PANELISTS: ROBERT COLD, MD; JAMES SPRACUE, MD; AND MOHAMAD JAAFAR, MD
Robert Gold, MD, is from Eye Physicians of Central Florida, Longwood, FL.
James Sprague, MDt is from Pediatrie Ophthalmology, McLean, VA.
Mohamad Jaafar, MD, is from Children's National Medical Center, Washington, DC.
Wagner: We're going to talk about the relationship between the pediatrie ophthalmologist and die hospital regarding retinopathy of prematurity (ROP). The first question I'd like to put forth, which may be an obvious one, is why do you think so many retinal surgeons have opted to limit their availability to treat ROP, and for that matter, why have many pediatrie ophthalmologists decided not to perform these ROP evaluations in the neonatal intensive case unit (NICU)? Dr. Gold?
Gold: I'll comment first about the pediatrie ophthalmologists. It's unfortunate that so many of our colleagues have decided not to screen or treat premature babies with ROP. I mean it's part of what we do as pediatrie ophthalmologists. We're trying to preserve the vision of the littlest patients, and unfortunately, the medicolegal climate of today has caused ROP to be under the microscope. Many of our colleagues don't want to have that held over their heads. For retina specialists, in particular, this is a small part of their practice, and treating these babies who may go on to have retinal detachment, despite their treatment, causes them to take on a risk that they may or may not want.
Wagner: Dr. Sprague, would you like to comment on that same question?
Sprague: In some of the retina groups, there might be one person who does most of the ROP work, and the other people in the group may be nervous about covering for that individual or taking on that responsibility because the big headlines for ROP have all been about the liability payments. It's a big problem in missing these babies, and it puts everybody off. I think that's true for the pediatrie ophthalmology community as well. If the pediatric ophthalmologist is hesitant to do ROP screening and has a certain approach as to how he or she wants to do it and finds that the hospital basically refuses to do that, then the pediatrie ophthalmologist is now in a position of deciding whether he or she wants to provide service in that environment.
Gold: I think there's another important issue about the care of patients with ROP. It takes a great effort to follow these patients, to monitor these patients, to make sure that the hospital is scheduling the patients properly, to make sure that once these patients are discharged from the hospital, proper follow-up is given, appointments are made, and then, if the patients don't show up for their appointments, they are tracked. You have to be able to find them. Where are they? If they don't come to your office, unfortunately, you can't just say, okay, they didn't show up. We have to go and find them, and that's part of the hassle of ROP, whether it's a pediatrie ophthalmology office or a retina office. If the patient doesn't show, you can't just say, okay, it's a no-show patient. You have to go and try to track the patient down, and that's what we do in our office, specifically, as well.
Wagnen Dr. Jaafar?
Jaafar: I have to disagree with you a bit, Dr. Gold. I think we, as physicians, have taken a little bit too much on our shoulders. I really don't know where we physicians have accepted the idea that if a patient does not show up for an appointment that they have been told about, it is our responsibility to go and look for those patients. If we can, we have to. But if we keep talking about it, we've taken responsibility for something that, number one, is very difficult to achieve, and number two, is not our responsibility. When a patient is scheduled for surgery, why is it our responsibility to clear the patient for the insurance company? It shouldn't be. I think we should think about it a little bit more lucidly, get out of what we have accepted to do and concentrate on what we can do best as physicians, diagnose and provide treatment, inform the families about what needs to be done, and so on, and stop there.
Now let's go back to the question. I agree fully with Drs. Gold and Sprague about the retina specialists. Again, these are kids who take a lot of time and investment for the retina specialist, who must leave his or her practice, go to the NICU, and examine the patient. The nurses are busy doing other things. Ittakes about4 hours from door to door for the retina specialist to see that patient and then make the diagnosis and treatment plan. There is time investment and also loss of income. Most of those retina specialists belong to large groups, as Dr. Sprague said, and the large groups are putting a lot of pressure on their colleagues who are still willing to do ROP work. We really have to find a way to, number one, decrease the apprehension about the liability, and number two, make it as easy as possible. They're not going to make the same money as if they are in the office seeing adult patients. It needs to be made more reasonable for them to keep doing services that are badly needed.
Wagner: Do you want to comment on this issue, Dr. Sprague?
Sprague: I agree with Dr. Jaafar about this question of doctors being involved and doing stuff that's not quite medicine, but in this particular case, the relationship with the follow-up ROP problem and the doctor's responsibility goes to a global issue of the doctor-patient relationship. What is the doctor-patient relationship with the premature baby? These kids are in the hospital for up to 3 months. They have charts the size of telephone books. They've seen multiple specialists. They are cared for by a team of neonatologists, some of whom are more involved in process than others. The breakdown that we're going to discuss later occurs when people don't know exactly where this child is in the system, and that is where we get involved in the tracking paperwork. Our doctor-patient relationship is ongoing when the child comes out of the hospital and the hospital basically stops its responsibility. The patient is discharged and if you have agreed to see that child for ROP issues, you are then responsible for follow-up. Unfortunately, in that particular situation, that follow-up can be difficult. In this particular situation, I think they have to say that the doctor's medical practice or service is going to be responsible for that kind of follow-up. As Dr. Gold said, this is a big hassle. Some people have given wrong phone numbers, some don't have easy transportation, some don't speak your language, and some are very hard to deal with. You can only make a good faith effort to find them, and that's basically what you have to do. If you don't look for them, it's very different from if you sent them letters, sent a social worker, and all this stuff.
Gold: That's exactly the point I wanted to make. You can only do what you can do, but although it may not be standard of care, it is what is in risk management appropriate care. For example, I may go to an extreme in this situation, but in my practice, I have an ROP coordinator. We see, between myself and my partner, probably in the neighborhood of 40 babies a week in the hospital, plus babies that we see as outpatients, so probably in the neighborhood of 60 to 70 babies a week. It's impossible for us to be able to follow every single baby exactly. We have one or two people in our office, we have databases, and we do things that are maybe a little more than need to be done in other practices, but we have a protocol that we are able to try to follow these babies. If they do not show up, we send letters. We sometimes make phone calls. Again, as Dr. Sprague said, the phone numbers are often not correct. The names may be changed, the last names, but it is something that we're doing our due diligence to try, and we do the best we can. When we have a baby discharged from the hospital with stage 1 or more ROP, we're going to find that baby. We are not going to let that baby go, and we may take it to a different extreme, but we feel more comfortable in the end that we've tried. If it's a certified letter, if it's a phone call, even if it is having the State Department of Health and Human Services, in particular the Department of Children and Families, go and find these people, that's what we've decided to do. Again, it may be extreme, but we feel very comfortable going to that extreme to try to save some of these babies' vision.
Jaafar: I still need to comment on this. I don't disagree with you, Dr. Gold, that this is the best way to preserve the vision in every eye that we come across, but logistically, it's very difficult. We have recently hired an ROP coordinator at Children's, and we are trying to make sure that each patient who has been given an appointment and written instructions before discharge makes it to that appointment. If they're not seen, they are contacted. The difficulty in the logistics is that we see patients in the main hospital, and we have six satellite offices. We're trying to figure out the best way to make sure that the child who has been given an appointment in one of the satellite offices and doesn't make it is also tracked by the coordinator. Then we give an appointment to a child who has been laser treated by the retina specialist to go and see the specialist either in die eye clinic or in the office. But if you have a retina specialist who is seeing 40 or 60 patients a day in a big practice of 15 retina specialists, how is that patient with ROP going to be identified and tracked? The protocol calls for the staff in that retina group to call the coordinator and she will go from there. The logistics are very difficult, and if we are taking this as our responsibility, I think we are taking a big bite that we really cannot swallow. Also, we are now talking about patients with ROP, but how about the retinoblastoma patients, the glaucoma patients, and so on? Some of them are going to go blind if they don't come back, and some may have a tumor. If we start accepting that it is our duty to get out of the office into the society and grab every patient, I don't think we can accomplish that.
Gold: Well, I think it's a nightmare, and I thinkyou make a perfect point. It's not only the patients with ROP. In our practice, we have three offices. Whenever a patient does not show up for an appointment, there is also a protocol for trying to contact these people. We review the charts, and yes, it's a hassle to have to do that, but because of the relationship that we've established, we're going to make sure that we're doing everything we possibly can to make sure these people don't fall through the cracks. Do people fall through the cracks? Unfortunately, yes, they do. But it is a nightmare. I don't disagree with you. It's not going to be perfect for every person.
Jaafar: Especially in practices that see a smaller number of ROP patients than yours. In your practice, you have to accommodate a large special constituency, but in a practice where you see a smaller number, it's going to be much harder.
Gold: Right, and you can adapt accordingly. Everybody has to have a plan. I think that's the key.
Wagner: One of the problems that we're experiencing in New Jersey is that because of the retinal surgeons' unwillingness to treat some of these kids, in many of the peripheral hospitals that have high-level NICUs, the kids are being screened by pediatrie ophthalmologists. They are being transferred to the university hospital when it's deemed that they need treatment. This is a big issue. Not only is it expensive, but I have also read that transporting babies between hospitals is associated with an increased risk in the progression of ROP, which would make sense, maybe because of the dynamics of the oxygen delivery in the transport vehicle and things like that, and it's something that's occurring. I don't know if you're experiencing that at your hospital. Are they bringing babies in from other places?
Jaafar: Yes. That's our agreement with the peripheral hospitals. If the child is going to need treatment, the child is transferred to the main hospital, Children's, in our case, and the transferring hospital has to agree that the child is going to stay in the main hospital until the retina physician says it's okay to be transferred back. The retina specialists are concerned about what happens if the child is transferred the next day after the laser treatment is done and there is no follow-up. We go back to the same thing.
Wagner: Right. We've spoken about these issues. Maybe we could talk about some measures that could be taken to improve this climate in the hospitals of the relationship between the pediatrie ophthalmologist and the neonatologist. Dr. Gold, are there specific contractual relationships between hospitals and physicians that you are aware of and that you're involved with? How might these be ideally structured?
Gold: It is similar to being on call for a hospital, and there is also a wave around the country of reimbursing physicians for being on call for the emergency room. Basically, as a pediatrie ophthalmologist, you are on call 24 hours a day, 7 days a week, with you or your group, for the NICU. So, you are responsible for all pediatrie ophthalmic consultations, whether for ROP, for congenital anomalies, for ruling out glaucoma, etc. The hospitals are speaking to pediatrie ophthalmologists in that regard to contract for services. There are two hospitals in our area, and we are contracted with both of them to be their pediatrie ophthalmologists 24/7.
Wagner: Dr. Jaafar?
Jaafar: The situation becomes a little bit more difficult when you have the retina specialists treating and they are not full-time staff at that hospital. What the retina specialists have been asking, which is the minimum, is to cover the liability exposure over and above whatever they carry themselves, which in a way, makes sense. It does make sense to the retina specialists, the pediatrie ophthalmologists, and the patients in the NICU. However, the hospitals say, well, we cannot cover somebody who is not our employee because of the anti-kickback regulation. It's a much more involved issue than we think about, as physicians. To make a long story short, one of the scenarios is to have hospitals hire retina specialists, and in this way, these specialists become part-time employees of hospitals and they can cover the liability exposure. The problem with that is where does the money come from? Who bills or collects from those patients, and so on? Is it the hospital's responsibility now, or is it the retina people's? So, we go back to logistics issues. It's easier in places like Dr. Gold's, where they have a very large premature patient population they have to serve versus the smaller hospitals, where they have one or two patients a year who require treatment and where the coverage comes from the community.
Gold: Well, in ours, basically, you're an independent contractor, but the retina specialists also are contracted in a similar way to be on call 24/7 at our disposal if we need them to come in for a consultation. It's different logistics, no question about it.
Wigner: Dr. Gold, the liability coverage, the insurance or malpractice coverage, is it part of your regular coverage, or is there something independently going on at the hospital?
Gold: It differs from one hospital to another, but the issue is that if there is a medicolegal action against a doctor for ROP, it's more than likely going to be for far more than the limits of your liability coverage. If you are indemnified by the hospital as part of your contract, then the hospital's attorneys are the first line of your defense, with your malpractice carrier being the second line. If you are not indemnified by the hospital, then your malpractice carrier would be your primary line of defense. We did not make indemnification an end all, and one of the hospitals did not even want to talk about it.
Wigner: Dr. Sprague, do you have experience with trying to contract with the hospital or experience with people trying to set up contracts?
Sprague: I've had some experience. You're sharing or shifting liability for ROP services. One way of doing it is to get indemnification from the hospital or to have the hospital buy additional insurance or pay you for whatever extra insurance you get. There's a lot of difficulty with all of that. You're talking about a child who's been in the hospital for 3 months, with multiple levels of care, with multiple providers. If ROP progresses, there may be a lawsuit. If the hospital and the ophthalmologist are not on the same page, the hospital can cut its losses and leave the ophthalmologist out. I haven't seen that in ROP cases, but I know of another case where that's happened. I think that having the hospital and the ophthalmologist together is important. Now, we're talking about private insurance for a private physician compared with the hospital paying for insurance. If the hospital doctor gets into trouble, the hospital is in trouble as well. For those who are in private practice, having an arrangement with the hospital is very important. One of the difficulties that people look at is, well, I've got this rider, the hospital is going to provide this rider for me. It's going to cover me as far as settlement. That doesn't prevent the hospital from going in its own direction in its own defense. You may be covered financially, but you will still have a black mark on your record.
Wagner: If you could come up with an ideal system, for example, in a relatively large hospital that's maybe without real fulltime employed ophthalmologists, either retinal surgeons or ophthalmologists, pediatrie ophthalmologists, that has a high volume of kids who need to be evaluated, is there an ideal system that you'd like to see?
Gold: I don't think there's an ideal system, nor do I think there ever will be an ideal system. I think that your relationship with the neonatologists is imperative, and hopefully, a relationship with the hospital that you all can get along with. Again, going back to what I said in the beginning, although there may be financial and medicolegal ramifications, the most important thing is that we're on the same page with the neonatologists. We want to be able to screen these babies and make sure that we preserve their vision, and there are a lot of different ways to do it, and there's no ideal situation, but you want the hospital to support you as well as you support them.
Jaafar: As Dr. Sprague said, these kids have many, many problems. The eye disease is not at the top of the list for the neonatologist. The eyes are also not at the top of the list for the family. These are children who have many, many medical and systemic problems, and these are families who have a huge socioeconomic burden. The family has many concerns beyond the eye disease and does not have the eye disease as the number one priority. The ideal system that you asked about would be to give the family a great deal of information at the initial consultation, the very first time the pediatrie ophthalmologist is asked to come to the nursery. Good contact with the neonatologist and good direct contact with the parents is very, very important. Unless we have that, the family is not going to come back for follow-up.
Wagner: Dr. Sprague, would you like to add anything?
Sprague: Dr. Gold's point that we'll never have an ideal system, I'm sure that's correct, but one of the things that you can do to mitigate that problem is to try to fill in the gaps. That means a policy that assigns responsibility for all the gaps that we've been able to identify. There are a number of them, but the fact is that the neonatologist is responsible to identify these babies and the hospital is responsible to provide a person who does nothing but coordinate their care and their scheduling, just in the hospital. The hospital is responsible for providing a discharge summary and discharge care that does not let them fall through the cracks by being clever by getting phone numbers or whatever is needed. That needs to be in writing, so it's clear who is responsible for what, and implementation has to be done with full cooperation. It may not be an ideal setting in terms of trying to plug the dike that we've been talking about, but you can put up a pretty good dike to really cover yourself in all these ways and make sure that these kids are going to be covered in terms of what they're cared for in die hospital. If the hospital agrees, you're at least reducing risk. If die hospital is unwilling to be cooperative, it is very frustrating. For example, making the hospital ROP coordinator a low-grade unit secretary who doesn't understand these kinds of questions, that is just not acceptable, and the economics of the NICU are such that the hospital should be able to help. So, that is advice for the pediatrie ophthalmologist, basically saying, well, this is not totally an insurance issue, it's not a financial issue. It's good, common, straightforward medical care, and they're not doing it.
Wagner: Great. I think, in some ways, it's unfortunate that the availability of such excellent care is compromised by many of diese nonmedicai issues, and these things have to be worked out. Thank you all for coming.
This Eye to Eye was conducted on Saturday, November 11, 2006, during the annual meeting of the American Academy of Ophthalmology.