what does the affordable care act mean for retina?

[soonmd1]

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Hey Guys,
Any predictions on how retina might be effected?

Are the crazy lucrative days of retina over? Can those of us joining the work force as specialists in 3-4 years expect to clear 500grand (not the first couple of years of course) with a reasonable work schedule in the midwest/midsouth or is that wishful thinking

looking for some honest answers! people seem to very reluctant to talk about salaries in our specialty (probably because of the variability across different locations) but any info would be appreciated about the real job market out there


Thanks!

 

[peroxidase]

so i'm no expert, but common sense tells me ACA or not, reimbursements for injections will only decrease in the coming years

just like reimbursements for colonoscopies, etc will also go down

if you're doing medical retina, that translates to big cuts in salary
if you're doing surgical retina, I assume you'll be safer because you're less reliant on injections as a source of income, and you have a wider variety of procedures that you can do

the key is to be in a field where you can do a variety of different things
that way if reimbursement is cut for one particular thing your practice does, you can shift your practice to focus on the other areas

 

[RestoreSight]

First, no one really knows the answer to this question, but a greater number of low-income insured patients means greater revenue depending on the community you are serving. Its important to remember most people in this country are still covered by employers, not medicaid. If your business is cataract then incomes are likely to continue to decline, but this is nothing new since reimbursements for cataract have been declining for decades. If your business is injections, incomes will also decline, but that depends on whether you are seeing a lot of medicaid patients or primarily doing Lucentis injections. With the CATT results out Avastin is the cost-effective option for medicaid patients. Its tougher to see big cuts in surgical retina because the procedures are more demanding and mandate greater time and resources from the physician. I would not be surprised if the ACA actually increases revenue for some retina specialists depending on the community you choose to practice in.

 

[Slide]

As RestoreSight said, the answer is uncertain, but directly it likely will not affect changes in payments. Payments for office visits, procedures, and surgeries are generally set by CMS, and insurance companies typically peg rates according to the guidelines set by CMS. Some private practices actually prefer to have more clinic days for injections because per hour, surgeries may result in less reimbursement compared to clinic visits and injections, especially since surgeries are being bundled more now. Medicaid patients typically end up at teaching centers or are seen on a charity basis, so they don't really affect private practices too much. With more people getting on insurance, it may increase and diversify the payment pool of patients as well. This may offset some of the reductions CMS may incur on procedures and office visits.

Also the thing about Retina is that it's a dynamically growing and changing field; injections haven't been around too long and the imaging technology for retina is changing practice patterns. Before the advent of OCT and anti-VEGF medications, conditions like ARMD and NPDR/PDR were monitored via office visits and fundus exams, and ancillary testing was essentially limited to FA/ICG. Now, there are better ways to view pathology and determine treatment plans, which have led to better outcomes. What this translates to is additional procedures, treatment plans, and surgeries that help diversify what you can do as a retina specialist. Obviously, this is a very rosy view of the retina field, but what can I say, I like the field.

 

[LightBox]

As RestoreSight said, the answer is uncertain, but directly it likely will not affect changes in payments. Payments for office visits, procedures, and surgeries are generally set by CMS, and insurance companies typically peg rates according to the guidelines set by CMS. Some private practices actually prefer to have more clinic days for injections because per hour, surgeries may result in less reimbursement compared to clinic visits and injections, especially since surgeries are being bundled more now. Medicaid patients typically end up at teaching centers or are seen on a charity basis, so they don't really affect private practices too much. With more people getting on insurance, it may increase and diversify the payment pool of patients as well. This may offset some of the reductions CMS may incur on procedures and office visits.

Also the thing about Retina is that it's a dynamically growing and changing field; injections haven't been around too long and the imaging technology for retina is changing practice patterns. Before the advent of OCT and anti-VEGF medications, conditions like ARMD and NPDR/PDR were monitored via office visits and fundus exams, and ancillary testing was essentially limited to FA/ICG. Now, there are better ways to view pathology and determine treatment plans, which have led to better outcomes. What this translates to is additional procedures, treatment plans, and surgeries that help diversify what you can do as a retina specialist. Obviously, this is a very rosy view of the retina field, but what can I say, I like the field.

The only downsides to retina (for me at least) are:

1) The monotonous clinic grind.

2) The lack of cash-paying patients (i.e. no LASIK, premium lenses, femto-cataracts).

3) Kissing up to referring providers (e.g. general ophthalmologists, optometrists).

Other than that, it is a great field.

 

[MstaKing10]

The only downsides to retina (for me at least) are:

1) The monotonous clinic grind.

2) The lack of cash-paying patients (i.e. no LASIK, premium lenses, femto-cataracts).

3) Kissing up to referring providers (e.g. general ophthalmologists, optometrists).

Other than that, it is a great field.

Some clarification from my perspective:

1. The monotonous grind will happen in comprehensive, glaucoma, cornea, or any other medical specialty for that matter if you let it. Retina is no different.

2. I chose retina in part because I wanted to avoid these cash paying patients. The high maintenance, demanding 20/20 pre-op patient looking for 20/15 post op vision is not for me. I'm not much of a salesman and didn't look forward to having to sell premium lenses and services to these folks. That's of course a very personal decision.

2. Comprehensive docs kiss up to optometrist and family practice/internist for referrals all the time, as do many other specialist. Retina is no different in this regard. In fact, a retina specialist in a multi-specialty group who has general ophthalmologist in the practice referring patients directly may have very little shmoozing to do, whereas the comprehensive docs will still have to in order to build their practice.

Agree with others in terms of the unpredictability of reimbursements in the future. Only certainty is uncertainty. I think finding yourself in a position or practice that is prepared for change and can be flexible is the most important thing.

 

[Dusn]

so i'm no expert, but common sense tells me ACA or not, reimbursements for injections will only decrease in the coming years

if you're doing medical retina, that translates to big cuts in salary
if you're doing surgical retina, I assume you'll be safer because you're less reliant on injections as a source of income, and you have a wider variety of procedures that you can do

Cuts to injections will hurt all of retina. Most of us in retina makes more money in clinic than going to the OR and it's difficult to just increase the number of surgeries you do -- only a certain percentage of patients have the pathology to justify a vitrectomy.

There are so many new technologies and treatments coming out in retina. Especially imaging modalities and improvements on existing imaging (ie. swept-source OCT and OCT that will be able to image retina vessels and blood flow, etc). Unfortunately declining reimbursements will stifle this growth as it's difficult to justify the cost of getting a new expensive machine every few years when you can't recover the money you spent on it. Most ophthalmologists don't even have anything close to the newest equipment currently due to cost issues.

 

[orbitsurgMD]

The ACA probably won't do much for retina practices either way. There will be more people buying or having bought for them Medicaid policies. Despite the law that says states must pay at the Medicare rate for their Medicaid claims, that requirement is time-limited and you are still going to be counting on the same agencies that routinely pay claims a half-year or farther behind. Those with income sufficient to afford commercial insurance through the exchanges and who comply and purchase from the insurance exchanges will buy a variety of products, but those looking for low cost plans will be buying high-deductible plans. So your practice will have to be watching out for those who have not paid their deductibles (as they already should anyway.) The scofflaws who don't buy mandated insurance will function as they do now.

Medicare will remain in the CMS vise, and continue to be squeezed. Expect more code bundling and other tricks to deny payments (no same-day E&M with procedures kind of stuff) that is relevant to retina, where you have to do exam and then a treatment on the same day. They have already been chiseling away at diagnostic services done the same day, so more headaches if you are doing 99214, an OCT or angio and then an injection or laser on the same day, which is very common in retina. The insurance companies will get very difficult with this, since it is a big part of retina, not so much the surgery.

New OCT will get harder to justify unless a device company creates something innovative at a price that is market transforming. Unless you are doing many studies per day, getting an OCT to pay its way will be challenging. Or you may see more stratifying of the OCT market with six-figure swept-source models aimed at big centers and more conventional technologies continuing at lower prices to the smaller practice market. That won't depend on ACA though.

The crazy lucrative days are probably over but busy retina practices will still probably out-earn all other specialties. There is an inherent advantage when a high percentage of encounters have a high-level E/M plus at least one diagnostic service and a procedure. No other subspecialty does as much of that as retina. You just have to turn up the volume to block out the screams.

 

[Dusn]

Medicare will remain in the CMS vise, and continue to be squeezed. Expect more code bundling and other tricks to deny payments (no same-day E&M with procedures kind of stuff) that is relevant to retina, where you have to do exam and then a treatment on the same day. They have already been chiseling away at diagnostic services done the same day, so more headaches if you are doing 99214, an OCT or angio and then an injection or laser on the same day, which is very common in retina. The insurance companies will get very difficult with this, since it is a big part of retina, not so much the surgery.

They'd be stupid to do this (but unfortunately they are pretty stupid). Once retinologists determine that the injections are working, the purpose of examining and performing testing on the patient is to see if we can decrease the number of injections without compromising vision. Monthly injections is the standard of care set by the major trials with the best overall visual outcome. But most patients do not need monthly injections.

So if they don't reimburse exams or testing, they'll see a decrease in exams and testing and a dramatic increase in patients getting monthly injections. They've already made it harder to get avastin due to restrictions on ordering it from compounding pharmacies and the $2000 per lucentis costs them much more than a few extra exams and studies by the physician to determine if the injection is really necessary every month.

But unfortunately the people running the government and insurance companies aren't usually too bright.

 

[LightBox]

They'd be stupid to do this (but unfortunately they are pretty stupid). Once retinologists determine that the injections are working, the purpose of examining and performing testing on the patient is to see if we can decrease the number of injections without compromising vision. Monthly injections is the standard of care set by the major trials with the best overall visual outcome. But most patients do not need monthly injections.

So if they don't reimburse exams or testing, they'll see a decrease in exams and testing and a dramatic increase in patients getting monthly injections. They've already made it harder to get avastin due to restrictions on ordering it from compounding pharmacies and the $2000 per lucentis costs them much more than a few extra exams and studies by the physician to determine if the injection is really necessary every month.

But unfortunately the people running the government and insurance companies aren't usually too bright.

There are also a sh**load of retinologists abusing the system with their OCT/FA/ICGs on every visit for made-up diagnoses. You can blame them as well for decreased reimbursements and bundling. It is much easier to abuse visit codes and testing since they are not as invasive as injections and laser. In other words, a patient may not mind some extra testing, but they might put up a stink if you are injecting them ad infinitum.

 

[Dusn]

There are also a sh**load of retinologists abusing the system with their OCT/FA/ICGs on every visit for made-up diagnoses.[/I]

I haven't seen this and I don't know how the retinologists you know are doing it, if true. If you repeatedly get more than 4 FAs on a patient per year, it's been my understanding that you won't get reimbursed for it or will get audited.

Even if you got an FA every month it would still be cheaper than the cost of 1 lucentis. So if you could give even 1 less injection per year by testing to see if you really need it you would save healthcare dollars.

Every review of medicare billing has shows that the numbers of FAs have decreased dramatically (look at some of the posters at the AAO or ASRS). OCTs barely reimburse anything anymore anyway and they usually really are needed at every visit.

At least in retina, physicians and the tests we do to better understand the patient's disease are not the cause of increased healthcare spending; the cost of the medications are.

 

[MullerCell]

Completely agree with DUSN. FA utilization is down significantly due to OCT, and OCT has been cut drastically. OCT is now considered a bilateral test (you are paid the same for one or both eyes), and the reimbursement is down about 50% compared with several years ago, so is like a 75% cut. There really is an indication for OCT at every visit if you are injecting and using a PRN or treat and extend protocol. Additionally, an office visit is indicated in most situations (new complaint, fellow eye with high risk disease, ect). They now are saying you cant bill extended ophthalmoscopy on the same day as a procedure. This is complete garbage. If I spend significant time on a scleral depressed exam to find a retinal tear, and then perform laser demarcation, the ophthalmoscopy is bundled. Eventually we are just going to be bringing people back the next day for treatment only on all but the urgent situations.

 

[dantt]

If I spend significant time on a scleral depressed exam to find a retinal tear, and then perform laser demarcation, the ophthalmoscopy is bundled. Eventually we are just going to be bringing people back the next day for treatment only on all but the urgent situations.

why should laser not be bundled with ophthalmoscopy? you shouldn't laser somebody before doing a thorough retinal exam, no? easy fix for cms: decrease reimbursement for laser

 

[MstaKing10]

Completely agree with DUSN. FA utilization is down significantly due to OCT, and OCT has been cut drastically. OCT is now considered a bilateral test (you are paid the same for one or both eyes), and the reimbursement is down about 50% compared with several years ago, so is like a 75% cut. There really is an indication for OCT at every visit if you are injecting and using a PRN or treat and extend protocol. Additionally, an office visit is indicated in most situations (new complaint, fellow eye with high risk disease, ect). They now are saying you cant bill extended ophthalmoscopy on the same day as a procedure. This is complete garbage. If I spend significant time on a scleral depressed exam to find a retinal tear, and then perform laser demarcation, the ophthalmoscopy is bundled. Eventually we are just going to be bringing people back the next day for treatment only on all but the urgent situations.

Correct me if I am wrong, but you can bill laser to tear but not include that in the exam. Extended ophthalmoscopy can then be billed with exam and another diagnosis (not tear) such as PVD, lattice degenaration etc. Same goes for injections. For example, can bill injection with wet amd, exam cannot have wet amd but can have another diagnosis such as dry amd, erm, pvd, retinal heme etc. Again, would appreciate any clarification for you coding gurus out there.

Codes will only get more complicated to deny more claims and limit reimbursement.

 

[MullerCell]

Obviously you are doing an extensive exam prior to treating with laser. That isn't the point. You are also doing an equally extensive exam if there isn't pathology requiring laser (lattice without holes). If you don't find a tear to treat, and they just have a PVD with lattice, you can bill the extended. It just doesn't make sense that if you are doing an equally extensive exam, and find more significant pathology that requires treatment, you aren't entitled to bill approriately for the exam.

There have been lots of denials for extended on same day as a procedure over the past several months, it doesn't matter if the diagnosis you link to the procedure is different from the extended. The just kick it out since the coding updates in July.

 

[dantt]

How long does it take to do the laser once you've already done the exam? How much more do you think you should be paid to do the laser? If medicare were to unbundle the laser with the comprehensive exam, you can bet you will end up being paid less.

 

[orbitsurgMD]

It isn't just about the time, but also the cost of the equipment, its purchase/lease, insurance and maintenance, having space to keep it, etc. There is no "technical component" charge as there is with diagnostic studies when it comes to laser. The professional time it takes to do the treatment is only a part of the cost, liability is another and materials is yet another. Most of the time, a laser sits turned off, but its costs have to be recovered by what it earns in use.

 

[Silent Cool]

Alright, let's just cut to the chase here: are retina docs going to be more or less rich than the previous generation of retina docs? (I mean, all else being equal? 🙂 )

thanx

 

[MullerCell]

The exam and laser are always unbundled using the 57 modifier when performed on the same day, this is standard practice for any same day exam and procedure. The cost of the laser is all the things Orbitsurg mentioned, in addition to the 2 or 3 additional extended exams with 360 scleral depression you will do for free in the 90 day global period. Additionally, if any new tears occur in that 90 days you treat them for free as well.

Overall, I think retina will be fine. Older retina docs were used to 30-35 pts being considered a busy day. With all the patients needing injections and the aging of the population this number has pretty much doubled. Surgery is much more efficient with small gauge instruments as well. There are many more patients that are surgical candidates than in the past. An efficient surgeon can do a significantly higher volume of cases in the same amount of time to balance reimbursement cuts.