Nagging Questions About Government Plans for Ophthalmology

Laird Harrison


April 14, 2016

In This Article

Bipartisan Legislation That Affects Physicians

Medicare for all! Repeal Obamacare! Import drugs from overseas! Open health insurance markets across state lines!

Tuning into coverage of the US presidential campaign, in which proposals like these have been fervently advocated, you could easily get the impression that the outcome of the election will soon transform the nation's healthcare system.

But according to policy experts, the impact of the candidates' proposals will fall short of what they claim. Meanwhile, the brouhaha over them has obscured bipartisan legislation and regulations that will soon hit most Medicare providers—including ophthalmologists—in the bottom line.

Coming changes include incentives to reduce the cost of care by using less-expensive "equivalent" drugs for certain ophthalmic conditions; accepting a single "bundled" payment for all the services involved in an "episode of care"; accepting payments based on outcomes rather than procedures; and accepting flat fees for patient care (in other words, capitated payments).

How Much Will Healthcare Actually Get Reformed?

Presidential candidates prefer to talk in bold strokes. On the Republican side, New York real estate developer Donald Trump, Texas Senator Ted Cruz, and Ohio Governor John Kasich have vowed to repeal the Affordable Care Act (ACA) and enact more market-based policies. On the Democratic side, Vermont Senator Bernie Sanders has promised to create a single-payer system by expanding Medicare to cover everyone in the country, and former Secretary of State Hillary Clinton has vowed to expand the ACA to people who still don't have health insurance.

But experts who study healthcare policy say that their sweeping proposals stand little chance of being enacted.

"We're not going to [institute] a single payer," says Robert Berenson, MD, a former payment policy director at the Centers for Medicare & Medicaid Services (CMS), who now studies healthcare policy at the Urban Institute, a liberal economic and social policy think tank. "We're not going to rescind the Affordable Care Act. Congress is not about to do either one of those things."

Dr Berenson points out that even when Democrats controlled the presidency and both houses of Congress, proposals to create a nationalized healthcare plan for all Americans went nowhere. Likewise, Republicans would need huge majorities—majorities that they do not currently have—to repeal the ACA.

Not only does the balance of Democrats and Republicans in Congress prevent either side from gaining the upper hand, but powerful special interest groups also have a lot invested in maintaining the status quo.

"We have a much larger private healthcare system than other countries, and it's really good at lobbying," says Robert Field, PhD, JD, MPH, professor of health management and public policy at the Dornsife School of Public Health at Drexel University in Philadelphia, Pennsylvania. "It's why the government can't negotiate drug prices, why specialists get paid more [than generalists], and why we can't import drugs."

Also, a lot of consumers would scream bloody murder if they lost their healthcare coverage if the ACA were repealed. Similarly, a lot of others who are happy with their employer-based coverage would scream bloody murder if they had to accept different coverage under a universal plan.

But despite their loud disagreements, Republicans and Democrats have actually agreed on some pretty substantial healthcare legislation. Without much fanfare last year, for example, they passed the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act of 2015 (MACRA) by a vote of 92-8 in the Senate and 392-37 in the House of Representatives. Starting next year, ophthalmologists (and other doctors) will feel the effects of the new law.

Meanwhile, new rules for Medicare Part B drug reimbursement could affect the way that ophthalmologists use the drugs bevacizumab, ranibizumab, and aflibercept this year.


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