Quick Hits

The fix is in

SGR is finally repealed; no one is setting off fireworks.

By Robert Calandra

Congress’ long awaited “permanent fix” to Medicare’s sustainable growth rate (SGR) formula probably won’t make many ophthalmologists — or any physicians — feel like celebrating.

But the legislation, passed with bipartisan support on April 15 and already signed into law, resolves some important issues, including stabilizing fee schedules. Still, it leaves other, more complicated problems for Congress to solve for another day.

“It’s not something you have a parade for,” says Michael X. Repka, MD, the medical director for governmental affairs for the American Academy of Ophthalmology. “There are definitely going to be some ophthalmologists who are very unhappy with this.”

It will take time for physicians to completely unwrap the 100-page law. But, from a quick first reading, Dr. Repka thinks the new legislation contains some positive things for ophthalmologists.

“I would argue that it is a step in the right direction,” he says. “It solves a few problems. There are things that you would like” that are not included.

IT WORKED, THEN IT DIDN’T

Included in the Balanced Budget Act of 1997, the SGR was designed to gain control over Medicare. Under the law, physicians’ fees were linked to an economic growth target, based on a fee schedule. And for the first five years it worked.

But in 2002, Medicare spending exceeded its target, automatically triggering a 4.8% reduction in physician reimbursements. Doctors were angry, and since then Congress has averted similarly scheduled cuts 17 times with last-minute patches.

President Obama and Academy CEO David W. Parke II, MD share a few words.

Even with Medicare’s current tight reimbursement schedule, Dr. Repka says comments “about a tide” of ophthalmologists leaving Medicare are unfounded.

“It is often said, but there is simply no data to support that comment,” he says.

A BILL SIGNED, CONCERNS RAISED

The president signed the bill into law on April 21; Academy CEO David W. Parke II, MD was present.

The new law takes a different tact on payments. Starting June 15, doctors will receive an annual raise of 0.5% through June 15, 2019. The rate freezes at the 2019 level through 2025. The payment schedule eliminates the possibility of another 2002 fee reduction fiasco. But doctors are concerned that the annual increase percentage is too low.

Dr. Repka understands his colleagues’ concerns, especially after the first five years.

“It is not going to keep up with the cost of living,” he says. “Doctors will still have to pay rent that is going to go up. They will still have to pay personnel costs that are going to go up.”

Dr. Parke concurred. “While not perfect, this bill is a meaningful step toward finally achieving stable funding to support continuity of care for a growing population of seniors who rely on long-term, ongoing treatment from their physicians of choice,” he said in a prepared statement.

A BIG WIN, AND THEN SOME

The new law does delay changes to global surgical payments that threatened to take away postsurgical bundles under the old law. Dr. Repka calls that a “big win” for ophthalmologists and surgeons in general.

“[CMS] now has a number of years to work on it and figure out what is really a fair way to pay surgeons for preoperative, intraoperative and postoperative care,” he says.

Another positive, Dr. Repka says, is that the new law simplifies incentive programs based on quality. It creates a merit-based incentive payment system of rewarding doctors based on value over volume. These values will be judged via EMR, meaningful use and clinical practice improvements.¹

Practices that can demonstrate that they are moving toward alternative delivery models, such as patient-centered medical homes, will also qualify for a 5% bonus. As for coding, coding expert Suzanne Corcoran says that for now, there will be no changes.

Although the fee schedule is fixed, the law retains the current penalty system. That won’t change until 2019.

That change has to come sooner, Dr. Repka says, “Or we could see ophthalmologists and doctors in general with fee schedule impacts of minus nine, minus 10 or minus 11%. Then the people talking about ophthalmologists fleeing Medicare might be right.”

The bill also does not include a delay for ICD-10 — the 10th revision of the International Statistical Classification of Diseases and Related Health Problems — scheduled for October.

But on first reading, Dr. Repka says the biggest concern doctors should have is leverage — the medical community no longer has significant leverage over Congress.

“But again, it does allow the Congress and CMS and physicians to focus on fixing the other things that need fixing,” he says. “And nobody would ever think about those things when they were dealing with SGR.”

REFERENCE

OPHTHALMOLOGIST PAY MOVING IN THE WRONG DIRECTION?

According to Medscape, which at least in its 2012 survey included bonuses and profit sharing, myriad factors dropped salaries for ophthalmologists, including meaningful use penalties and CPT code changes.

Derek Preece, BSM principal and executive consultant, concurs and adds more reasons. A clear, slow trend has emerged in the last few years for higher overhead rates, he says. Practices are paying more today to comply with government regulations — electronic health records, quality reporting — and reimbursements are dropping, so some ophthalmologists are making less than they used to.

By the end of June, data from the AAO 2014 benchmarking data survey will be available, Mr. Preece says, so ophthalmologists will be able to compare those to figures from 2013, providing ideas of where the trends in income lie.

The FDA wants trials, no more tribulations

We stand accused of stating the obvious: the United States is no longer the only predominate power player in the world of clinical trials. Where places like Asia gained — East Asia an impressive 127% between 2006 and 2012 — North America lost ground: -2.44%.¹

The FDA has taken notice that these trials have flown overseas. At the recent ASCRS meeting in San Diego, the head of the agency’s division of ophthalmic and ENT devices discussed the agency’s reaction to this unwanted emigration.

Malvina B. Eydelman, MD, among myriad other upgrades, said the FDA’s early feasibility program — established two years ago, why it appeared dormant wasn’t readily explained — is meant to ensure that device trials stay in the United States. The parameters: trials can only have a small number of subjects; devices must be early in development; and, the applicant needn’t have large amounts of clinical data, because the FDA might not require them to approve the device.

Dr. Eydelman said a survey of venture capitalists detailed what changes would “have the greatest impact on investments from changes at the FDA.” These included becoming more efficient, making speedier decisions and improving transparency of communications.

She also said that two people at the agency are dedicated to answering emails from device designers. Direct correspondence can be emailed to DOED__EFS@fda.hhs.gov.

Audience reaction seemed favorable. Said one attendee: “It will put us back on the map where people can learn about new technology.”

What a long, strange trip it’s been

“Stiffs, Skulls & Skeletons” reveals medicine’s journey

By René Luthe, Senior Associate Editor

With the publication of “Stiffs, Skulls & Skeletons,” ophthalmologist Stanley B. Burns, MD, uses his remarkable collection of historical medical photographs to illustrate, among other things, physicians’ evolution in their treatment of patients. The more than 400 photographs of — yes, corpses and various bones, along with their proud human companions — in Dr. Burns’ 44th book range from the mid-19th through the mid-20th century and tell a timeless message, he believes.

PATIENTS AS OBJETS D’ART

“A recent issue of the New York Times featured an article titled, ‘Doctors strive to do less harm.’ It discusses how we treat patients,” Dr. Burns says. Not that the doctors in his book, often posing happily with corpses, didn’t respect their patients, he clarifies, but “it was a different era. The doctors in these photos were just as smart and innovative as we are today, but they labored under inferior knowledge and technology. And in 100 years, when doctors look at what we are doing now, they will think of us the same way. These photos are an historic document that shows where we’ve come from.”

A PEOPLES’ HISTORY

Dr. Burns, also a clinical professor of medicine and psychiatry at NYU, cites photographic medical history as his avocation. He claims to have the largest early medical photo collection in the United States, with more than 1 million in his archive (See them on Burnsarchive.com). Dr. Burns began collecting the photographs in the 1970s when they were relatively easy to obtain, he says, “because many institutions still had not appreciated photographs as historic documents.” Art photography was what museums and universities were interested in at the time.

“There are really two histories of photography,” Dr. Burns says. “One is the history of photography by the innovators and famous art photographers. The other is the history of how photography was used by people and professions.”

Photography, Dr. Burns claims, has been essential to the development of modern sciences, as well as of ophthalmology. “It was critical to the specialty’s advancement,” says Dr. Burns, also the author of a four-volume history of ophthalmology.

Dr. Burns’s new book takes readers back to the earliest days of medical photography.
IMAGES COURTESY STANLEY B. BURNS, MD

Édouard Meyer performing cataract surgery in 1870.

LESSONS OF THE MORE RECENT PAST

In his 45 years practicing ophthalmology, Dr. Burns has seen a lot of history occur in the specialty himself. The business of physicians is to put themselves out of business by curing disease, he notes; ophthalmologists have “been extraordinarily successful” at this in regards to cataract surgery.

“In 1976, I was in charge of auditing the cataract surgery at Lenox Hill Hospital in New York City,” he explains. “The average hospital stay was 10.6 days. Now we do the surgery in 10.6 minutes. The development of phacoemulsification was one of the great advances of ophthalmology. And the profession is moving on, as all of medicine does. The conditions we treat now are not going to be the conditions we treat 20 years from now, as we get more involved in genetics.”

Dr. Burns has found another way to put his knowledge of medical history to use: as a medical adviser for a television series called “The Knick.” Directed by Steven Soderbergh, the series appears on Cinemax and looks at life in New York’s Knickerbocker Hospital during the early 20th century. OM