Fee-splitting and Co-management in Optometry and Ophthalmology: the Evolving Landscape of Eyecare

(Part two of a two-part series)
By Evra Taylor

legalanglePart one of this series examined the changing legalangle2relationship between the worlds of optometry and ophthalmology and the concept of fee-splitting. As in Quebec and other parts of Canada, professional associations in the U.S.have taken a strong stand against this dubious practice, which relegates the needs of patients to less than top priority.

The American landscape

A number of medical and ophthalmological organizations in the U.S.have implemented guidelines stipulating that the surgeon is responsible for postoperative care, which can only be ceded in uncommon circumstances. A joint position paper of the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) on ophthalmic postoperative care states, in part: “The operating surgeon has the responsibility for the postoperative care and disapproving if economic considerations drive the decision to transfer the care of a patient following surgery.

Although this obligation may be ethically ceded to another healthcare provider, it is anticipated that this will be an exceptional, rather than a routine, occurrence. If the reason for sharing postoperative care with another provider, however well trained, is economic, specifically as an inducement for surgical referrals, or the result of coercion by the referring practitioner, it is patently unethical and, in many jurisdictions, illegal”.

The position paper highlights one of the most important concerns, namely, “The transfer of care must not occur unless it is clinically appropriate and in the patient’s best interest”.

Patient co-management: a new norm

As guidelines and regulations disallowing fee-splitting have been instituted, a shift to more “normalized” – and ethical – patient-co-management has taken place. The practice of medicine in general, including the eyecare sector, has transitioned from a lone practitioner model to one based on a collaborative team of professionals. A new paradigm has emerged in light of the fact that optometrists network with ophthalmologists, and that they see more patients on a more frequent basis than do their surgeon colleagues.

In one practice model, optometrists would refer patients to ophthalmologists whenever surgical intervention was necessary, and they would “keep” the patient since their primary revenue stream is the six-month eye check-up. This applies especially in the case of older patients for whom they would likely do a pressure check for glaucoma and examine the back of their eyes for diabetes, for example.

In the above scenario, the eyecare cost would be split. With a glaucoma patient, for instance, the optometrist would charge for patient visits and the ophthalmologist would assess how far the glaucoma had spread and whether surgical intervention was warranted. The ophthalmologist would charge for his or her portion; the patient would return to their optometrist for regular visits and the optometrist would bill accordingly. This is not fee-splitting: it’s co-management or, as some professionals have deemed it, “patient splitting.” In co-management, the patient is being managed by both sides, with each one charging their respective fee.

The current reality is that in some instances, “shared care” is a function of lack of resources. In rural areas where people don’t have easy access to ophthalmologists, postoperative surgical care is handled by optometrists. Some practitioners hold that optometrists should be able to handle it: in light of optometrists’ current advanced level of training, they maintain the point of view that either an OD or an MD is equipped to handle patient follow-up.


While fee-splitting represents the “bad news” of the day, the response of various governmental bodies and professional associations in both Canada and the U.S.represents “good news”. These groups have provided clear guidelines that outline the framework within which optometrists and ophthalmologists divide and share patient care.

Given that the Hippocratic Oath includes the promise “to abstain from doing harm,” and in light of the aging population and increased stress on the healthcare system in Canada, patients must be assured that their health and safety is at the forefront of every practitioner’s mind and practice.