 90 days, so any visits after that are a charged visit. However, for premium IOl’s (mutifocal of toric), we use a one year follow-up period and there is no charge for that. The co-management fee is much higher to the OD for those IOL’s.
Utilize Existing Instrumentation
To properly participate in cataract co-management the optometrist should have all the equipment necessary as part of their normal equipment needs. Of course, this assumes the doctor has the proper equipment to perform normal eyecare!
Set Patient Expectations
Multifocal IOLs will take extra time in the pre-op care. The patient needs to fully understand the proper expectations of how these lenses will work. This is where we as optometrists excel. We have a long history with the patient, often over ten years. We know if the patient has worn multifocal contacts, or monovision, or couldn’t get used to these. We understand the patient’s visual demands. The surgeon only has a few minutes with the patient to help determine the proper lens for implantation. We can greatly assist with this by giving the surgeon our past history with the patient. If the patient wore multifocal contacts, then they should be a great candidate for a multifocal IOL. If they wore monovision contacts for the past 20 years, then they most likely should be kept in monovision. If they are an extremely picky patient, then a single-vision IOL may be most appropriate.
We should help guide the patient and inform them of the possible choices and relay this to the surgeon. It is important to know what lenses the surgeon we refer to will use. Typically, the best surgeons use multiple designs, as each has their own benefits for certain patients.
Explain Possible Continued Need for Glasses
In my practice, we tell the patient that it will take a few months for their brain to fully adapt to the new vision. We tell them that we expect them to be spectacle-free for 80-90 percent of their day, but may still want help for certain tasks they may do. We explain the possibility of glare and halos, and go over how IOLs work. We try to make sure the patient’s expectations are realistic, and most importantly, we try to under-promise and over-deliver.
In the case of monofocal lenses, we talk about residue astigmatism and the need to wear glasses to correct that, as well as, reading vision. For toric IOL cases, we tell the patient we are trying to provide the best distance vision, and they will need readers. For multifocal patients, we talk about the possibility of the need for some type of enhancement procedure to finalize the optimal prescription. We work with a surgery center which includes any enhancement as part of the premium fee the patient pays. It is important to know what the policy of your surgery center is, as it will anger a patient if after paying for advanced technology lenses they have to pay for a laser enhancement. We have found with the accuracy of our surgeons we only need to enhance less than 5 percent of our patients.
We also make sure we talk about the need for a YAG in the future. With multifocal IOL’s a small PCO will make a big difference in vision and we do YAG’s very early for these patients. For our toric and multifocal IOL patients, we include the YAG for the first year. We educate the patient about this and tell them it no big deal to fix and is a common occurrence.
Establish Relationships with Eye Surgeons
I recommend that the optometrist visit the surgeon at their office and observe a couple of cataract consultations. See how the office or surgical center will treat its patients. Determine if this is a place you would send your mother. Get comfortable with the surgeon so communication can flow freely. Visit the surgery center and observe at lease one procedure so you can help understand what your patient is going through. Don’t be afraid to ask questions. Most surgeons are happy to answer questions and happy to get feedback.
The doctor must have a good working relationship with the surgeon, as well as someone on the surgeon’s staff as a point person. The doctor must show their patient confidence in their recommendation of a surgeon and be able to talk about the procedure and calm the patient’s fear of surgery.
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