Ethical Lines Blur as Eye Surgery Gains Popularity
When laser eye surgeries began to surge in the last couple of years, optometrists feared their practices would get burned as more people shed glasses, contact lenses and perhaps even optometrists themselves.
Not only have optometrists avoided extinction, they have managed to profit from the boom, increasingly cutting lucrative deals to refer patients to eye surgeons and laser centers in exchange for performing examinations before and after laser surgery. An estimated 800,000 Americans are expected to pay an average of $4,000 for the vision-correcting procedure this year, almost twice as many as last year.
But as optometrists reap fees of as much as $1,000 per laser eye patient, they have come under increasing fire from doctors and medical ethicists who say the financial arrangements encourage unnecessary laser surgery and make profits a higher priority than patient welfare.
Critics say optometrists aren’t as qualified as ophthalmologists--doctors who perform eye surgery--to detect infections and other complications from laser surgery. What’s more, a growing number of optometrists have taken financial stakes in eye laser centers in which they are referring patients, sparking the kinds of ethical questions that were raised when physicians were known to have a personal interest in MRI centers that scan patients and provide images of such areas as the brain, joints and spinal columns.
Optometrists, who examine eyes, prescribe corrective lenses and treat some eye disorders, counter that they know their patients’ eyes better than eye surgeons and are qualified to provide necessary care.
Referrals That Earn Fees Raise Questions
Jon Morrison is among the legions of optometrists who have benefited from the popularity of laser eye surgeries. In the last four years, the 52-year-old owner of Lake Forest Optometry in Orange County has referred about 200 patients to ophthalmologists, picking up fees for the preoperative and postoperative exams. Morrison often sends patients to an eye center in which he is a part owner.
“I think [laser eye] surgery is among the best things to have happened to my business,” said Morrison, who estimates he generates more than 10% of his revenue through his arrangement with eye surgeons.
Morrison, an optometrist since 1975, won’t say how much he has invested in Pacific Laser Eye Center in Irvine. But he says that he tells every patient whom he refers there that he owns a stake in the center.
However, many optometrists fail to reveal their financial arrangements with eye surgeons, raising all sorts of ethical questions, experts said.
“You want to know whether an optometrist is referring you for this surgery because it’s best for you or because they’re making money from referrals,” said George Annas, a professor of health law at Boston University School of Public Health.
In April, Dr. Dave Edmiston, a Sacramento ophthalmologist, said he dissuaded a patient from having surgery. The man, who had come to Edmiston for a second opinion, was a poor candidate for the procedure, but had been encouraged by his optometrist to have the operation, the ophthalmologist said.
“I’ve seen patients who were pushed by optometrists to have it done,” Edmiston said. “The referring [optometrist] was just after an inflated fee.”
Harvey Hanlen, president of the American Optometric Assn., rejects such characterizations. If money were truly their biggest motivation, optometrists would try to keep their patients in glasses and contact lenses, which would generate more income over the long run than fees tied to eye surgery exams, he said.
Rather, optometrists are referring patients for laser eye surgeries because the procedures are safe and many customers want them, Hanlen said.
In the surgery, a laser is used to reshape deformations in the cornea that cause nearsightedness or farsightedness. The outpatient procedure usually takes just a few minutes, and while it doesn’t work for everyone, the surgery has been gaining popularity as prices have fallen sharply as a result of intense competition.
The Medical Board of California, which licenses and regulates physicians, says it is investigating a handful of complaints regarding business ties between optometrists and ophthalmologists, including possible kickbacks and improper referrals. Spokeswoman Candis Cohen said she could not comment about ongoing investigations.
By contrast, the California State Board of Optometry said it has received no complaints about alleged irregularities stemming from these financial deals.
Although state law makes it illegal for licensed medical professionals to receive a fee for referring patients to other specialists, supporters of these optometrist arrangements insist that the deals are proper because optometrists are being paid for a service--performing eye exams before and after surgery. Ophthalmologists can but often don’t perform such exams.
An estimated 75% of the nation’s optometrists have arrangements with ophthalmologists to “co-manage” patients. The American Optometric Assn. recently said the arrangements are ethical and legal, provided such partnerships serve patients’ interests.
But others aren’t so sure the patients’ best interest is being served.
These relationships “create a strong financial incentive for optometrists to choose ophthalmologists based on how much they pay rather than on their skills or reputation,” said Marc A. Rodwin, a medical ethics expert and associate professor of law and public policy at Indiana University.
Some Say Patients Gain Most From Deals
The controversy has led to litigation.
Bay Area ophthalmologist Dr. William Ellis has sued two eye surgeons in Superior Court, accusing them of paying off optometrists for patients. Ellis claims that he’s losing more than $100,000 in business a month because of these cozy relationships and that optometrists are being overpaid for the work they’re providing.
In a strongly worded statement, the American Academy of Ophthalmology condemned the financial arrangements between optometrists and ophthalmologists, arguing that eye surgeons should perform preoperative and postoperative care, except in extreme circumstances, such as when a patient cannot travel to a surgeon’s office because of the distance.
“Optometrists don’t know what they don’t know,” said Dr. Paul N. Orloff, a New York ophthalmologist who helped craft the academy’s voluntary guidelines. “They are convinced they do a fine job and are equal to ophthalmologists, but I don’t believe it.”
Eye surgeons’ attacks on optometrists are motivated by greed, said Dr. Les Walls, president of the Southern California College of Optometry in Fullerton. “They want to steal our patients and have all of the patient care and fees to themselves,” he said.
Morrison, the Lake Forest optometrist, argued that patients gain the most when optometrists and ophthalmologists work closely together. As an example of this cooperation, Morrison pointed to Pacific Laser Eye Center Management Group Inc., a company near Sacramento with outlets in seven cities, including Irvine, Torrance and La Jolla.
The fast-growing company was founded four years ago by a pair of ophthalmologists and 22 optometrists concerned about the effects of the growing popularity of laser eye surgeries.
“We wanted to do something to protect our practices, take care of our patients and make sure we were part of it,” said Pacific Laser board member Palmer Lee, an optometrist.
Unlike many other laser eye surgery outfits, Pacific Laser sells optometrists and eye doctors a stake in the company--at $2,500 a share. An estimated 210 optometrists and 12 ophthalmologists own about 40% of the business, Chief Executive Randy Fuerst said.
These optometrists, along with 460 others in the Pacific Laser network, handle most postoperative and preoperative care, earning more per procedure than even the surgeons.
Business is booming at Pacific Laser. Sales are expected to rise to as much as $18 million in 2000, up from $10 million last year, Fuerst said, adding that all centers are profitable.
Pacific Laser received a strong endorsement from Manhattan Beach resident Sandra Sims, 54, who opted for surgery after wearing glasses for nearly half her life because of farsightedness.
Her optometrist, John Funnell, who has a financial stake in Pacific Laser, referred Sims to the Torrance center. The total cost, including exams by her optometrist before and after the surgery: $4,500.
Sims, who was able to toss her glasses, said she had no concerns about her optometrist’s financial ties to Pacific Laser, which Funnell had disclosed to her.
“My optometrist wanted excellent care for me and wouldn’t have referred me to a place he didn’t think was the best,” she said.
