Are Medical Societies & MDs Out of Sync?

Many ophthalmologists see associations as not being very good at what they most need them to do.

By René Luthe, Senior Associate Editor

During the acrimonious debate over healthcare reform, many physicians likely recalled or at least felt kinship with Benjamin Franklin's famous quote, “We must all hang together, or assuredly we shall all hang separately.” With such upheaval to the medical profession being hashed out by politicians, physicians needed advocates in Washington pleading their case—and speaking with one voice. Medical societies by their very nature are charged with the responsibility to fight the good fight for their members. But judging from the misgivings most physicians have about the legislation finally enacted in March 2010 (the Patient Protection and Affordable Care Act), it's fair to say many feel let down by their professional societies.

“When President Obama wanted backup on his health plan, we all knew the two most important needs of the practicing physician were elimination of the annual SGR update/reduction dance by getting rid of the SGR completely, and tort reform,” says Paul S. Koch, MD, of Warwick, RI. “All we had to do was hang tight. Instead, the AMA came right out and announced its support for the bill without demanding those two things all doctors needed.”

And yet, representatives of many high-profile medical societies feel they do in fact play an instrumental role in shaping legislation to better serve practicing physicians. Why the disconnect between associations and their members? In this two-part series, we look at how the efforts of medical societies and the desires of practicing ophthalmologists do—and sometimes don't—overlap, beginning this month with advocacy issues.

Perception vs. Reality?

Many ophthalmic societies most active in the political arena urge ophthalmologists to remember that the society accomplished things many physicians agreed were critical to reform, such as prohibiting the denial of insurance coverage because of pre-existing conditions.

The American Academy of Ophthalmology's medical director of health policy, William L. Rich, III, MD, also wants members to keep in mind that physicians in areas with large numbers of uninsured patients will now get paid for their services. Disadvantaged urban populations with diabetic eye disease, for instance, will now be billable patients—a boon rather than a burden to the practice.

Dr. Rich also points out that before the creation of Medicare in 1963, ophthalmologists, the lion's share of whose patients are elderly, did not do very well financially. While many physicians hated the idea of a government program like Medicare, its passage provided a considerable boost to ophthalmology. “All of a sudden, our patients could pay for these services, so there was a big influx of money for biomedical research and technology, and our economic well being dramatically improved with the passage of Medicare,” he says.

Dr. Rich contends that member opposition to the proposed legislation often sprung from misunderstanding. “Some physicians got all of their information from blogs and were very upset about the Academy's support.” He says the AAO offered “measured” support. “We didn't like all of the bill, but most of it we did support. I supported the bill because I thought it was best for the patients and, frankly, it's best for our docs. We did okay.”

The head of the society most vilified—or misunderstood, depending upon one's political vantage point—for its position on the Affordable Care Act, the American Medical Association, offers a similar argument. “It's a major step forward in healthcare reform,” says AMA president, Cecil B. Wilson, MD. “It covers 32 million more people, it gets rid of pre-existing conditions, it gets rid of lifetime caps on payments for chronic care, and keeps children under the age of 26 on their parents’ policies. It also sets up the so-called insurance exchanges for people who now will be able to buy insurance and establishes a marketplace that we expect will improve competition and price and value.”

The leaders of both groups say that while the Act is not perfect, there is hope for improvement as the focus now turns to implementation. Regulations are being developed and it is here the societies can protect their members’ interests and ensure that the Act will make sense for both physicians and their patients.

“This is not the final act,” Dr. Rich points out. “It's going to take years and years of refinement. The Medicare Act of 1963, he notes, still gets legislative changes year after year. “We have just begun. Now our focus is no longer legislative, it's regulatory.”

The issues on which the AAO plans to concentrate include accountable care organizations, bundling initiatives and the Independent Payment Advisory Board. If medical costs exceed projections, and they usually do, the IPAB is mandated to cut $16 billion between 2015 and 2020 which he calls a threat to all physicians. Hospitals are exempted despite the fact they are a bigger driver of spending than physicians. “Doctors will have to pay. The whole idea of exempting hospitals, which are one of the biggest drivers of healthcare costs, from paying for growth that exceeds expectations after 2015 is ludicrous,” says Dr. Rich. “It represents the power of hospitals politically.”

David Karcher, Executive Director of ASCRS, says he understands that many of the society's members would like to see a more aggressive approach in government advocacy but notes that success usually depends on the lawmakers involved. “Unfortunately, we have to live with the legislators and that is a card law-makers play on a daily basis,” he explains. “They will do what they think will get them re-elected, regardless of what is in the public's best interest. It is very frustrating indeed.

Progress on the Reimbursement Front

The 21.2% SGR cut to physician's Medicare reimbursements was temporarily beaten back for another year, but both physicians and medical societies continue to yearn for permanent repeal and replacement of the SGR. While that is not here yet, the AAO's executive vice president, David Parke, MD, points to what he calls a significant win.

“We successfully defended the new practice expense calculations that appropriately valued the costs of ophthalmology practice and led to about $500 million in additional Medicare payments to ophthalmologists.” The Academy, he notes, led the coalition that achieved this.

Also on the Academy's radar is the new paradigm of results-oriented reimbursement, as mandated by the Affordable Care Act. “We are working very hard to develop the regulatory framework under which we are going to get paid in the future,” Dr. Rich explains.

Changes to the Independent Payment Advisory Board (IPAB), established under the Affordable Care Act to cut costs from Medicare, are another priority.

“We believe that as presently constituted, it will actually make matters worse,” says the AMA's Dr. Wilson. “It will establish another formula, or another target for Medicare payment, and so physicians may end up, in essence, in double jeopardy. They already have the SGR, and now there would be this additional body looking to cut payments.” He is concerned that presently, the IPAB does not provide any means by which it might recognize the need for a payment increase. “The AMA will be working on that this year, as well.”

ASCRS Government Relations Committee chair Brock K. Bakewell, MD, says that the society is similarly focused on potential problems such as the IPAB. “ASCRS will work in conjunction with the Alliance of Specialty Medicine, and other physician specialty organizations to enact changes to and/or repeal certain key issues of the Medicare/Healthcare reform provisions being implemented that will have a direct effect on the specialty/surgical community,” he says. He lists those provisions as the numerous penalties associated with the quality improvement and EMR initiatives, Medicare payment reform and alternative payment systems, and medical liability reform.

One solution to the problem of Medicare reimbursement cuts that many members hope the societies can achieve in their advocacy efforts is balance billing. While some societies, such as AMA and ASCRS, have come out in favor of allowing physicians to bill patients the difference between their fee and what Medicare allows, others, such as the AAO, have not.

“Right now there's a limit to how much we can charge patients if we don't belong to Medicare,” Dr. Koch explains. Under balance billing, the dollar amount for, say, cataract extraction, would be frozen where it is now. “It might be $700—then, if you drop the price for cataracts to $500, we can still charge the $700, but the patient has to pay the rest. The doctors don't get hurt, but Medicare pays out less. And patients now have the choice of going to a doctor who balance-bills up to $700, or going to a doctor who accepts the full Medicare assignment and balance owe nothing.” Giving surgeons a freer hand to set their fees is also seen as critical to the success of premium procedures such as femto cataract surgery. Should the professional societies succeed in lobbying CMS to ease up on its patient-shared billing regulations, that would be a huge victory won on behalf of their members.

The Outpatient Ophthalmic Surgery Society (OOSS) is similarly concerned with payment rates from Medicare, primarily facility reimbursement to ambulatory surgery centers. At the top of the society's agenda each year, Michael Romansky, JD, OOSS's Washington Counsel and Vice President for Corporate Development, reports, is the annual ASC payment update.

“We believe that the ASC annual update should be the same percentage afforded hospitals—the Hospital Market Basket, not the Consumer Price Index, which bears no relationship to health care costs.”

OOSS reports that it has achieved some notable successes for its 350 member-facilities as well. Virtually all ophthalmic surgical services are now eligible for ASC facility payments. While payment rates for cataract surgery have leveled off, reimbursement for a number of vitreoretinal and glaucoma procedures have increased by 50-100 percent over the past few years. Mr. Romansky also points out that OOSS and the ASC community have repeatedly beaten back efforts to by legislators and regulators to curtail physician ownership of ASCs.

What About Tort Reform?

The absence of medical liability reform thus far has been another concern voiced by physicians of all stripes. It is one of the areas ASCRS pledges to address, but medical societies have taken some heavy criticism for its being left out of the Affordable Care Act. The AMA's Dr. Wilson readily acknowledges that the Act recognizes a problem, but does not do enough to remedy it. The AMA board felt the Act was “truly historic legislation” that it “could not walk away from” so it backed the bill, he says—with the clear understanding that its support was conditional. “As we stated in our letter providing support, issues such as liability reform and Medicare payment reform would have to be worked on in the coming months and years.”

The good news now, he believes, is that for the first time in federal legislation, there was recognition that liability reform is necessary. “We will continue to push for that.”

Recently the AMA's Chair, Ardis D. Hoven, MD, testified before the House Judiciary Committee on the need for liability reform. She told the Committee that caps on non-economic damages have worked for the past 35 years in California, and are currently working in Texas and Louisiana. “We believe that caps need to be put in place at the federal level, so we are working to support legislation related to that.” In the meantime, the AMA says it will continue to work to both pass and protect liability reform laws at the state level.

One bit of good news on tort reform in the Affordable Care Act, Dr. Wilson points out, is its provision of funds for investigating alternative liability reform projects. Among the possibilities that will be examined are medical courts, “early offer programs” and safe harbors for physicians who practice according to scientific guidelines.

“In other words, if physicians follow those guidelines, that can provide them protection if they have to go to court,” Dr. Wilson explains. Another possibility being studied is administrative determination of awards, in which once it is determined that the awards need to be made, formulas are established to determine what will be appropriate.

Advocacy Victories

One happy chapter in its advocacy efforts, the AAO points out, is the continuing and thus far successful battle to protect patients “by preventing optometric surgery gained by legislative fiat rather than the years of training, experience and validated competency that ophthalmologists complete,” Dr. Parke says. “With the exception of a bizarre and unique situation in Kentucky this year, no similar bill has passed a state legislature in over ten years.”

While many state optometric societies are not lobbying to gain surgical rights, and Dr. Rich notes that most optometrists do not wish to perform surgery, it is an issue that flares up in some states. “But it's a line in the sand that can't be crossed,” Dr. Rich says.

Dr. Parke notes that the AAO's strength in numbers helps make such victories possible—he says that 94% of practicing ophthalmologists are members—and its willingness to work with other ophthalmic societies to form coalitions translates into a powerful leveraging of the specialty's wishes. “We have a large PAC that was extraordinarily effective in the last election cycle, as well as a wonderful group of members who are actively engaged in building relationships with key legislators,” he says.

The American Glaucoma Society points to the victory it was able to achieve for its patients two years ago when it addressed the problem of patients frequently running out of topical medications before their allotted 30-day prescriptions would be renewed. Cynthia Mattox, MD, then AGS chair of the Health Policy and Advocacy Committee, working with the AAO, spearheaded the effort to change Medicare's policy for eye drop refills. Dr. Mattox explains that patients were unable to get refills on their glaucoma meds when they requested them. “We had a task force investigate what was happening and what had changed.” Insurers tinkering with the pharmacy benefit system seemed to be the cause, initially private insurers and then Part D Medicare plans as well.

Insurers were counting drops per bottle. They would assume that 100 drops in a bottle should last 50 days (if given two times per day), as if they were pills, says Dr. Mattox. “But hardly anyone in the world, much less our elderly patients who are visually impaired, can put one drop in their eye exactly, and use the bottle to the perfect amount.”

While insurers insisted that prescriptions included enough to allow for typical spillage, patients continued to complain of insufficient volume. Insurers remained unconvinced, and continued to stonewall when CMS inquired at the prompting of AGS. AGS asked its members to instruct their patients in how to register a complaint with CMS, and posted instructions online.

“Doctors were giving them out right and left to patients in their offices,” Dr. Mattox says, “because it was getting to be that almost every other patient was having this problem.” Participation was impressive. “The next time we went to the CMS committee to talk to them, they said, ‘Yup, we're hearing about it now!’”

Changed guidance was published in June 2010.

Dr. Mattox feels that the episode and the outcome the AGS and AAO were able to achieve is instructive for all physicians because the limitations likely affected more than just glaucoma meds. “A combined effort of the Academy and the AGS, as well as a grassroots effort by the glaucoma doctors and their patients” resolved the problem and improved patient care.

Striving to Stay Close

Medical societies reject the notion, voiced by some members, that leadership positions are dominated by a small group of select physicians. Frequent member surveys to determine the direction the “average” clinician wants on a host of issues are a common feature.

“There are probably more surveys than the members care for,” jokes American Association for Pediatric Ophthalmology and Strabismus committee chair Derek Sprunger, MD, “but I think it's the best way to keep a pulse on what the membership does want.”

Dr. Rich shares that view. “In the old days, maybe 30 or 40 years ago, decisions were often made by the board without consulting members. That is no longer the way we do things.” Instead, the AAO uses a standardized survey instrument every year. Members are asked what is important to them, and to rate the AAO's performance on those matters. “It's very extensive,” Dr. Rich says. “The results dictate what we do and what programs we develop.”

OOSS also strives to take an accurate pulse of its membership, conducting at least two surveys each year. “We will conduct focused, topical surveys that address clinical, financial, or advocacy-related issues,” Mr. Romansky explains. “These help guide us in terms of development of our government agenda and our educational programming.” The strategy appears to be working, as OOSS has doubled its membership over the past five years, Mr. Romansky reports.

ASCRS's communications director, John Ciccone, argues that ASCRS is smaller and thus more nimble than other ophthalmic societies. Policy and direction come from its government relations committee and its nine clinical committees representing refractive, cataract, glaucoma, cornea, retina, pediatric, comprehensive, young physicians and residents, and practice management sectors to make it as relevant to the organization's various specialists as possible.

American Society of Retina Specialists president Suber S. Huang, MD, MBA, also views smallness as an advantage in better representing members. The 2,500-member organization also conducts regular surveys to make sure the agenda reflects their priorities. However, he believes that the open, nonhierarchical nature of that society helps ensure that it is what the members want it to be.

“The growth and vitality of the society directly comes from the open, collegial and egalitarian nature of our group,” Dr. Huang explains. “For example, each ASRS annual meeting is devoted towards showcasing innovative advances in the management of retinal disease, maximizing educational opportunities, and fostering meaningful interaction between all meeting attendees.”

E Pluribus Unum

When it comes to assessing the success of medical societies, Dr. Rich offers a very simple metric: “How many ophthalmologists belong to your association?” He notes that at 94%, the AAO has the highest percentage of any specialty. Further, Dr. Rich says, more than 50% of the Academy's members also belong to subspecialty societies. Such statistics would seem to indicate that while no organization is perfect, members believe that they are better off with them than without them.

Next month, part two of our special coverage of medical societies will address new benefits and projects the groups are developing to appeal to members. OM