Proposed MIGS reimbursement change will affect patients, physicians, innovation
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Medical economics is complicated. Reimbursement to physicians, facilities and manufacturers often defies logic.
In a recent editorial, I stated that when I started practice 4 decades ago, there were only two parties in the examination lane and surgical suite: the patient and the physician. We physicians in that simpler time personalized a treatment plan for each individual patient, educated the patient concerning risks, benefits and alternatives, and trusted that payers would reimburse in a reasonable and customary fashion.
Today, there are three parties present during every physician-patient interaction: the patient, the physician and the payer. We physicians now must not only discuss risks, benefits and alternatives, but also whether our recommended treatment will be covered by the patient’s third-party payer and what will be the patient’s share of the cost. Often, we are forced to modify our and the patient’s preferred treatment plan because it is not covered by the patient’s insurance payer or the patient’s share of the cost is prohibitive for them and their family. In many cases, we physicians absorb the cost of doing the right thing for each of our patients by waiving all or a portion of our professional fees, but the days where we can afford this altruistic act are disappearing fast.
In this commentary, I will offer a few personal thoughts on the proposed CMS physician fee of $34 for the implantation of a trabecular bypass MIGS stent and the potential impact of low reimbursement on the innovation cycle and ophthalmologist income in general. I may ramble a bit, but I hope the overall message is clear: Adequate reimbursement is critical for patient access to appropriate treatment, sustainable innovation by industry and physician well-being.
CMS currently uses a resource-based relative value scale to determine payment for any patient service. Three parameters are considered with the following weighting: physician work at 51%, treatment expenses at 45% and cost of liability insurance at 4%.
To determine work required, physician time is multiplied by the technical skill and work effort required plus the mental effort, judgment and stress involved. As I mentioned above, it is complicated, and trying to compare a cataract surgery with lens implantation to a cholecystectomy, a total hip replacement, or even a routine history and physical examination is no easy task. However, it is clear to me that a $34 surgeon reimbursement for the placement of a trabecular bypass MIGS stent makes no sense whatsoever.
It takes significant additional time to place a MIGS stent. For me, 5 or more minutes are required to adjust the operating microscope and my surgeon positioning, reform the anterior chamber with viscoelastic, perform gonioscopy to delineate the anatomical landmarks, plan an intelligent trabecular bypass MIGS stent placement, properly implant the stent, confirm its location by further gonioscopy, and finally return the operating microscope to a more vertical position and adjust my surgeon positioning to complete the usual accompanying cataract and IOL implantation procedure. To take the position that combined cataract/IOL surgery with placement of a trabecular bypass MIGS stent takes less time and no more skill than cataract surgery alone is absurd.
And from a “relative value” perspective, placement of a punctal plug in the operating room under the microscope reimburses about $120. Any ophthalmic surgeon having performed both procedures would concur that intraoperative placement of a trabecular bypass MIGS stent requires more time, technical skill and judgment and is far more stressful than placing a punctal plug.
We can only hope that the review process will serve its purpose and that thoughtful review by CMS will result in a more appropriate reimbursement for this important procedure that has benefited so many patients. If not, it will surely affect patient access as surgeons gravitate to better-reimbursed alternatives.
Inadequate reimbursement will also negatively affect the innovation cycle. Studies at several university centers and so-called think tanks estimate the time and cost to bring a new device such as a trabecular bypass MIGS stent for glaucoma to market approach 8 years and $500 million, and for a new drug, even longer and $1 billion or more. Also, regulatory approval is just the first challenge faced in the innovation cycle. Once approved, a device or drug must be commercially launched with significant additional expense. Physicians and their patients must find the new product superior to currently available treatments and adopt it. Critical to patient adoption is third-party payer coverage for the new treatment, or many patients will not find the treatment affordable.
We physicians must be paid a fair and reasonable fee to provide the treatment, or we will favor other better-reimbursed alternatives. Again, it is complicated to value the benefit to an individual patient and society of safely and effectively reducing IOP and progressive visual loss in a potentially blinding disease such as glaucoma, but when compared with many other well-reimbursed treatments, a trabecular bypass MIGS stent placement seems a bargain. The bottom line is, if reimbursement to the provider, the facility and the manufacturer is not adequate, a treatment will fail to remain available to patients in need, and further innovation in the field will cease.
Finally, a few thoughts on overall ophthalmologist reimbursement. Medscape is my preferred source for information on physician income, and the numbers I share are available on the internet.
If one defines primary medical care as pediatrics, family medicine and internal medicine, mean primary medical care physician income was $160,000 in 2010, $193,000 in 2015 and $232,000 in 2021. That is a 154% increase over a decade. For ophthalmology, mean reimbursement was $250,000 in 2010, $293,000 in 2015 and $379,000 in 2021. That is a 152% increase over a decade and similar to our primary medical care colleagues. Ophthalmology for most providers is office-based primary medical care focused on the eye 4 days a week and surgical eye care only 1 day a week. As I have discussed in several prior commentaries, office-based practice and primary medical eye care are critically important to most ophthalmologists’ income and have aligned us with our primary medical care colleagues. Each will have their own opinion, but we arguably remain well compensated when compared with our primary medical care colleagues. And because of our primary medical eye care focus, we have fared better than most of our surgical subspecialist colleagues over the past decade.
Reimbursement remains critical to the well-being of our patients, our profession and the industry that supports us. The No. 1 payer in America today for ophthalmology is CMS. Our ophthalmology professional societies have punched well above their weight in Washington, D.C., and have represented us well in the past decade. It is critical to the future best interest of our patients and ourselves that we support our professional societies financially and engage actively in the political process. In addition, we must each get to know those who represent us locally in congress, communicate with them and their staff about our needs and especially our patient’s needs, and yes, contribute to them annually. Our future and the future of our profession depend on it.
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