Quick Hits

Why physicians detest the ACA exchange plans

Verification problems, misinformed patients.

By Zack Tertel, Senior Associate Editor

Physicians are largely dissatisfied with dealing with the Affordable Care Act (ACA) exchange plans that have enrolled more than 8 million consumers, and a recent report by the Medical Group Management Association (MGMA) pinpoints the sources of that dissatisfaction.

“Physician group practices are expressing dissatisfaction with the complexity and lack of information associated with insurance products sold on ACA exchanges,” says Susan Turney, MD, MS, FACP, FACMPE, president and CEO of MGMA.

“The more administrative complexity introduced into the health-care system, the less time and resources practices can devote to patient care,” Dr. Turney says. “Even though there hasn’t been a huge influx of patients into physician offices as many predicted, simple tasks such as obtaining patient insurance coverage information or finding specialists for in-network referrals have proven to be significant challenges.”

The MGMA ACA Exchange Implementation Report surveyed more than 700 medical groups and included 40,000 physicians. Almost 60% of respondents say verifying patient eligibility and obtaining cost-sharing or network information is somewhat or much more difficult compared to patients with traditional commercial coverage.

Respondents also found significant patient confusion about the cost-sharing related to many plans the ACA exchange offers, with about 75% of respondents reporting that these patients are likely to have higher deductibles than traditionally covered patients. Practices not participating with ACA exchange products cited concerns stemming from the collection of these high deductibles.

Alice Gosfield, a Philadelphia attorney who advises physicians on structuring their practices, compares these misunderstandings to those associated with the early days of managed care.

“People are signing up for plans for which they really don’t understand what the coverages are, and, much like what happened in the early to mid-1990s, physician offices go mad trying to find clarifications that aren’t easily available and really aren’t clear,” Ms. Gosfield says.

Michael X. Repka, MD, AAO medical director of government affairs, recognizes that part of the responsibility of educating patients has fallen on the practice. “Front-office personnel may be explaining an insurance product that the patient doesn’t understand,” he says. “They may be explaining for the first time what a deductible or co-payment is to the beneficiary.”

Steer your patients away from summertime dry eye triggers

Are you warning them about air-conditioners, ceiling fans and other eye-drying culprits?

By Bill Kekevian, Senior Associate Editor

Some clinicians may be routinely overlooking a couple basic summertime triggers of dry eye symptoms: air-conditioning and ceiling fans.

Dry eye “is triggered by the environment,” explains Kendall Donaldson, MD, MS , a cornea specialist at Bascom Palmer in Miami. “It’s hugely impacted by the environment, so that’s the first thing [ophthalmologists] can address before even talking about medications or other types of intervention. Patients need to know, they’re going to need to change their lifestyle.”

Adds Clifford Salinger, MD, of VIP Laser Eye Center in Palm Beach Gardens, Fla.: “I see many patients who have seen three, five or seven eye-care professionals.” When he explains environmental triggers to them, “a light bulb goes on and they ask, ‘Why didn’t anybody else tell me about that?’”

“The car and bedroom environments can exacerbate dry eye,” says Dr. Donaldson. In particular, she is referring to air-conditioning in the car and ceiling fans in the home.

“I’m in Florida, where the use of air-conditioners is constant,” says Dr. Salinger. He tells patients: “Be more aware of the environment or else, no matter what we [doctors] do, you’re still going to be symptomatic.”

Doctors should warn patients, in particular, of situations in which the air conditioner or fan is blowing directly at their faces, such as in the car.

“These patients are an annuity,” says Dr. Salinger. If arming them with the knowledge they need to avoid seasonal environmental triggers helps them control their symptoms, “They’ll be singing your praises,” he says. “You can build a very significant practice if you’re committed to serving the dry eye patient base.”

Study suggests how Medicare could save on anti-VEGF drugs

But CMS’ own rules get in the way.

By Rich Kirkner, Executive Editor

Medicare could save almost $2 billion a year by moving all beneficiaries currently on Lucentis for wet AMD and diabetic macular edema onto the less expensive Avastin, but Medicare’s own policies make it difficult to give ophthalmologists incentives to use the less expansive drug, according to a team of researchers at the University of Michigan.

The study, published in the health economics journal Health Affairs (2014;33:931-939) noted that increasing the physician reimbursement for Avastin (bevacizumab) to equal that of Lucentis (ranibizumab) theoretically could save Medicare money, lead investigator David Hutton, PhD, says. “If just 8% of prescriptions switched to Avastin, it would be budget neutral, and anything above that would save CMS money,” Dr. Hutton says.

The study noted that Medicare pays physicians an average of $121 for each Lucentis injection, which yields an average margin of $95 vs. $29 for Avastin. The study noted that between the two drugs, currently 67% receive Avastin and 33% Lucentis. Spending on Lucentis comprised approximately 17% of the entire Medicare Part B drug budget in 2010, the study noted, but switching all patients with wet AMD and DME to Avastin would constitute about 2% of the Part B budget.

Medicare’s 106% rule

However, the authors noted incentivizing doctors to switch to the less expensive drug is problematic because of Medicare’s 106% reimbursement rule for pharmaceuticals. That is, Medicare reimburses single-source drugs or biologicals at 106% of the average sales price or wholesale cost, whichever is lower.

Dr. Hutton admits that how a change in reimbursements would change physician behavior is not clear. “We know that the theory is a larger reimbursement could influence ophthalmologists, but there is no evidence that has been driving behavior among ophthalmologists in using Avastin or Lucentis,” he says. The study team conducted an informal survey of ophthalmologists at the University of Michigan Kellogg Eye Center. “It doesn’t seem that reimbursement has a strong influence on prescribing behavior,” he says.

But, Dr. Hutton notes, “In light of the Medicare payment data, which showed ophthalmologists were among the highest paid providers, and how anti-VEGF drugs may have factored into that, it’s hard to say there aren’t some people who are influenced by the higher reimbursement.” That data for 2012 showed nearly half of the 100 highest paid Medicare doctors are ophthalmologists, many of whom are retina specialists.

But whether Medicare can make adjustments to change the behavior of ophthalmologists who use anti-VEGF drugs “are far from assured,” the study authors stated.

Genentech responds

Genentech, manufacturer of both drugs, noted in a statement that Lucentis and Avastin “are not the same medicine. Genentech scientists specifically designed Lucentis for use in the eye and to clear quickly from the bloodstream to minimize side effects. Avastin is not manufactured or approved for use in the eye. Avastin is only approved for the treatment of certain forms of cancer.”

The company noted the clinical trails and large observational studies have suggested the risk of systemic serious adverse events may be higher with Avastin vs. Lucentis for intravitreal injection. “Genentech works to develop innovative medicines that offer substantial added medical benefit compared to current treatment options,” the statement read. “A development program for the ophthalmic use of Avastin would not offer any added medical benefit over Lucentis or other available treatment options.”

FDA panel’s safety questions about Kamra device explained

But the corneal insert for presbyopia moves closer to approval.

By Bill Kekevian, Senior Associate Editor

The mixed vote last month by the FDA’s Ophthalmic Devices Advisory Panel to recommend approval of the Kamra corneal inlay turned on safety issues surrounding the device itself, which a clinical adviser to AcuFocus, the manufacturer of the device, put into perspective.

The panel addressed three questions: one on efficacy, one on safety of the device in the eye, and one on whether the benefit outweighed any safety issues, according to Daniel S. Durrie, MD, an adviser to AcuFocus. The panel’s vote on the safety of the device itself was 5 to 4, with one abstention; it voted yes on the other two questions.

According to Dr. Durrie, who attended the meeting, the panel based its split vote on AcuFocus not meeting all the predefined study endpoints.

“The majority of the safety issues were transient,” he says. “There were some IOP rises that were temporary and had to do with postoperative steroids, so those showed up in the data.” Some patients lost best-corrected vision at one visit but regained it at the next, he notes.

Other issues involve surgical technique and training requirements. “As the surgical technique evolved during this study, we were able to notice that some doctors used different equipment,” Dr. Durrie says. “In the approved labeling it will be indicated for the best procedure placed at the best place in the cornea, using the best equipment and the best surgical technique.”

The KAMRA Inlay is a first-of-its-kind device, which is why the panel had to review it before sending it to the FDA. “Devices or drugs that have been on the market before or are not the first of their kind usually don’t have to go through the panel approval process,” explains Dr. Durrie. The Kamra Inlay is approved for use in 55 countries.

Match your patients’ wits on cost transparency

tip of the month

Patients are becoming more sensitized to healthcare costs as deductibles and co-pays continue to climb, and as more health plans adopt reference pricing for services – that is, setting a ceiling for what the plan pays for a procedure – and encourage members to use tools that allow them to compare costs for a procedure among many providers.

Health economist and bioethicist Uew E. Reinhardt, PhD, of Princeton University has called price transparency in health care a disruptive innovation.

Health plans big and small and employer-funded plans have embraced reference pricing and price transparency. Patients are more likely than ever to know how much a procedure should cost before they talk to their physicians. How will you respond?

One place to get a sense of what patients are up to is HealthCare Bluebook (www.healthcarebluebook.com), a portal that provides information on “fair pricing” of 200 different medical procedures, among them 10 ophthalmological procedures.

The tool customizes the search by ZIP code. For example, the total “fair price” of cataract surgery in Cincinnati is $3,244 — $1,549 for the facility fee, $1,244 physician fee, and $451 for anesthesia.

Other total “fair prices” in Cincinnati are:

• Glaucoma laser surgery, 1,529.

• Laser iridotomy, $1,493.

• Retinal photocoagulation, $3,085.