COMMENTARY

Understanding What the ACA Means for Ophthalmology

American Academy of Ophthalmology 2013

Roger F. Steinert, MD; Nancey K. McCann; Brock K. Bakewell, MD

Disclosures

November 22, 2013

In This Article

Untried and Untested Models

Dr. Steinert: Putting on my hat coming from an academic medical center, we have an entirely different set of threats and concerns. We are still [part of an] ambulatory [surgery center], and yet we are part of the hospital-based system. We are getting dragged along without any real input or playing a major role in the decision-making, and yet, those decisions potentially are going to have a huge impact on our patient access. If you are doing a reasonable amount of tertiary care, suddenly things are carved up and patients are discouraged from coming to you, if not out and out prevented from doing so. You worry that this is an added strain on a system that is already highly challenged to survive. Do you have any thoughts about where this is going for academic medicine -- not just ophthalmology, but academic medicine in general?

Ms. McCann: I don't. I also would like to say that these models are untested. There is no proof that they save money or improve quality, so that is a big question mark.

Dr. Steinert: Wasn't there a story that the model ACOs, once their contract was up, they said they were walking away from it? They were not going to continue.

Ms. McCann: Yes. Those models were a little bit different, but yes, they did not sign up. They did not re-sign. That is what I mean when I say these are untested models. No one knows whether they will save any money or improve quality of care. Quality of care and improvement are hard to measure, and you have to have risk adjustment. We could have a whole conversation just on that. Proper risk adjustment and patient compliance are huge issues -- how you have control over what the patient does.

I will use glaucoma as an example. Much of the outcome depends on the patient continuing to be compliant, using the drops, attending their visits, getting the pressures checked -- all of those things. How can the physician be in total control of that? Those are the kinds of issues that we continue to raise about these different models. The medical home is very similar. The medical home is where the primary care provider controls all of the care. Do you see a theme here? It is all about primary care, and that is the future. If you look at all the different proposals, they are talking about primary care controlling everything and money being redistributed from specialty care back to primary care. Primary care prevents the chronic diseases and prevents patients from being hospitalized and so forth. That is where we are headed.

Another point that I would like to make is that this is bipartisan. It is important for people to realize that this is not a Democratic idea and it is not a Republican idea; it is both of them together, and very few things in Washington are bipartisan these days. So these are not going away. The trend is to reward physicians and pay them based on quality, outcomes, and efficiencies. Even though a lot of these things have been untested, we are moving away from fee-for-service. The ACO model is based on fee-for-service right now, and MedPAC, which is the advisory body to Congress, had a meeting last week and was talking about the fact that with the way ACOs are modeled now, on a fee-for-service basis, how can they control costs? They can't keep patients in the system. A few years from now they might decide to change this. That could happen.

Dr. Bakewell: It is all experimental. We really don't know that any of these models are going to pan out, and that is one of the things that is very frustrating. This is being thrust on us without it being tested thoroughly, so I am sure that there are going to be modifications down the road. Right now it is kind of scary because we don't know what to expect for the future.

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