CMS wields the axe; now what happens?

Effective glaucoma surgeries targeted for reduced reimbursement, but who actually pays the price?

By Cynthia Mattox, MD

For patients with progressive advanced glaucoma failing to respond to treatment, most glaucoma specialists agree that trabeculectomy or an aqueous shunt surgery is necessary to prevent future blindness. Yet, after recent rulings in payment policy by the Centers for Medicare and Medicaid Services (CMS), the economics of providing these clinically effective surgeries for patients is becoming less of a sure thing.

This could have a drastic effect on the costs for our practices and the health of our patients.

Blow #1

The first blow from CMS rulings on glaucoma surgeries came in January 2015, affecting not only physician payment but also those for supplies used in the surgical facility where the aqueous shunt surgeries are performed.

As is current policy, CMS required that the Resource Value Scale Update Committee (RUC) revalue the entire family of aqueous shunt codes when the new Category 1 code for Ex-PRESS shunts 66183 was first presented for valuation. During the process to create a physician payment value for 66183, claims data showed that the other large aqueous-shunt codes (66180 and 66185) had an associated claim for 67255 “scleral reinforcement with patch graft” more than 70% of the time. The RUC had created a new physician payment for 66183 that was effective in January 2014, but the large aqueous- shunt codes were delayed and referred to the AMA-led CPT committee to create new CPTs, then resurveyed for RUC valuation. (See “Aqueous shunt CPT codes,” this page.)

The RUC valuation led to a reduction in physician payment of about 30%, as surgeons could no longer bill for the additional scleral reinforcement code. Also, this valuation affected facility payments provided by CMS as the patch graft material was now “bundled”; CMS expected the provider to pay for the material out of the facility payment, which did not increase to account for the additional supply costs. The American Glaucoma Society (AGS) and AAO anticipated the lack of adequate facility payments and reminded CMS multiple times, but it did not adjust the facility payments adequately for these procedures as we anticipated. Private payers also typically follow CMS payment policy, albeit at different rates.

ASCs in particular felt the lack of adequate facility payment for aqueous shunt surgery with graft — they receive approximately 50% of hospital outpatient departments’ payments. Immediately, surgeons said they could not perform their shunt surgeries in their ASCs due to inadequate facility payment to cover shunt and graft tissue costs along with other supplies and OR time and staff for these lengthy procedures. The solution: surgeons had to take their cases to the more costly setting of the hospital OR, where CMS would have to pay nearly twice as much to the facility; the patient would have to pay a higher copay.

Blow #1: A survey

An AGS survey revealed that 210 of 274 respondents (about 76%) perform most or all of their aqueous shunt surgeries at ASCs. Also, about 260 respondents (about 95%) reported using a patch graft during their shunt surgeries. When asked how they might respond to the facility cuts, surgeons responded with the following:

• About 25% would learn new techniques that do not require graft material

• About 25% would urge their ASC to allow the financial penalty

• About 50% would either take their own cases to a hospital or refer to a colleague who does have hospital OR time (71% of respondents lacked admitting privileges or block time at a hospital OR).

The AGS estimated that if even half of the current annual Medicare aqueous shunt cases in ASCs return to the hospital, CMS would incur more than $9 million in increased costs, about 50% more than the cost savings of not paying for the graft code for all 13,000 procedures.

CMS allowed a short-term fix for the facility costs in ASCs whereby a temporary loophole in the cornea tissue payment policy allowed for cornea patch material for shunts to be paid separately at invoice cost starting on April 1, 2015. However the agency has since closed this loophole, and the original facility payment bundle is slated to go into effect for ASCs in January 2016 without a viable solution. The AGS and AAO plan to submit a proposal for a higher facility payment category but, even if the process is effective, it will not go live for one to two years. By this time, the unintended effect of a shift back to the hospital will likely be entrenched.

Blow #2

The second blow to glaucoma reimbursement came with the November 2015 Final Rule publication of the 2016 physician payment for laser trabeculoplasty 65855 and trabeculectomy codes (66170, 66172). CMS targeted these codes due to the large number of postoperative visits. Trabeculectomy had not been valued by the RUC for over 20 years when the process was much different than it is today. The AGS and AAO presented the codes to the RUC using the AMA’s required aggregated survey results, and both societies defended the number of postoperative visits for the trabeculectomy codes. The RUC survey of surgeons who perform tracbeculectomy revealed a reduced intraoperative time compared to the original valuation, and the current RUC process requires lower values for each postop visit in its calculations.

So, the expected somewhat lower RUC values were referred to CMS for a final decision. In an unprecedented move for ophthalmology (although not for other specialties like GI, cardiology and radiology), CMS did not accept the RUC valuation and proceeded to recommend cutting the physician payment of the three codes by 25% to 35%. In doing so, CMS’s rationale justified the cuts solely based on the reduction of intraoperative time, ignoring the technical skill required and surgical risk. (Fortunately, the reduction is capped at 19% for 2016 by statute, and the remaining decrease is expected in the 2017 fee schedule.)

Conclusion

The implications of these large cuts to the physician payment for intense and risky glaucoma surgeries are yet to be seen. Glaucoma specialists who rely on both trabeculectomy and aqueous shunt surgery to save their patient’s sight will be adversely affected economically and will need to find ways to continue to provide these necessary services for the benefit of our society. In the long run, the cuts could change practice patterns, force some surgeons to give up surgical glaucoma care, or reduce the numbers of residents choosing glaucoma as a subspecialty. Patients may be adversely affected as they wait for a slot at a hospital OR, pay higher copays at a hospital outpatient department or need to travel long distances for both their surgical and numerous postoperative visits.

In an ideal world, payment policy would pay for the value of care to our patients, rather than cause disruption and dismay to those afflicted with a blinding disease and to those who care for them. OM

About the Author
	Cynthia Mattox, MD practices at New England Eye Center, Tufts University, Boston, and is vice president of the American Glaucoma Society. Contact her at Cmattox@tuftsmedicalcenter.org.