Eyeing a Potential Conflict

Millions of Americans have had laser-eye surgery and many of those patients have relied on their optometrist for information or referrals to eye surgeons who perform the popular procedure. Many optometrists have signs or brochures about Lasik surgery prominently posted in their offices.

But what many consumers don’t know is that their optometrists’ referrals may be influenced by controversial financial arrangements known as “co-management” deals, in which the optometrist receives a portion of the Lasik surgery fee in exchange for referring patients to a particular eye doctor or group of eye doctors.

Under these arrangements, optometrists often will perform some screening exams before the surgery and provide care after surgery. While co-management arrangements are legal, some critics of the practice say they can create conflicts of interest that might harm patients.

Some doctors are concerned that co-managing arrangements create an environment in which money can cloud professional judgment. “When you put a price tag on someone’s head, objectivity becomes limited,” said Dr. Samuel Masket, a clinical professor of ophthalmology at UCLA. Many optometrists used to be adamantly opposed to refractive surgery, mostly because they lost business when some patients no longer needed glasses. Once optometrists found a way to profit from the Lasik boom, “then they became very proactive,” Masket said.

Optometrists see the situation through a different lens. Though they acknowledge that the practice has a potential for abuse, they believe co-management can benefit patients. Optometrists know their patients’ visual needs, they say, and if they need temporary glasses or contacts after Lasik surgery, they can prescribe them. “Who is better qualified to follow these patients than someone who has known them for years?” asks Joseph P. Shovlin, a Scranton, Pa., optometrist and spokesman for the American Academy of Optometry in Rockville, Md. “To a certain extent, this is just a turf battle between optometrists, who want to keep their patients, and some of the ophthalmologists.”

Indeed, this controversy reflects an ongoing struggle between the two professions as to whom is best-suited to administer care. Optometrists, who attend four years of school after college but are not medical doctors, can prescribe medication and treat infections. But ophthalmologists, who undergo several years of training after medical school, have long argued that they are better qualified to provide certain services.

In February 2000, in fact, the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery jointly issued guidelines for co-management agreements to their members. The guidelines state that the practice should only be done in special circumstances--if the patient lives far away from the surgeon, or if the doctor is unavailable because of illness or is out of town. Co-management deals should not be routine, the groups concluded, and any fees paid should reflect fair market value for the services performed. “The best interests of the patient must come first,” says Dr. I. Howard Fine, an ophthalmologist in Eugene, Ore., and president of the ASCRS. “We should not be self-serving.”

Still, eye doctors acknowledge that financial incentives--and not just expertise--play a role in referrals. “I’ve had referring doctors say to me, ‘I think you’re a fantastic surgeon but I’m not going to send patients to you because you don’t pay enough,’” says Dr. Robert K. Maloney, director of the Maloney-Seibel Vision Institute in L.A..

Given this, what can consumers interested in laser-eye surgery do to be better informed?

Ask your optometrist questions, experts suggest. They are legally bound to answer truthfully. Find out if the optometrist is experienced and has special training in Lasik surgery--in evaluation before surgery and in postoperative care, which includes treatment of infections and the ability to spot potentially serious problems. Once you’ve decided to undergo the procedure, be sure the ophthalmologist performs adequate pre-screening and follow-up care. Anywhere from a week to four weeks of follow-up visits are standard.

Ask your optometrist if he or she has a financial interest in the clinic to which you’re being referred. A “yes” answer should raise a red flag. Ask them what their monetary arrangement is with the surgeon. An 80-20 fee split--with the surgeon keeping the lion’s share--is considered equitable. Anything more than that, Maloney says, “looks like a deal sweetener.”

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To see a video explaining the Lasik procedure, visit www.latimes.com/lasik.