The unkindest cuts of all?

They might as well be. Retinal surgeon Jorge Calzada discusses CMS’s reductions and their multiple effects on his specialty.

By René Luthe, Senior Editor

Since Jan. 1, The Centers for Medicare and Medicaid Services have been returning smaller reimbursement amounts to retina surgeons for four commonly performed vitrectomy procedures (see Table). To the dismay of retina surgeons, these cuts are sizable. Jorge I. Calzada, MD, president of the Charles Retina Institute in Memphis, spoke with Ophthalmology Management on the likely pall that could descend on the subspecialty regarding CMS’s actions.

Ophthalmology Management: Would you explain to nonretina specialists what the cuts mean for your subspecialty?

Jorge I. Calzada, MD: I think the cuts are going to have a significant impact on my practice and many others. This is a devaluation of surgical services. It specifically targets macular surgery and surgery for diabetic patients — the specific problem areas retinal surgeons are seeing. CMS suggests the reason they are doing this is because we have become faster with our surgeries — which is kind of funny, because the surgeries are so very difficult. Particularly membrane peels in macular surgery are very, very difficult to master.

We run a fellowship program with three fellows at a time. It takes a year and a half for a fellow to learn to perform macular surgery at the level we are comfortable with — after three years of residency, after all the previous medical training. So CMS’s action is very disheartening, because the reimbursements they propose for macular surgery are not consonant with the effort and training required to do this.

OM: How do you think the vitrectomy reimbursement cuts will affect physicians?

Dr. Calzada: I think we are going to see the same sort of process that has occurred in cataract surgery, where there are very few low-volume surgeons. If you are going to survive, you have to be a high-volume surgeon. In every city, there are a handful of very high-volume cataract surgeons, and that’s about it. I think CMS’s reductions may drive the same sort of thing.

Historically, retina has been a world in which one surgeon may do on average three or four surgeries a week. I think that kind of surgeon will cease to exist because it’s just not a reasonable, economically viable way to operate. This may lead to some older physicians bowing out.

Ultimately, I think physicians will require practice extenders to deal with this high-volume system. Because if you think about how many patients you need to see in clinic to generate one surgery, you realize that to make $800 worth of surgery, you need to see five to 10 patients.

OM: Can surgeons overcome CMS’s reductions by being more efficient? Can the greater efficiency of ASCs compensate?

Dr. Calzada: Our surgical times cannot decrease any further. We know why the decrease in times happened: because we got faster in the OR with sutureless surgery, 25- and 23-g surgery. The next technology, 27-g, even though it will be great, it will not decrease surgical times much more than what we have now. In my opinion, we are as near the maximum of surgical efficiency per person inside the OR as we can be for the next 15 years, unless some technology shows up that I cannot predict.

Surgery centers are going to have to figure out ways to decrease the turnover time and increase the throughput, because that’s the only way to survive the reimbursement cuts.

CMS’s action also implies the end of hospital-based, elective retinal surgery services. No hospital, no matter how good, can survive it because they have problems with surgical efficiency. You do not see today cataract surgeons doing surgery in hospitals. In the ‘80s, it was regularly performed in hospital; now it’s migrated to ASCs.

That migration has begun in retina. I think this [CMS cuts] will push that trend very strongly. Because, like I always say, there’s no CPT code for sitting in the doctor’s lounge during turnover time — meaning, when you’re sitting in the doctor’s lounge, you can’t bill for that. Every hospital will have turnover time that’s much longer than in a surgery center, and that’s not viable now.

This causes elective retinal surgeries to migrate to ASCs. It’s also going to cause a migration to office-based work. That is, many doctors are going to maintain practices, and basically sit in their offices; they will see little benefit to going to the OR to do two to three cases when they can be much more productive in their offices. It’s not that we get paid more for a patient in the office, it’s that in an office we can work much more efficiently than we can in an OR.

Put simply, you cannot operate on more than one patient at a time. You can have more than one person in the office and proceed on one while having another patient undergo imaging, though.

OM: Do you think the CMS cuts will affect broader health-care delivery?

Dr. Calzada: Yes, and this is my most depressing comment: I think this implies the end of the primacy of the United States retina surgeon in the world perspective. Retina surgery in the United States has always been at the forefront, but we’ve ceded much of the push to Asia, Europe and Latin America. I think this CMS development will provide further impetus; U.S. surgeons will be famous for their medical work, but less and less relevant for their surgical work.

It’s sad to think economics will cause that, but we just have to look it in the eye and realize that people are not going to put that much effort into surgical work when it’s not remunerated.

In cataract surgery, the development of premium IOLs and other things have given certain practices that cater to patients who are able to pay for them another way to generate income; that doesn’t exist in retina. So retina will decline from the surgical perspective. I think we are in a golden time of the medical retina world, but the surgical retina world is going to decline.

I believe this will also have an impact on surgical fellowships. Retina fellowships, historically, have been medical or surgical. As physician-surgeons move away from being in the OR, that will have an impact on retinal fellowships. Already in Europe, they choose either medical retina or surgical retina; in the United States, we do both. And I predict that in a number of years many fellowships are going to start concentrating on medical retina work and avoiding the surgical side.

OM: Won’t “pay-for-performance” help to compensate for these cuts?

Dr. Calzada: With pay-for-performance, the deal is, “If you’re much better than everyone else, we’re going to give you a 5% payment.” Five percent of an $800 surgical reimbursement is $40. Great, I can take my wife to Starbucks! So pay-for-performance is not going to make a major difference in surgeons’ incentive.

OM: Do you think patients will be affected?

Dr. Calzada: Yes, particularly Medicare patients. Because of their expectations of what a physician will do for them, because of what they’ve experienced in their 65+ years, they want to see their doctor — they don’t want a practice extender. So as we shift to volume-based surgery — that’s very different from what they expect. These patients want that one-on-one, which is fine, except you can’t merge one model with the other. OM

About the Author
	Dr. Jorge I. Calzada is a vitreoretinal surgeon and President of Charles Retina Institute in Memphis Tennessee. He specializes in macular diseases, complex retinal detachment repair and pediatric retina surgery.