What are your thoughts on the proposed 2020 fee schedule?

[hello lady!]

As a first year resident, I was wondering what do you think would be the most useful fellowship?

The one that you enjoy the most.

Do a fellowship because you love the subspecialty. You'll find a way to make it work out in the real world. I couldn't imagine doing glaucoma fellowship and having that garbage chronically dumped on me from other eye docs - I would rather leave the field entirely. Even if it meant that I'd be making serious cash.

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[Lazyeye9]

When you place a toric and get that 20/15 vision, realistically how long does it last? Every patient I've seen (including from high volume refractive experts) ends up needing correction after ~3-5 years. Do you LASIK/PRK q5 years? I've never seen someone avoid reading glasses beyond the 5 year mark for multifocals, either.

In my hands, if they are 20/15 at 1 mo, they stay that way. The eye rx does not change. Unless they have something else going on inside the eye. The MF Alcon lens once it gets glistenings can have that problem. Fortunately we have many more options now.

 

[Dusn]

With all due respect, you are probably not a cataract refractive surgeon. To say everyone can learn to put in a premium lens or do refractive when you have patient expectations of seeing 20/15 and J1+ downplays how challenging it can be to do perfect cataract and refractive surgery for these patients. It is that mindset that gives poor outcomes and unhappy patients.

You're right. I'd actually go further and say that no one can satisfy patients when they expect to see 20/15 and J1+. I'd argue that the correct course would be to not operate on these patients until they can demonstrate more realistic expectations.

But of course, we see ophthalmologists operating on these patients all the time. Which leads me to believe that some ophthalmologists are so desperate to do cataract surgery that they will continue to do it even if they cut reimbursements further.

I'm not happy about the situation; I just want us to have realistic expectations of our future so that we donate to our PACs and so we can plan, save, and diversify our skill sets and income streams.

From the front page of the AAO website:

"CMS is not making any changes that the Academy requested to its E/M proposal, meaning scheduled 2021 fee increases remain unapplied to post-operative visits in the global surgical payment. This is an unacceptable decision, reaffirming that this is an issue on which the Academy will aggressively focus in the coming year.

CMS is also declining at this time to provide parity for our profession’s eye visit codes, opting to reassess this issue in the future.

Both these combine to threaten our profession’s financial sustainability and your ability to run a successful ophthalmology practice. The post-operative visits decision is not just unfair – it is also illegal, in violation of federal law."

 

[Slide]

You're right. I'd actually go further and say that no one can satisfy patients when they expect to see 20/15 and J1+. I'd argue that the correct course would be to not operate on these patients until they can demonstrate more realistic expectations.

But of course, we see ophthalmologists operating on these patients all the time. Which leads me to believe that some ophthalmologists are so desperate to do cataract surgery that they will continue to do it even if they cut reimbursements further.

I'm not happy about the situation; I just want us to have realistic expectations of our future so that we donate to our PACs and so we can plan, save, and diversify our skill sets and income streams.

From the front page of the AAO website:

"CMS is not making any changes that the Academy requested to its E/M proposal, meaning scheduled 2021 fee increases remain unapplied to post-operative visits in the global surgical payment. This is an unacceptable decision, reaffirming that this is an issue on which the Academy will aggressively focus in the coming year.

CMS is also declining at this time to provide parity for our profession’s eye visit codes, opting to reassess this issue in the future.

Both these combine to threaten our profession’s financial sustainability and your ability to run a successful ophthalmology practice. The post-operative visits decision is not just unfair – it is also illegal, in violation of federal law."

For those who are wondering what DUSN is referring to, here is the link for more news.

Academy Analysis Confirms Massive Cut to Ophthalmology Due to E/M Change

The top surgical specialties will experience immediate, significant, across-the-board cuts, including 7% for our profession.

www.aao.org

If you can't log-in or don't want to read it, the tl;dr summary is ophthalmology is expected to get a 6.57% percent cut. Procedures other than E/M visits will be devalued starting in 2021.

 

[Lazyeye9]

You're right. I'd actually go further and say that no one can satisfy patients when they expect to see 20/15 and J1+. I'd argue that the correct course would be to not operate on these patients until they can demonstrate more realistic expectations.

But of course, we see ophthalmologists operating on these patients all the time. Which leads me to believe that some ophthalmologists are so desperate to do cataract surgery that they will continue to do it even if they cut reimbursements further.

I'm not happy about the situation; I just want us to have realistic expectations of our future so that we donate to our PACs and so we can plan, save, and diversify our skill sets and income streams.

From the front page of the AAO website:

"CMS is not making any changes that the Academy requested to its E/M proposal, meaning scheduled 2021 fee increases remain unapplied to post-operative visits in the global surgical payment. This is an unacceptable decision, reaffirming that this is an issue on which the Academy will aggressively focus in the coming year.

CMS is also declining at this time to provide parity for our profession’s eye visit codes, opting to reassess this issue in the future.

Both these combine to threaten our profession’s financial sustainability and your ability to run a successful ophthalmology practice. The post-operative visits decision is not just unfair – it is also illegal, in violation of federal law."

I love hearing retina docs talk about cataract refractive surgery like they know what they are talking about. I commonly get pts seeing 20/15 and J1. This is not retina surgery, this is modern refractive cataract surgery. It has nothing to do about being desperate, but using all available technology to deliver a premium result.

Now basic cataract surgery, yeah that will go away like I am saying, or those patients will be sent to residency programs. But cataract refractive surgery will be alive and well.

 

[Openglobetrotters]

Refractive cataract surgery is said should be a fellowship itself by some

 

[MstaKing10]

I love hearing retina docs talk about cataract refractive surgery like they know what they are talking about. I commonly get pts seeing 20/15 and J1. This is not retina surgery, this is modern refractive cataract surgery. It has nothing to do about being desperate, but using all available technology to deliver a premium result.

Now basic cataract surgery, yeah that will go away like I am saying, or those patients will be sent to residency programs. But cataract refractive surgery will be alive and well.

No need to defend my retina colleagues but I'll step in nonetheless. Our disdain for a few of these refractive specialists is their push to place premium IOL's on candidates that clearly have no business getting a premium IOL. Unfortunately as retina specialist we see this all the time and are asked to clean up the mess. This is not a rare event in my office, though I understand there is a selection bias there and it likely is very rare in your office. Kudos to you for offering the latest technology and upgraded services and more importantly the perfect outcomes. Sadly, not all of your colleagues have the same results.

 

[airplanes]

In my hands, if they are 20/15 at 1 mo, they stay that way. The eye rx does not change. Unless they have something else going on inside the eye. The MF Alcon lens once it gets glistenings can have that problem. Fortunately we have many more options now.

I love hearing retina docs talk about cataract refractive surgery like they know what they are talking about. I commonly get pts seeing 20/15 and J1. This is not retina surgery, this is modern refractive cataract surgery. It has nothing to do about being desperate, but using all available technology to deliver a premium result.

Now basic cataract surgery, yeah that will go away like I am saying, or those patients will be sent to residency programs. But cataract refractive surgery will be alive and well.

Well this is interesting. Going very quickly through your post history, you applied for fellowship in Summer 2017 which means you started fellowship (if you matched in to one in Summer 2018). With a one year fellowship, you then presumably graduated in Summer 2019. Six months of work in your own practice is really not enough of a track record to confidently claim your Rx does not change. In fact, you haven't even seen patients for their six month follow ups if you operated on them in September or later.

While I am not saying your patients aren't going to be doing spectacularly well at 6 mo, 1 year, 2 years, and for the remainder of their lives, I don't think you have the experience or evidence to back up your claims. Operating on patients in fellowship is not the same as your hands. The best refractive cataract surgeons in the world are going to continue to improve for their first several thousand cases.

You also feel comfortable making very bold predictions on the future of cataract surgery (monofocal phacos to be only offered by residents? lol what?) with about half a year of real world experience.

I admire your confidence, but it's a fine line between confidence and arrogance.