One on One with Kenneth Tuck, MD

It was a significant year on the calendar and Kenneth D. Tuck, MD, found it to be a significant year in the history of the American Academy of Ophthalmology to be the organization’s president.

The year 2000 will be remembered in ophthalmology for the introduction of a controversial statement on comanagement of surgical patients, the first (perhaps faltering) steps toward a “patients bill of rights” and, on the most positive note in years, the slowing and reversal of major cuts in reimbursement for eye care under the Medicare program.

At each development, Academy president Dr. Tuck was there to issue a statement on the position of organized ophthalmology. He began his term by emphasizing the importance of political advocacy, and as our interview with him shows, that emphasis has been carried throughout the year.

A 1958 graduate of the University of Virginia School of Medicine, Dr. Tuck completed his fellowship in general ophthalmology at the Mayo Clinic in 1964. Today he is in a private group practice in Roanoke, Va. We spoke with Dr. Tuck about the activities of the Academy during his tenure and its goals for the future.

by Joseph Hoffman
Editor in Chief

Ocular Surgery News: Let’s start with the annual meeting. What sort of new events, features or improvements are in store for the ophthalmologists who attend?

Dr. Tuck: Technology is the theme of the whole meeting – the impact of technology on education, practice management and patient care. The opening session and the subspecialty days will emphasize that, as will the Technology Pavilion.

I think the Technology Pavilion is going to offer a lot of opportunities for ophthalmologists to update themselves, to become familiar with the new technologies that are available and begin to prepare themselves to work in the electronic world. We look toward a future with the e-Academy, and this year we are in the beginning stages of that.

OSN: What do you mean when you say “the e-Academy”?

Dr. Tuck: It’s the new electronic Academy. We know that in the future members will be looking toward receiving educational materials and services electronically. Over the next few years we’ll work toward offering all of our educational materials and services electronically as well as in print.

OSN: I suppose this is the next step in the trend that started with renaming the Academy’s official publication EyeNet.

Dr. Tuck: Right.

OSN: And last year the Academy introduced a service to help members set up their own Web sites.

Dr. Tuck: That is correct. The Academy’s member Web site also is being redesigned and will be updated over the next 3 years so that our members can have access to whatever they need, when and where they need it.

And then there is the super Web site Medem, which the Academy along with other prestigious medical associations have developed. This site makes health care information available directly to patients or through individual physician web sites, which is what the Academy has been providing to our members.

OSN: That’s interesting. The electronic Academy is not just a service for the physician members, but a large component of it is directed toward the public.

Dr. Tuck: Yes, absolutely. The Academy, the American Medical Association, the American Academy of Pediatrics and several other groups have recognized the importance of patients having access to information that they can trust and that will be updated on a regular basis. It will be a comprehensive site based on the type of information that is in the peer-reviewed literature.

OSN: One of the high-profile things the Academy did in the past year was work with the American Society of Cataract and Refractive Surgery (ASCRS) in drafting the joint statement on comanagement, which got a lot of attention.

Dr. Tuck: You’re right there. This has been a year that we have tried to focus upon unity in everything: how we do business and how we communicate with one another, with the rest of medicine and with the public. This was one of the early examples of where the Academy worked with ASCRS to develop voluntary guidelines in response to an outcry from the membership of both organizations to provide them with some guidance.

A joint committee from the Academy and from ASCRS worked on the statement, and then it was presented to our boards for approval.

OSN: I understand the Council of the Academy was involved as well.

Dr. Tuck: Yes, this was all supported by the Council, of course.

OSN: The debate over the statement seems to be continuing. The single greatest objection is probably the lack of an explicit statement on patient choice. The Academy has made their position clear that through the suggested requirements for disclosure and consent, patient choice is addressed.

Dr. Tuck: Right. If the patient is given all of the relevant information, information that is to give informed consent, then patients do have a choice.

OSN: So will there be any further statements coming from the Academy on the issue of comanagement?

Dr. Tuck: No. There has been strong support for the guidelines from our membership. There have been questions from members regarding the interpretation of the guidelines and what they should do, and we think that is evidence that it is truly influencing behavior. Our members are taking another look at their comanagement arrangements.

OSN: So would you say that the release of the statement had the intended effect, at least of getting people to pay attention to the issues?

Dr. Tuck: Yes. The issue is to be sure that quality of care for the patient is never sacrificed. The patient must always be first in the consideration of the operating surgeon when deciding whether to comanage or not. And there are instances where it is considered appropriate. The Office of the Inspector General has eliminated the legal safe harbors for cataract surgery in particular and comanagement arrangements in general.

OSN: Some of the other big news in recent months was the surprising move by the Wisconsin board of optometry. (Editor’s note: This summer, the Wisconsin Optometry Examining Board unanimously approved a motion stating that the use of lasers was within the scope of practice for optometrists. Only a few weeks later, the board rescinded the motion in response to the protests of state lawmakers and other lobbying groups and in an effort to clarify the intent of the original motion.) The Academy got involved there, at least in a support role, with the Wisconsin ophthalmologists.

Dr. Tuck: The Academy is a co-plaintiff in a suit there. The state medical society in Wisconsin is also participating in that, as is the American Medical Association. So this is another example where you can seen our coming together to deal with issues of concern in patient care.

OSN: How does the Academy decide to get involved in an issue like that on the state level?

Dr. Tuck: Well, the Academy and the states work closely together. We have a state affairs secretariat, and there is excellent consultation between the Academy staff and the leadership. Ultimately, we get involved because the state asks us to get involved.

OSN: Some of the state ophthalmology society leaders feel maybe a little under-supported — or at least under-funded – by their members when they compare themselves to the state optometry societies. Why do you think that is?

Dr. Tuck: I think there are a number of reasons. One is that some ophthalmologists are not involved because they do not recognize the real importance of their involvement in the state society activities. That goes far beyond the scope of practice issue. We all know that major legislation occurs at the state level covering patient care issues, especially those dealing with managed care and its impact on how we are able to take care of patients. We do provide information to all of our members emphasizing the importance of getting involved, but sometimes you already have to be involved to truly recognize what is at stake. Eye MDs are quite busy with their practices, and we don’t always stop to consider the fact that advocacy is an extremely important part of patient care.

This is the basis for my involvement. I have felt from the very beginning of my medical career that being politically involved is another way of advocating for our patients. Our continuing medical education is extremely important, but we also have to advocate for patients to ensure that they have access to us and that we have timely and adequate reimbursement. If we can’t make ends meet, we can’t take care of patients and in the end, quality of care does suffer.

But we alone cannot always make our voices heard. We need the help and support of our patients. We heard that in Washington when it came to the patient protection bill, for example. All of those quality of care issues applied at the federal level to that bill, and we were able to reach out to the public and help them recognize the importance of it.

OSN: The Academy also invites doctors to write to their representatives on appropriate issues.

Dr. Tuck: Right. And the Academy is a member of the Patient Access Coalition, of which over 65 specialty groups are part. So far, we have sent over 55,000 e-mails to Congress on this issue through a cyber-advocacy Web site. We plan to engage at a grassroots level again to start calling congressional representatives trying to press for some meaningful reform in this Congress. We think the patient protection bill is an issue that is extremely important to our patients, and we think that it’s an important health care reform issue this election year too.

OSN: Speaking of the elections, I saw some announcements about OPHTHPAC being at both parties’ conventions?

Dr. Tuck: Yes, it was at both.

OSN: What were the goals there?

Dr. Tuck: To have access to the decision makers. There were opportunities to discuss our issues with members of Congress on a one-to-one basis. This was with regard to the patient protection bill, health care reform and Medicare and managed care issues that are of concern to us. The other major issue that has been our priority this year has been the collective negotiation bill, the Campbell bill. We also are currently promoting a patient benefit bill, the glaucoma detection bill. That is a big one right now.

OSN: What is that bill about, and what stage is it at?

Dr. Tuck: I was just in Washington last week, so I can bring you right up to date on that. This would be part of the proposed Medicare bill introduced in the House and Senate that we are hoping will be the first blindness prevention benefit. There are about three million people in America with glaucoma, and only about half of them know they have it. In Medicare, we already have preventive benefits like mammograms, Pap smears and colorectal screening covered, but this would be the first for blindness prevention. Currently, Medicare beneficiaries who have no symptoms cannot go to a doctor and say, I would like to be checked to be sure I don’t have glaucoma. They must have some kind of a symptom, and as we know, glaucoma is a sneak thief in the night. This new bill is targeted toward high-risk patients in Medicare — those with a strong family history of glaucoma or other major risk factors.

We know that Congress is looking to give back some of the money that was taken from us back in the balanced budget act of 1997, but right now we don’t know what will be included in that Medicare bill. With the two bills in the House and Senate, there is at least an opportunity for our congressmen to support it. By the time of our annual meeting we’ll know if we got anywhere.

OSN: The Academy previously worked to get ocular photodynamic therapy reimbursement in order.

Dr. Tuck: Right, and that is an important issue. Our Washington office has been providing HCFA with data developed in cooperation with our members. We don’t know exactly how much will be allowed for photodynamic therapy. We have seen the proposed 2001 Medicare fee schedule, but the final rule won’t come out until November.

For the 5-year period of 1998 to 2002, we did predict that we would have a 6% increase in the overall annual payments to ophthalmology as a result of implementing the latest relative value units. There’s a decrease of 1% in total payments right now by our latest calculations, but I believe ophthalmology will retain about 5% of the total increase, which is about $200 million annually.

OSN: I understand the Academy has been very busy going to the next generation of ophthalmologists and involving residents in some sort of advocacy training. What exactly is that program?

Dr. Tuck: That is the Residency Advocacy Program, and it is important for our future. The goal has been to help residents in ophthalmology now become aware of the importance of advocacy to the future of their careers. There is a 4-hour course that has been developed by the Association of University Professors in Ophthalmology [AUPO], the Academy and state societies. The goal was to reach 100 teaching programs, and I think we’re getting close to reaching their goal.

The response has been outstanding. I think involving residents at an early stage of their training is important so that they are participants in the legislative and political process.

OSN: This being an election year, it certainly raises everyone’s political awareness. Does the Academy offer any sort of endorsement, or analysis of candidates’ positions?

Dr. Tuck: No. Neither the political arm of the Academy — OPHTHPAC — or AMPAC, which is AMA’s political arm endorse either party’s candidates at the national level.

We do work with the AMA and others in promoting the involvement of our members in the political process. In fact, the AMA did a “house call,” where they had a mobile unit trying to encourage the candidates to talk about health care issues.

OSN: How about closing with a look at the Academy and your time as president? How would you sum up your experience?

Dr. Tuck: Well, first of all, it’s a wonderful organization. The staff and the volunteers make the Academy great, and the opportunity to work with these people has been an experience that I will never forget. This year we have seen a number of developments for which we will not see the results until the years that follow.

One of these is the e-Academy. We’re beginning to talk about quality standards and performance measurements. Quality has become a buzzword in Washington. Now that the National Institute of Medicine issued its report on medical errors, I believe that we will hear more about this. The issues have become so complicated, and so important for our survival, that I think we’ll need more cooperative efforts within ophthalmology and with other groups. The time is also approaching where a number of our members will be required to be re-certified, and already there are plans to develop a curriculum for maintaining competence.

Another big issue is with diabetes. For the first time, a specialty society has partnered with a governmental agency – HCFA — the PROs and state and subspecialty eye societies, in providing a service to the diabetics in Medicare who have not had an eye examination within the past 3 years. They can call the Academy’s national eye care project hotline and they will be referred to a volunteer ophthalmologist within their community to have a free eye examination and be given care for that whole year.

Another pet project of mine is a pilot program bringing ophthalmologists from economically underdeveloped countries into our communities for a week and into the annual meeting for a week in a program that is funded jointly by Rotary clubs and the Academy Foundation. If we are successful with this program, we are hoping that it will be expanded and be a vehicle for promoting educational opportunities and assistance as an avoidable blindness project.

There are about 180 million people in the world who have subnormal vision and about 45 million who are totally blind. There are many organizations addressing that need and providing public service around the world. But if we just do no more than we’re doing now, those numbers are going to double by 2020.