Ophthalmologists Confront Affordable Care Act Complications

Caroline Helwick

November 28, 2013

NEW ORLEANS — Ophthalmologists are wondering what the future holds for their specialty in light of changes introduced under the Affordable Care Act, and are gearing up for innovations to adapt in this time of uncertainty.

"I think the future of ophthalmology continues to be bright; it's certainly better than the future of the Affordable Care Act," said John Clarkson, MD, executive director of the American Board of Ophthalmology, and professor of ophthalmology and dean emeritus of the University of Miami Miller School of Medicine. "Still, we must continue to adapt to the changes that are underway," he said.

Dr. Clarkson and other ophthalmologists and policy experts gathered here at a the American Academy of Ophthalmology (AAO) 2013 Annual Meeting to discuss what the Act means for their field.

Paul Lee, MD, from the Duke Eye Center in Durham, North Carolina, noted that "regardless of what happens with the Affordable Care Act, there are things we need to do and things we can consider" to ease the pain of transitioning to a new system of healthcare delivery.

Presenters talked about the growing demand for healthcare and the corresponding need for an appropriate workforce and for emerging mandates to demonstrate quality of care and reduce costs.

Many of the speakers suggested that the challenges faced by ophthalmologists could also be seen as areas of opportunity.

One of the principal ways the Act will affect ophthalmology is by increasing the number of people insured, many of whom need vision services, Dr. Lee said.

It is estimated that by 2019, there will be 20 million new people insured through Medicaid and 30 million insured through the healthcare exchanges. Employers will provide 69 million to be insured.

"That's the kind of market we are looking at," Dr. Lee said. Some of the growth will be moderated by increased cost sharing, he added. There is a linear relation between out-of-pocket expenses and the use of healthcare resources, and many plans within the Act will have high out-of-pocket costs.

"We are looking at uncharted territory in terms of demand utilization under the lower-paying plans," said Dr. Lee. "We know we have to become better at preventing illness and managing our sickest patients," he said. He called on ophthalmologists to become "even more productive," and to find alternative revenues under fee-for-service streams.

Accountable Care

Dr. Lee suggested that ophthalmologists consider integrating into an accountable care organization, but he acknowledged that the new models have some "fundamental structural problems" that could lead to "unintended consequences."

What has already become clear, according to Dr. Lee, is that new models, such as accountable care, have ramifications for the way ophthalmologists organize themselves as practices.

"The Affordable Care Act has the net effect of pushing people, by means of a variety of regulatory incentives and disincentives, toward larger group structures," he said. "It will be harder for solo and small group practices to keep up with the regulatory burden. There will also be financial constraints of being able to afford the various improvements necessary to survive."

Dr. Clarkson said he agrees. "Whether organizational practices such as accountable care organizations will work out or not, ophthalmologists are being pushed, and we will need to find a model that is more workable for us."

Dr. Clarkson noted that because of the predicted workforce shortage as the population ages, ophthalmologists will need to refine the team approach to healthcare delivery and adopt systems such as home disease monitoring to reduce the need for office visits.

He predicts that healthcare disparities will worsen, largely within states that have rejected the Medicaid expansion and will therefore relinquish federal funding.

"The hospitals thought the Affordable Care Act was going to provide insurance coverage or Medicaid to all individuals, and they therefore agreed to reduce the amount of money they were receiving for their disproportionate share. Hospitals in states that refused the Medicaid subsidy are going to see hits in the range of $50 to $100 million a year," said Dr. Clarkson. "This will clearly have an impact on the care of those who need it most."

The bundled payment model also carries problems for ophthalmologists, added Michael Repka, MD, from Johns Hopkins University School of Medicine in Baltimore.

The aim is to reduce expenditures by aligning the financial incentives for providers, but the emphasis will be largely on primary care, and specialists will be ignored, he said.

Bundling Opportunities in Ophthalmology

UnitedHealth Group, Human, Aetna, and most Blue Cross and Blue Shield plans are making efforts to initiate bundling, but there have been no clear successes yet in the outpatient setting, explained Dr. Repka.

In ophthalmology, there are potential bundling opportunities for the treatment of age-related macular degeneration, diabetic retinopathy, glaucoma, and other chronic eye diseases, he added, but whether authorities will recognize these as such remains to be seen.

But not everything under the Affordable Care Act spells doom for ophthalmologists, said Dr. Clarkson.

He spoke with Massachusetts ophthalmologists — both in private practice and academia — to assess their feelings about so-called Romney care in a state where 98% of the population is now insured. The rise in medical expenditures has abated and healthcare is now the state's largest employer.

 
Ophthalmologists are innovative.
 

"The academic institutions indicated that sequestration has been more of a problem than Romney care, and both academic and private ophthalmologists feel they are better off now than before it was instituted," he said.

William Rich III, MD, medical director of health policy for the AAO and an ophthalmologist from Northern Virginia Ophthalmology Associates, added that in spite of affordable care and increasing regulatory demands, "ophthalmologists are innovative."

"Despite cuts in cataract surgery, filters, injections, and so forth, looking just at the Medicare population, our revenues increased from $3.7 billion to $5.9 billion in just 7 years with us working no more hours a week," Dr. Rich said. "This doesn't diminish the ridiculousness of the bureaucratic demands in our practices, but we have figured out new methods for productivity," he added.

Randall Olson, MD, from the University of Utah School of Medicine in Salt Lake City, explained that "we have just finished interviewing new resident candidates, and compared with other fields, these young physicians see ophthalmology as one field with a bright future. I happen to agree."

Dr. Lee reports financial relationships with GlaxoSmithKline, Genentech, Medco, Merck, Novartis, Pfizer, Quorum Consulting, and Vitaspring Health Technologies. Dr. Olson has consulted for Abbott Medical Optics, Allergan, and BD Medical–Ophthalmic Systems. Dr. Clarkson and Dr. Rich have disclosed no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2013 Annual Meeting. Presented November 19, 2013.

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