Mid-Year Forum Experience: Optometric Surgery & More

This was the first year residents were invited to attend the Mid-Year Forum. The goal was to raise awareness of political issues and to increase resident involvement. I'm back from the AAO Mid-Year Forum. I learned tons, and I have increased respect for the AAO and state medical societies. These organizations are fighting for our future as ophthalmologists and demanding high quality of care for our patients. The AAO does wonderful things for ophthalmology and patients. In addition to the political side of ophthalmology, there were sessions on documentation of resident competency, bridging the gap between academic medical centers and private practitioners, and Medicare fee solutions. I'll discuss some of these issues in detail below.

My goal is to pass on what I learned so that medical students and residents interested in ophthalmology can become more involved. As residents, we need to prepare ourselves intellectually, surgically, and politically. The political process is very important. We all must start by giving money to our Political Action Committees (PAC). There are 40,000 optometrists and 14,000 ophthalmologists in the US. Optometrists, historically, have given several fold more than ophthalmologists; thus, organized optometry is a powerful and formidable political group. The average ophthalmologist gives $50/year to his/her PAC. As residents, we can easily match this. As attendings and staff, we should be giving several fold more. Perhaps we should learn from our colleagues in law who give an average of $1000/year!

I. Optometric Laser Surgery in the VA

The #1 agenda was advocating for surgeons doing surgery in the VA system. Oklahoma is the only state that allows their optometrists to perform some laser procedures. However, with the events last week, a bill, if signed by the Governor, will make Oklahoma optometrists into ophthalmologists. Because Oklahoma ODs can perform laser procedures, they started performing laser procedures in the VA located in other states. It's ironic that these same procedures, if performed across the street in a private office, would be illegal.

http://www.aao.org/aao/news/release/20040407.cfm

"Fueling the debate, the Academy recently was made aware of credentialing sheets [for optometrists] from VA facilities in Los Angeles outlining that include surgical privileges for multiple eye procedures, including ?focal photocoagulation of microvascular fundus lesions,? ?pan-retinal photocoagulation for proliferative retinopathy and iris neovascularization,? and ?parenteral injection of pharmaceutical agents for treatment of complex diseases or conditions of the eye.? In Tuscon, YAG capsulotomy is not even listed on ophthalmology?s privileging sheet, but does appear on optometry?s, along with ?local subcutaneous injection of pharmaceutical agents,? and ?excision of minor lid lesions??evidence of optometry?s effort to establish these surgical procedures as part of its standard of care."

Dmitry Pyatetsky, MD and me on advocacy day.
see below

Representative Leach and me after our meeting.
see below

After meeting with Senators and Representatives, I realized several things. It's important for physicians to be involved politically. It's our duty to maintain a high standard of care for our patients and for future generations. If I had not attended advocacy day, then nobody from Iowa would have met with Representative Leach, one of the co-sponsors of the VETS bill. He needed more information about the key issues. Many members of congress do not have a good understanding of our training and what it takes to be an eye surgeon. It was helpful for Representative Leach and his staff to hear from a physician's perspective. Otherwise, they only hear from organized optometry who claim that their graduates complete "residencies", when in fact, these "residencies" are only 1 year long and less than 10% of ODs complete a "residency".

The AAO advocates for patients and physicians. One of the political agendas was to ask for federal funding to assist low-income children with eye problems.

Statement by Michael Redmond, M.D. American Academy of Ophthalmology President

WASHINGTON??Some 11 million uninsured children in this country are a step closer to getting the eye care they deserve thanks to the recent introduction of the ?Children?s Access to Vision Care Act of 2003,? H.R. 3602. The American Academy of Ophthalmology worked with Reps. Vito Fossella (R-N.Y.) and Sue Kelly (R-N.Y.) to develop a bill that provides $75 million in state grants for eye exams and treatment for uninsured children. The American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Family Physicians also support this legislation.

?We applaud these representatives and the leadership and compassion they have shown for the uninsured children in this country who have no access to sight-saving exams or follow-up treatment. Because it was also important to provide this help in a fiscally responsible way ? particularly at a time when so many states face record budget deficits ? this legislation builds on existing vision screening programs that many states already have, by providing money to pay for proper follow-up exams and treatment for uninsured children who have already been identified through a screening as having potential vision problems.

?Introduction of this important legislation is just a first step. Today, I urge all members of Congress to join us in supporting a bill that will help ensure all children have the opportunity to begin their school years seeing clearly and able to perform to the best of their ability.?

Current AAO president Dr. Jensen and me.
http://forums.studentdoctor.net/attachment.php?attachmentid=2228

America's medical liability system is broken. Skyrocketing medical liability premiums across the nation are seriously threatening patient access to care.


Medical Liability Reform Issue Brief
http://www.aao.org/aao/advocacy/federal/malpractice/liability_brief.cfm

H.R. 5/S. 607
Rep. Jim Greenwood (R-Pa.) and Sen. John Ensign (R-Nev.)


Executive Summary

Skyrocketing insurance premiums are seriously compromising the nation?s health care delivery system. Liability insurers are leaving the market or raising rates to astronomical levels. In turn, more physicians, hospitals, and other health care providers are severely limiting their practices or are simply unable to practice medicine. Without federal legislation, the exodus of these providers will continue, and patients will find it increasingly difficult to obtain needed health care.

To combat this crisis, the House of Representatives on March 13th passed H.R. 5, the ?Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act? by a vote of 229-196. The attention now turns to the Senate where Sen. John Ensign (R-Nev.) has reintroduced the companion HEALTH Act (S. 607). The real battle will be over what form the bill takes coming out of the Senate.

Background

In order to address this crisis, the Academy has joined the Health Coalition on Liability and Access (HCLA), a national advocacy coalition comprised of organizations representing physicians, hospitals, health care insurers, business, producers of medicines and health care consumers. The goal of HCLA is patient safety and injury prevention first. The HCLA believes that a reformed system would do a better job of protecting patients by promoting access and innovation. It would also discourage defensive medicine that costs billions, and at times can cause needless suffering. The HCLA supports basic medical liability reforms nationwide that have been proven to be effective in some states across the country. These reforms include:

* Placing a $250,000 ceiling on non-economic damages,
* Halting double recovery,
* Holding each defendant responsible only for the portion of non-economic damages attributable to their own acts or omissions,
* Limiting the amount of attorney contingency fees,
* Paying awards for future expenses or losses over time,
* Providing for a uniform statute of limitations,
* Encouraging alternative dispute resolution methods,
* Reforming punitive damages.

President Bush in his State of the Union speech mentioned the need for meaningful medical liability
reform and has made it a priority for his administration. He even personally lobbied undecided lawmakers before the vote in the House of Representatives. Presidential commitment to this issue is one of the key reasons that there is an improved environment for passage.

Right now the battle centers around the Senate. Senator Dianne Feinstein (D-Calif.) is poised to introduce a bill based on California?s MICRA, which has successfully kept down insurance premiums. She has been working with Senate Majority Leader Bill Frist (R-Tenn.) on this legislation. All speculation revolves around what will be contained in the legislation and the fact that this bill, with bipartisan sponsorship, and not S. 607, will be the base bill for medical liability reform. Once the legislation is introduced the Republican leadership is committed to bringing it to the floor as soon as possible for a vote. The plan is to have a one-week long debate on the issue.

The major test will be on the cloture vote in the Senate. In order to stop debate and move to a vote on a bill, a cloture motion must be filed and must pass with 60 votes. If it does not receive 60 votes, debate can continue ad infinitim. This is otherwise known as a filibuster. If the cloture motion receives 60 votes then the debate is limited and a vote is scheduled.

Sen. Feinstein has targeted nine democrats as key to getting this legislation passed. They are: John Breaux (La.), Mary Landrieu (La.), Blanche Lambert-Lincoln (Ark.), Mark Pryor (Ark.), Zell Miller (Ga.), Max Baucus (Mont.), Ben Nelson (Neb.), Jon Corzine (N.J.), and Frank Lautenberg (N.J.). During your meetings with these senators or other Democratic senators please ask them to vote yes on the ?motion to proceed.? They may not agree with you on the final vote, but they shouldn?t stand in the way of this issue at least getting a straight yes or no vote.

If this bill gets out of the Senate, it will go to a conference committee of House and Senate negotiators, which will be dominated by the Republican leadership. The final product that is produced by the conference committee will look more like the Senate bill than the House-passed bill. Some House Republicans are not happy with a $250,000 cap, but voted for H.R. 5 regardless, in hopes of forcing Senate action and with the understanding that the cap would more than likely be made higher in the Senate or conference committee.

This bill faces significant opposition from the trial lawyers who have raised millions of dollars to defeat the initiative. See Point-Counterpoint.


What to Ask Congress

In the Senate

Democratic senators ? Ask your Democratic senators to contact and work with Senator Feinstein on a Federal MICRA bill.

Republican senators ? Urge your Republican senators to pass proven and effective medical liability reform, such as MICRA.

Ask your senator to VOTE YES on the ?motion to proceed? to medical liability reform and to support passage of the bill in the Senate.

In the House

Request that your member support the final version of the medical liability reform legislation that is produced by the conference committee.

This is an old article, but summarizes the current problems with the current Sustainable Growth Rate (SGR) formula used for Medicare reimbursements.

http://www.aao.org/aao/advocacy/federal/Halt-Cut.cfm

Academy, AMA and Others Fine Tune Strategy to Halt Cut in Medicare Payments and Replace Update Formula

Member Alert: Jan. 15, 2002

With Congress returning to Washington in a couple of weeks, the Academy, the AMA and other medical specialties, have reorganized to fine tune a strategy to halt the implementation of the 5.4 percent cut in physician Medicare payments, or $200 million for ophthalmology. The coalition, now 50 organizations strong, is also working to replace the current update formula with one that will ensure fair updates for physicians in 2003 and beyond. This fight for fair reimbursement tops the Academy's priority list, and we call for every ophthalmologist to join the battle in order to achieve our goal.

Action Plan: Build upon our grassroots support and work with our congressional champions for immediate relief.

Due in part to your earlier efforts and the Academy's intensive lobbying, the first session of Congress ended with more than 66 sponsors in the Senate and 288 in the House for a bill to limit the 2002 cut. There were even last-minute efforts on our behalf to just freeze the conversion factor at the current level (2001) by key leaders in Congress. Thank the members who have weighed in on the issue for us, and tell them it is time for action. Every Eye M.D. must personally relay the key messages to his or her member of Congress to ensure success (call, fax or e-mail). The Academy will continue to work closely with payment-fix champions and other members of Congress. To determine if your member has sponsored our legislative effort, see our co-sponsor list (.pdf version*). Develop an alternative formula that will ensure fair updates for physicians in the future.

Clearly as a result of the outcry by physicians, Ways and Means and Energy and Commerce committee chairs have already asked that money be set aside in the budget resolution for this session of Congress to ensure that physicians do not get another cut in 2003. All indications are that the physician payment update will be negative again next year if Congress does not intervene in 2002. The Academy, the AMA and other members of a select subset of the coalition, is in the midst of an intensive effort to develop a new process for updating physician fees that relates to the Medicare Economic Index (MEI), an index that reflects the impact of inflation on the cost of practicing medicine. In addition, the Academy has submitted comments to the Medicare Payment Advisory Commission (MedPAC), an independent body, that will develop recommendations this week for Congress on the issue.

Key messages to relay to your member of Congress:

* Halt the 5.4 percent cut in physician Medicare payments immediately that went into effect on Jan. 1, 2002. Physicians have already sustained four major fee cuts over the past 10 years, bringing the average update over that period to a 1.1 percent increase a year-significantly below inflation and the growing costs of practice.
* Replace the current Medicare formula with one that will ensure a fair (positive) update in physician payment for 2003 and beyond.

The highlight of the Mid-Year Forum for me was meeting COL Donald A. Gagliano. He is the Commander of the 30th Medical Brigade in Iraq. He established the medical system in Baghdad for our troops and helped build the medical system in Iraq. He gave Iraqi physicians a voice in a system that squelched their ideas and creativity. He brought in residents from surrounding countries and trained them. He gave lectures on trauma medicine to the Iraqi physicians.

His troops delivered high quality care to soldiers, civilians, prisoners, and children. He established a state of the art burn unit for war victims. The care delivered was sophisticated. The military had an ICU and burn unit in the middle of the desert. His accomplishments in Iraq are awesome.

The inspiring thing for me, as a future Navy Ophthalmologist, is that COL Gagliano is a board certified ophthalmologist and retina surgeon. Awesome!

http://www.30thmed.army.mil/Units/Command/30th Med Commander.htm

COL Gagliano and me at the Mid-Year Forum.
http://forums.studentdoctor.net/attachment.php?attachmentid=2230

Dr. Cynthia Bradford and me.


More photos here:
http://www.ofoto.com/I.jsp?c=y5wb7ul.67c77wj5&x=1&y=q6v834

Richard_Hom said:

Dr. Doan,

I had the pleasure of working with COL Gagliano when he was at LAMC at the Presidio of San Francisco in his earlier years during after Desert Storm. In face we shared an 18-year-old patient who unfortunately suffered a direct laser blast to the left eye and who had been originally diagnosed as self inflicted "solar retinopathy". I think he might remember that circumstance because of the several complicating issues associated with this patient.

Richard_Hom

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Interesting! How many years did you serve?

Richard_Hom said:

2 yrs active + 1activation (Desert Shield / Storm) + 2 deployments on the USS A. Lincoln and USS C. Vinson.

My research interest back then was laser wounds and when I saw this patient I had a feeling about the prevailing diagnosis.

Richard_Hom
on a Jornada

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Richard,

What types of research funds are available to scientists in the Navy? I've heard Navy scientists can apply for NIH, NEI, and other private grants. Have you seen many Navy scientists who were competitive for NIH and NEI funding? If one applies for a NIH grant, then can I apply the funds to hire techs and research assistants?

I see you're replying to posts via the Jornada. Is web surfing on a Jornada easy to do? That's pretty cool.

Best regards,
Andrew

Richard_Hom said:

Some interesting subjects that I thought might be of intererst:

1. Identifying laser retinal injuries from rangefinders or target locators . I don't think there is sufficient work in this area. This might involve working with the Marines.

2. What are the "long term" effects of submariner environment on the morbidity, if any, of LASIK?

3. G-forces greater than 4G's on a "flap"

4. Ejection from a jet aircraft with a patient with LASIK.

5. Use of the ocular and LASIK in a head mounted targeting system in either rotary wing or tracked vehicle environments.

ETC, ETC, ETC,
Richard

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Richard,

These are interesting ideas. Do you plan on collaborating with any Navy docs in regards to these research ideas?

Andrew