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Retina specialists anticipate regulatory hurdles, growth opportunities
As health care reform ushers in integrated care and changes to the Medicare payment structure, it may also expand the patient base.
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Health care reform poses a plethora of regulatory challenges and unprecedented growth opportunities for retina specialists, one specialist said.
Most major provisions of the Patient Protection and Affordable Care Act (ACA), such as value-based modifiers, expanded Medicare coverage, health care exchanges and accountable care organizations, are scheduled to be in place by 2017, David Parke II, MD, said at the American Society of Retina Specialists meeting.
“Those within our profession who can anticipate the changes ahead and flex with them are going to have a better chance of thriving than those who are inflexible in the face of inevitable change,” Parke said.
The ACA and a sluggish economic recovery have sparked a sense of trepidation among many physicians, he said.
“Many feel that we are on an inevitable path toward a major detonation. … While we may not enjoy the ride, we can survive it, and some of us will really thrive,” he said.
The upside, he said, is that with an additional 33 million Americans expected to get health insurance coverage under the ACA, the demand for pediatric services and diabetic retinopathy care is likely to increase. He noted that a growing influx of aging baby boomers will create access challenges and benefits for ophthalmology in general and retina in particular.
David Parke II
Proposed payment structure
Under proposed changes to the Medicare payment structure, compensation for some highly lucrative specialties would decrease, while compensation for primary care would increase, Parke said.
In the last decade, Medicare payments to ophthalmologists increased from $3.9 billion to $5.1 billion.
According to survey results recently released by the American Medical Group Association, ophthalmologists’ mean compensation was $344,000. Mean annual compensation for orthopedic surgeons and neurological surgeons was almost $700,000, while mean compensation for pediatric allergy specialists and geriatric specialists was less than $200,000, Parke said.
“There’s going to be downward pressure on all physician payments and even more downward pressure on more highly compensated proceduralists in general, with some political pressure already apparent to increase compensation on the lower end,” Parke said. “We’re going to have some flattening of the slope.”
Value-based modifier
Payments will be increasingly linked to outcomes of care, patient service and bundled payment per episode of care, in addition to the fee-for-service model, he said.
“Traditional fee-for-service is not going away anytime soon,” Parke said.
Under the ACA, the Centers for Medicare and Medicaid Services is mandated to compensate physicians based on care quality and efficiency. A value-based modifier is scheduled to be phased in between 2015 and 2017. The modifier, if implemented, will be based on physician resource use and quality of care.
Retina specialists whose resource use falls outside standard parameters will likely see significant cuts in compensation, while those who are efficient should see increased payments, Parke said.
“The principle of a value-based modifier payment is one that is likely to survive any changes in health care reform, not solely because Congress demands it but because the commercial payers and the employers demand it,” he said.
Accountable care organizations
More integrated health care systems, whether as accountable care organizations (ACOs) or not, are likely to survive any changes to the reform law, Parke said.
Ophthalmologists, retina specialists particularly, will be less affected initially than other physicians because they are less attractive to hospital systems as practice purchase targets, according to Parke.
“Part of the physician angst comes from the apparent predatory behavior of some large hospital systems,” he said. “While these systems are buying physician practices left and right, ophthalmology, even retina practices, are not particularly attractive relative to the facility impact of primary care, cardiology, neurosurgery and orthopedics. … That means, in general, that retina specialists, like all ophthalmologists, are generally going to be operating outside the employed physician structure as an affiliate.”
Parke advised retina specialists to be engaged in the development of ACOs by helping to set standards of care, patient access, referral mechanisms and electronic medical record protocols, Parke said.
He noted that ophthalmologists and the American Academy of Ophthalmology in partnership with subspecialty societies have had important impacts for the profession.
“We’ve had success, for example, in ophthalmology practice expense calculations and meaningful use regulations, among others,” he said. “These two wins, together, have combined to yield hundreds of millions of dollars a year for ophthalmology practices in appropriate service reimbursement. … In all of our advocacy efforts, philosophically, if we always keep the patient first, we’ll make wise decisions.” – by Matt Hasson