Medicare Reimbursement

[PDT4CNV]

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There was an interesting article in the Bulletin of the American College of Surgeons this month on the state of Emergency Services in this country.

Tables 1 and 2 on page 15 in the article shows the changes in medicare reimbursement for various procedures between 1989 and 2006.
Reimbursement for cataract surgery decline by 57%. Laminectomy and Coronary artery bypass surgery declined by 49 and 48%. However, reimbursement for Partial Colectomy and Mastectomy declined by only 2 and 5%. Hernia repair declined by 16%.

Seems like the general surgeons know the right people

For emergent procedures, reimbursement for repairing a nasal fracture declined 31%, repairing a heart wound declined only 6%. Reimbursement for orbital fracture repair declined by 20%. But, reimbursement for retinal detachment repair has declined by 50%. Currently, a retinal detachment repair doesn't pay but a few hundred dollars more than making a burr hole for a hematoma. It used to pay more than a ruptured abdominal aortic aneurysm repair.

As you can see, medicare reimbursement for intraocular surgery has decreased tremendously, much more than surgical procedures done by other surgical specialties. Please be proactive in emailing your congressman as we are slated for another 5% cut. The academy's website makes this easy.

Maybe I'll just pay 50% of my taxes because of the "great" job our politicians are doing. Pay for performance...it was their idea. 3 years of law school vs. 10 years of medical school/internship/residency/fellowship and WE are getting screwed.

 

[ckyuen]

reimbursements are determined by a formula that calculates rvus or relative value units. what saves ophtho, even though you think reimbursements are low is that the formula takes into account intensity of the procedure and overhead. overhead for optho is very high and the intensity for eye procedures is in line with neurosurgery. anyone you ask who does cataracts can tell you it is the least forgiving procedure where fractions of a mm mater, and the way you breathe even matters. Trust me everyones reimbursements suck. I heard from a g surgeon friend they get less than 200.00 for an appendectomy. I think a cabg pays less than a vit. I'm not sure how globals work for them, they may not have any global periods which changes things drastically. Under imbursed codes for ophtho at the top of the list is pterygiectomy with conjunctival autograft, which pays a lot less than a focal laser and about as much as an in office lpi. interestingly if you use an amniotic membrane graft reimbursement is 2x as much even though the procedure takes 3 to 4 minutes less. down side is the membrane cost 795.00.

 

[ckyuen]

if you want to see ridiculous reimbursements look at what radiologist get for reading mri's and cat scans that is way too high for the wishy washy diagnoses they often give.

 

[PDT4CNV]

if you want to see ridiculous reimbursements look at what radiologist get for reading mri's and cat scans that is way too high for the wishy washy diagnoses they often give.

I agree with you in that everyone's reimbursements suck. What bothers me is how much ours have decreased over the last 15 years relative to others. Down 57% for a cataract is a lot! Down 50% for RD repair is a lot.
And you know, medicare plans to cut reimbursement another 39% over the next 9 years. Current reimbursement for a cataract is around $680. Who plans to do cataracts if it hits $450? Is it worth your time? Is it worth the liability?

Who would want to spend 4 years after medical school training to be an eye surgeon when the #1 surgery you perform pays a measly $400.

 

[FamilyMD]

I agree with you in that everyone's reimbursements suck. What bothers me is how much ours have decreased over the last 15 years relative to others. Down 57% for a cataract is a lot! Down 50% for RD repair is a lot.
And you know, medicare plans to cut reimbursement another 39% over the next 9 years. Current reimbursement for a cataract is around $680. Who plans to do cataracts if it hits $450? Is it worth your time? Is it worth the liability?

Who would want to spend 4 years after medical school training to be an eye surgeon when the #1 surgery you perform pays a measly $400.

Actually, it is about to get MUCH worse for you guys. The biggest news in years is us cognitive guys (Primary Care) will get quite a raise b/c E&M RVU's are about to jump come 1/2007. Because of budge neutrality rules, our raise must come from somewhere....guess who gets the cut...surgical codes. BIG NEWS!

 

[Olddog1]

I agree with you in that everyone's reimbursements suck. What bothers me is how much ours have decreased over the last 15 years relative to others. Down 57% for a cataract is a lot! Down 50% for RD repair is a lot.
And you know, medicare plans to cut reimbursement another 39% over the next 9 years. Current reimbursement for a cataract is around $680. Who plans to do cataracts if it hits $450? Is it worth your time? Is it worth the liability?

Who would want to spend 4 years after medical school training to be an eye surgeon when the #1 surgery you perform pays a measly $400.

Your are right it is barely worth doing them at $680. When I get a glaucoma consult I bill for a consult, pachy, gonio (which likely never had been done), HVF and possibly optic nerve OCT or photos depending if they had them in the past, or if I will be following them. That starts to add up and there is much less liability (unless I miss the diagnosis) than if I tear the posterior capsule, get an RD, endophthalmitis, wrong lens power, etc.....

 

[VA Hopeful Dr]

I agree with you in that everyone's reimbursements suck. What bothers me is how much ours have decreased over the last 15 years relative to others. Down 57% for a cataract is a lot! Down 50% for RD repair is a lot.
And you know, medicare plans to cut reimbursement another 39% over the next 9 years. Current reimbursement for a cataract is around $680. Who plans to do cataracts if it hits $450? Is it worth your time? Is it worth the liability?

Who would want to spend 4 years after medical school training to be an eye surgeon when the #1 surgery you perform pays a measly $400.

2 easy fixes to this. 1) Open your own surgery center, there's big bucks to be had using that route. 2) Be exceptionally speedy at doing the surgery. I observed a guy in Birmingham who could do 6 of them in an hour. $4200 per hour ain't too shabby.

That being said, I do think its unpleasant how much things have been cut across the board. Make that a political goal for next year maybe? You could get every kind of provider on board such an attempt, I'd wager.

 

[Olddog1]

2 easy fixes to this. 1) Open your own surgery center, there's big bucks to be had using that route. 2) Be exceptionally speedy at doing the surgery. I observed a guy in Birmingham who could do 6 of them in an hour. $4200 per hour ain't too shabby.

That being said, I do think its unpleasant how much things have been cut across the board. Make that a political goal for next year maybe? You could get every kind of provider on board such an attempt, I'd wager.

Item 1 - Good luck opening a surgery center in some places. Some states have already made it impossible to obtain the licenses to open one. Also, in some places unless you are well connected politically the local hospital (as well as your competition with their own surgery center) will do everything they can to prevent you from opening your own center because of the major $$ they lose from high volume out patient surgery. I think you need to justify a "need" in some locales and that is where the hospital and government argues there is no need.
Item 2 - 6 cataracts an hour. Pretty impressive. I would bet well under 25% of those patients are happy with their experience as part of a cattle call. Also, some high volume cataract surgeons have a referral network of 50, 100, 150 optoms who feed them business, sometimes telling the patient to drive 100 miles right past the opthalmology practice across the street to go to the distant cutter so they can co-manage. I am not really sure either of these is right for the patient. And no I am not bitter, yes I am a good surgeon, and yes I do some co-management (subspecialty).

 

[VA Hopeful Dr]

Item 1 - Good luck opening a surgery center in some places. Some states have already made it impossible to obtain the licenses to open one. Also, in some places unless you are well connected politically the local hospital (as well as your competition with their own surgery center) will do everything they can to prevent you from opening your own center because of the major $$ they lose from high volume out patient surgery. I think you need to justify a "need" in some locales and that is where the hospital and government argues there is no need.

I was unaware of the problems with opening a surgery center, I'll gladly retract that one.

Item 2 - 6 cataracts an hour. Pretty impressive. I would bet well under 25% of those patients are happy with their experience as part of a cattle call. Also, some high volume cataract surgeons have a referral network of 50, 100, 150 optoms who feed them business, sometimes telling the patient to drive 100 miles right past the opthalmology practice across the street to go to the distant cutter so they can co-manage. I am not really sure either of these is right for the patient. And no I am not bitter, yes I am a good surgeon, and yes I do some co-management (subspecialty).

I don't know about patient satisfaction, as I was only with the co-managing ODs for the first week of post-op care. They said the surgery was very well done, least inflammation of any surgeon they'd ever sent patients to.

I agree with you that sending patients great distances, past otherwise capable surgeons, just for co-management is a very shady practice that does the patient little good. On the other hand, if you have the choice between a decent surgeon 15 minutes away, and a fantastic one an hour away.... it gets trickier.

But that's neither here nor there; no matter how you cut it, reimbursements getting decreased hurts both doctors (and future ones with large debts), and patients (as many providers will try to see more patients to make up for the cuts).

 

[drgregory]

sorry to bud in on the ophthal forum YET AGAIN, but my partners (ophthalmologists) and i (an optometrist) have discussed this at length. we are in the process of our cataract suite design. however, problem is with ancillary personel. ever figured out how much you need to pay surgical techs and a nurse anesth.? it sucks. in our state, the building is not the issue, its trying to lure a surgical tech and nurse anesth to be standing by for only 5 hours worth of surgery per week. sometimes if you can figure out and get some other surgeons to give you their "word" that they want another surgical location they will do their surgery at your suite, and you collect suite fees. but you have to make sure the said suite doesnt have an optical, obviously. again sorry to bud in. and please note how in my little fairy tale world ODs and MDs get along quite well. we each know our roles.

 

[new-eye]

With increasing overhead and staff salaries, some cataract surgeons are performing cataract surgery without an IV/IV meds and without anesthesia personel (topical cases only , of course). Another consideration is utilizing an RN to monitor patient but not requiring a CRNA/MDA.

 

[drgregory]

With increasing overhead and staff salaries, some cataract surgeons are performing cataract surgery without an IV/IV meds and without anesthesia personel (topical cases only , of course). Another consideration is utilizing an RN to monitor patient but not requiring a CRNA/MDA.

our surgeons do 98% of theirs topical, or at least attempt to, but your always going to have the non-fixators that require peribulbar or retrobulbar. im not a physician, but i know that our surgeons would rather have an anesth. do the blocks too.

 

[7ontheline]

our surgeons do 98% of theirs topical, or at least attempt to, but your always going to have the non-fixators that require peribulbar or retrobulbar. im not a physician, but i know that our surgeons would rather have an anesth. do the blocks too.

This surprises me a little. While it's nice to have someone else do your blocks I personally have not found a lot of anesthesiologists that I would trust to do my retrobulbar blocks. Peribulbar whatever.

 

[PDT4CNV]

This surprises me a little. While it's nice to have someone else do your blocks I personally have not found a lot of anesthesiologists that I would trust to do my retrobulbar blocks. Peribulbar whatever.

There are some active suits against anesthesiologists performing RBBs. These patients claimed that the complications occurred because the anesthesiologist is not as qualified to do the block nor is he/she trained to handle the complications of a RBB. Whether or not this has any validity to it, there is definitely some liability anesthesiologists take on who wish to perform RBBs themselves. Furthermore, it is possible that the ophthalmologist could be held liable for a complication of RBB performed by the anesthesiologist under current malpractice laws.

At our institution none of the anesthesiologists do the blocks. And I suspect I will continue to do my own out in practice just because I am OCD about doing everything myself to make sure its done how I like it. There is definitely an art to even a RBB. When I first started out, most of my patients had very little akinesia and only moderate anesthesia. Its much better now that I have tweaked my technique.

 

[drgregory]

There are some active suits against anesthesiologists performing RBBs. These patients claimed that the complications occurred because the anesthesiologist is not as qualified to do the block nor is he/she trained to handle the complications of a RBB. Whether or not this has any validity to it, there is definitely some liability anesthesiologists take on who wish to perform RBBs themselves. Furthermore, it is possible that the ophthalmologist could be held liable for a complication of RBB performed by the anesthesiologist under current malpractice laws.

At our institution none of the anesthesiologists do the blocks. And I suspect I will continue to do my own out in practice just because I am OCD about doing everything myself to make sure its done how I like it. There is definitely an art to even a RBB. When I first started out, most of my patients had very little akinesia and only moderate anesthesia. Its much better now that I have tweaked my technique.

while im somewhat unqualified to agree or disagree since im not the attending physician (or even a physician for that matter) - i agree with you in that i cannot see someone better qualified than the surgeon her/himself doing the block, especially given that complications will likely fall under their liability anyways, regardless if the anesth or surgeon performed the block. the liability thing was our surgeons reason, but we actually have talked about what you noted - are they really lowering liability anyways.

 

[Olddog1]

while im somewhat unqualified to agree or disagree since im not the attending physician (or even a physician for that matter) - i agree with you in that i cannot see someone better qualified than the surgeon her/himself doing the block, especially given that complications will likely fall under their liability anyways, regardless if the anesth or surgeon performed the block. the liability thing was our surgeons reason, but we actually have talked about what you noted - are they really lowering liability anyways.

Two of my friends finished anesthesia residency 2 years ago at a large univeristy with an active ophthalmology program, and neither ever did a retrobulbar. The reason they said was the didn't get reimbursed (it may be included in the global) for the procedure or it was very little. Also, when the RB "didn't take" some of the docs were constantly bitching at the anesthesiologist so they just stopped doing them.
As far as your surgery center, you may need to see if some othe practices want to utilize your facilities. If the surgery center sets idle, that is a good amount of potential revenue not being used, and as you said it is tough to recruit staff for a one day a week.

There was also a post about RNs monitoring for cataracts. There was an article last month (?) out of University of Iowa in JSCRS. I can't remember the specifics, but they used an RN for a large number of VA cases without any major complications and had to consult anthesia on a few, with, I think, one case needing to have anesthesia intervention. Obviously, I didn't read it very closely and I don't have it here, but it would be a good look up if you are considering using RNs.

 

[drgregory]

Two of my friends finished anesthesia residency 2 years ago at a large univeristy with an active ophthalmology program, and neither ever did a retrobulbar. The reason they said was the didn't get reimbursed (it may be included in the global) for the procedure or it was very little. Also, when the RB "didn't take" some of the docs were constantly bitching at the anesthesiologist so they just stopped doing them.
As far as your surgery center, you may need to see if some othe practices want to utilize your facilities. If the surgery center sets idle, that is a good amount of potential revenue not being used, and as you said it is tough to recruit staff for a one day a week.

There was also a post about RNs monitoring for cataracts. There was an article last month (?) out of University of Iowa in JSCRS. I can't remember the specifics, but they used an RN for a large number of VA cases without any major complications and had to consult anthesia on a few, with, I think, one case needing to have anesthesia intervention. Obviously, I didn't read it very closely and I don't have it here, but it would be a good look up if you are considering using RNs.

thanks for the info. ill check it out. exactly what you said - right now we are at a stand still as we, individually as a group, do not have the surgical volume to support a suite. and depending on others to fill it...makes most of us a little leary. we're talking with some ENTs - we'll see what becomes of that.

 

[orbitsurgMD]

Actually, it is about to get MUCH worse for you guys. The biggest news in years is us cognitive guys (Primary Care) will get quite a raise b/c E&M RVU's are about to jump come 1/2007. Because of budge neutrality rules, our raise must come from somewhere....guess who gets the cut...surgical codes. BIG NEWS!

Don't buy that boat just yet.

CMS has sold primary care a bill of goods before in exchange for cooperation on cuts, and it went very similarly to what is happening now. "Go along with these procedural cuts and we will give you the spoils." Except it never turned out that way. They figure you are desperate enough to be played again.

 

[Visioncam]

reimbursements are determined by a formula that calculates rvus or relative value units. what saves ophtho, even though you think reimbursements are low is that the formula takes into account intensity of the procedure and overhead. .

This is just the Communist party line. The actual reason for RVS is to game the system in order to cut payments.

Another party line thing on the horizon is monitoring for quality control factors. If you monitor these, they say you will get higher payments. In fact, the things they want you to monitor has nothing to do with quality and are so difficult to keep tabs on that most doctors will eventually get a pay cut.