Eyeworld

16 Ophthalmology Business • March 2016 continued from page 15 GB: I don't know how you'd define "common," but I've certainly come across it. I suspect that you would see it more in larger towns where there are multiple ophthalmology practices com- peting for patients so that each one is trying to improve its competitive advantage. JB: This case clearly raises conflicts of interest that should be managed. But I'm amazed that until I started becom- ing acquainted with ophthalmology, I didn't know about these "dark secrets." GB: That's because we ophthalmolo- gists are generally a quiet and reserved group of professionals. We don't make waves. We don't call attention to our- selves. We're a "grin and bear it" group. Also, these optometric-ophthalmologic referral arrangements have become rather entrenched in the system and, for numerous reasons, seem very hard to change. JB: But I know that many states have laws about professional-owned prac- tices—such as when an orthopedic surgical group owns the physical ther- apy practice next door to which the orthopods refer patients. I know that a number of states require the owners to inform patients about their finan- cial interests and holdings and give patients the option of going elsewhere. GB: Sure, but many, probably most, patients aren't listening very well, or they might be very concerned about upsetting their doctor or optometrist, so they often do anything he or she recommends. Just a simple, "Mr. Jones, you need to know that I'm a co-owner of the practice next door, which I nevertheless trust a lot because I work closely with them and I know their work better than I do other practices," will be enough to sway most patients to that practice. JB: Then there's the fact that some patients aren't going to be sophisticat- ed consumers of care and they'll just follow the recommendations of the treating professional. GB: When I was in private practice in the 1980s, I'd frequently ask new pa- tients why they came to see me rather than other ophthalmologists in town. The answer I got most frequently was, "I looked in the Yellow Pages under ophthalmologists, and 'Broocker with a B' was at the top of the list, so I called you." JB: Have you any practical recommen- dations on this case? GB: I recently retired, and I must say that I've watched questionable prac- tices like this one slowly evolve over the course of my career. The "corpo- ratization" of medicine today amazes me because when I started, physicians would frown on advertising, much less these complex co-ownership arrange- ments. If what we're doing is putting the business of medicine ahead of its patient-centered goals, then we are turning healthcare into a job—a very good job, don't get me wrong, but much less than it can be. By the way, you're leaving something out. JB: What's that? GB: You haven't talked about oph- thalmologists who are no longer on active staff at community hospitals and don't take call, and who, I believe, have contributed to this problem. I've come across any number of practices and hospitals that identify ophthal- mologists as affiliated with a hospital or clinic, but when patients present with "inconvenient" emergencies, or no insurance, or are the kinds of patients these physicians don't like to treat, they refuse to see them. So the patient winds up going to the few facilities that are required by law to provide them services. Physicians not covering call contribute to the cherry picking of patients that contributes to these problematic referral patterns. For- tunately, though, we also have a lot of ophthalmologists who do a great deal of pro bono work, which gratifies me a great deal. JB: Any last words? GB: I'll be interested to see what Tara has to say because these dilemmas, as I've mentioned, are very hard to eradi- cate from the system. Also, the people who engage in them probably see themselves doing nothing wrong. An interview with Ms. Adyanthaya JB: Ms. Adyanthaya, what is your ethi- cal and legal take on cases like these? TA: I'll begin with the ethical perspec- tive: Patients' best interests must be given priority over financial self-in- terest. As you suggested, potential financial conflicts of interest should be disclosed. Patients have a right to information necessary for evaluating recommendations that enables them to weigh alternatives to proposed treat- ments. It's also troubling when referral patterns force certain providers to bear disproportionate burdens in treating clinically and financially challenging patients. JB: Talk about the legal perspective. TA: Whether referrals run afoul of the law is fact-sensitive, with the devil dancing in the details of the par- ticular arrangement, services, payers, patient mix, and state in which the participants practice. Because of the complexity of the analysis, state law variations, and the fact-specific nature of the inquiry, providers should

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