Ophthalmology’s lobby had a busy first quarter

Managed care and shrinking Medicare reimbursement have strengthened the bonds among ophthalmology’s subspecialties, and it shows behind the scenes.

Issue: June 15, 2000

ByKevin Murphy

Lobbyists at the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) do not have the luxury of a winter or spring recess like their friends in Congress, and their Day Planners are generally harder to get into than a Broadway show on opening night.

But lately they seem to be working even harder than usual. AAO scored a victory when it countered the Health Care Financing Administration’s (HCFA) attempt to make permanent nearly $200 million in cuts to cataract surgery last year, and ASCRS saved cornea reimbursement codes from virtual destruction. They came together on a comanagement white paper and locked horns over a surgical coalition proposal that the AAO felt was a “bad deal” for ophthalmologists.

Now they are both hard at work on managed care reform, trying to make the Patients Bill of Rights a reality and get collective bargaining legislation enacted. “We are probably one of the only subspecialties in medicine that is so active in Washington,” said Nancey McCann, ASCRS’ government relations manager.

Patient access

The Patient Access Coalition has spent 7 years working and reworking legislation aimed at protecting patients and specialists from the abuses of managed care. The coalition supports the House bill, sponsored by Reps. Charles Norwood, R-Ga., and John Dingell, D-Mich., because it protects patients’ options to choose their own health care providers and guarantees access to needed specialty care, among other things.

The coalition, chaired this year by Ms. McCann, launched a cyber appeal just as House and Senate members in a joint conference committee met to craft a compromise reconciling the differences between bills passed by the House in October and the Senate last July. The cyber campaign, which urges Internet surfers to “Tell Congress you want an end to HMO abuses,” can be found at congress.nw.dc.us/pac. The appeal reportedly cost $25,000 and can be found as a banner ad on Slate, Microsoft’s online magazine, as well as a banner ad and pop-up ad on Juno, an Internet service provider.

According to Ms. McCann, the House bill is a lot stronger, and that is directly related to the fact that there are many “vulnerable” House members who are up for re-election. “That’s why the [House] feels an urgency more than the Senate. This is a very important issue with the public, and I think there’s a recognition that something needs to be done. Part of the reason why the Republican leadership in the House went forward is because they have a lot of vulnerable Republican members, and they’re in danger of losing the House,” she explained.

The most problematic issue of concern to the coalition, according to Ms. McCann, is the scope issue — how many people will be covered by the bill. The Senate bill is limited only to those 58 million Americans covered by self-insured plans, while the House bill would cover all of the approximately 160 million people with private health coverage. “The senate wants to exempt small businesses with 50 or fewer employees,” Ms. McCann said. “That’s a lot of businesses, and those are the very people who need to be protected with an option to go outside the network,” she said. She added that she believes the Patient Protection Bill will become a big election year issue.

White House backing …

AAO President Kenneth Tuck, MD, was invited by the White House to participate in a patient protection strategy session with the Clinton Administration, including White House Chief of Staff John Podesta and Health and Human Services Secretary Donna Shalala. Dr. Tuck expressed concern about the delay in passage of a meaningful patient protection bill. “Action must come now, before other issues sneak into the limelight and steal the momentum,” he told the administration. Dr. Tuck said the conference committee is talking about a lot of things, but agreeing to almost nothing.

The AAO had an opportunity to bring many of these concerns to the forefront during its third annual Advocacy Day. One of the participants, Lyle Thorstenson, MD, said he believes his participation made a difference. “One of my meetings was with Rep. Max Sandlin, D-Texas, and I noticed that his name was not on the co-sponsor list for the collective negotiation bill. I asked him to be a co-sponsor, and he agreed to sponsor not only that bill, but our glaucoma bill, as well. I believe my visit made a difference. I’ve helped with his campaign and have gone to rallies, so he knows me. Our issues weren’t high on his radar screen, but now it appears he will play a more active role on our behalf,” Dr. Thorstenson said.

Participation this year was limited to AAO members whose congressional representatives sit on committees considered gatekeepers to advancing ophthalmology-friendly legislation.

AAO and ASCRS are working with the American Medical Association and a large coalition of medical groups on the Campbell bill, aimed at achieving collective bargaining power for physicians. The House Judiciary Committee overwhelmingly (26 to 2) passed the Quality Health Care Coalition Act (H.R. 1304), after Judiciary Chairman Henry Hyde’s, R-Ill., “sunset provision” was included in the language. The sunset clause requires that the legislation be renewed 3 years after taking effect. There is no Senate companion bill, which insiders say limits the bill’s viability.

The problem is that Republicans have expressed interest in sponsoring the bill in the Senate, and bipartisan support is necessary for eventual passage. “Maybe getting a Democrat to introduce it at this point would be OK because at 26 to 2, the Republicans in the house can certainly say it’s their bill,” said Catherine Cohen, AAO’s vice president of federal affairs. “But it has to pass the floor first, and that’s going to be rocky.”

Ms. McCann also pointed out that the Campbell bill has tremendous opposition from several major powers: the insurance industry, the Department of Justice and the Federal Trade Commission, to name a few. “But stranger things have happened,” Ms. McCann said. “Just about everyone was opposed to the [procedure] patent legislation several years ago, and we ended up getting it enacted.”

Surgical coalition controversy

AAO and ASCRS were recently divided over a proposal initiated by the Specialty Surgical Care Coalition be-cause AAO saw that the proposal would have cut Medicare payments to 95% of ophthalmology by $20,000 to $50,000 a year, beginning in 2002, while ASCRS saw it as a way to eliminate further cuts to surgical and procedural codes. After a behind-the-scenes tug of war, both AAO and ASCRS are satisfied with the compromises made. The initial proposal would have allowed the 10 Evaluation and Management (E&M) codes to increase, while remaining codes would be frozen at 2000 levels. In order to achieve a unified front and accommodate the AAO’s demands, the proposal now allows the 10 E&M codes to increase, but in addition to that, it also allows the four primary eye visit codes and five office consult codes to increase to projected 2002 levels.

“This trade off would have resulted in a $100 million loss in revenue for ophthalmology in 2002 because of the freezing of these codes,” said Ms. Cohen. This way, instead of making an exception for ophthalmology, all specialty groups will benefit. Ophthalmology as a whole would actually see an increase over the projected 2002 levels, if the proposal is enacted.

The proposal still needs to make its way through a whole circus of hoops (Congress and HCFA, for example) before anyone will know if it has a fighting chance, but some say the risks are worth it.

“We’ve been seeing reductions since the 1980s,” Ms. McCann said. “When I first started at ASCRS, [cataract] reimbursement was $1,800 on average. It’s now down to $600 and dropping, plus we have the 5-year review coming up, and of course the cataract code is always on the chopping block … ”

Ms. Cohen said, “At the last RVS [relative value scale] Update Committee meeting, HCFA singled out the AAO as the model of how other specialties ought to be approaching [practice expense] refinement. We’re working the refinement better than anyone else, but this proposal would end refinement, so we thought ‘we’re not going to end refinement unless it’s worth the risk to us, unless it seems to be a good payback to ophthalmology.’ ”

Complementary endeavors

Most of the time the groups complement each other and work well together, according to Ms. McCann and Ms. Cohen. In fact, just prior to the Surgical Coalition confusion, the AAO and ASCRS issued a joint position paper on comanagement, which provides guidelines for members regarding the delegation of postoperative care.

The position paper, which applies to all ophthalmic surgery, was faxed to AAO and ASCRS members in late February. It states that the operating surgeon has responsibility for postoperative care and presents specific circumstances where comanagement is considered justifiable. Ms. Cohen and Ms. McCann both stress that the guidelines are nonenforceable and serve only to broaden members’ knowledge about comanagement.

Another example of how the societies work together came to fruition just as this article was going to press. The Outpatient Ophthalmic Surgical Society worked with ASCRS and AAO to persuade HCFA to increase reimbursement for new technology IOLs (NTIOLs). The “new technology” designation increases reimbursement by $50 per lens above the standard reimbursement from Medicare to ambulatory surgery centers when they use an NTIOL.

In determining which lenses met the criteria of the NTIOL, HCFA “relied on clinical data and evidence submitted to the Food and Drug Administration by the various manufacturers, demonstrating that these lenses have specific clinical advantages and superiority over existing lenses,” according to the Federal Register.

For Your Information:

Keven Murphy directs planning operations and legislative affairs for a social services agency. You may contact him c/o Ocular Surgery News, 6900 Grove Road, Thorofare, NJ 08086; e-mail: osn@slackinc.com
Catherine Cohen can be reached at 1101 Vermont Ave. NW, Ste. 700, Washington, DC 20005; (202) 737-6662; fax: (202) 737-7061.
Nancey McCann can be reached at 4000 Legato Road, Ste. 850, Fairfax, VA 22033; (703) 591-2220; fax: (703) 591-0614.
Kenneth Tuck, MD, can be reached at 3320 Franklin Road SW, Roanoke, VA 24014; (540) 344-6770; fax: (540) 345-3973. Dr. Tuck has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
Lyle Thorstenson, MD, can be reached at 3302 N.E. Stalling Drive, Nacogdoches, TX 75961; (409) 564-2411; fax: (409) 564-1280. Dr. Thorstenson has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.