A Zero-Sum Game
Some doctors are losers in this zero-sum game
Although retired from my practice of ophthalmology, I still keep up with the latest developments from the Centers for Medicare and Medicaid Services (CMS) as they impact my former specialty. A decades-long reimbursement system based upon relative value units for exams and procedures is part of the fabric of practicing medicine. The tug-of-war among specialties over assigning value to services is an annual competition in the Relative Value Scale Update Committee (RUC) meetings. The consensus of the committee forms the basis of recommended changes to the fee schedule that CMS must update annually. The report justifying major cuts for cataract and intraocular lens (IOL) surgery, the most successful surgery performed in this country with lifelong improvement in vision and in the quality of life, is included in a 1,700-page document issued by Health and Human Services. I don’t plan to read the entire document, but the leaders of my specialty society, the American Academy of Ophthalmology (AAO), issued an alert regarding the proposed changes. A 22% reduction in cataract and IOL fees is proposed, dropping the global fee for the surgery and 90 days of post-op care from $654.47 to $557.58. The warning from the AAO on the overall effect of more stringent quality measure documentation and reduced fees is stark: “Because of the changes to Evaluation and Management codes, and cataract and ophthalmoscopy codes, ophthalmology would experience one of the largest decreases among all medical specialties.” I’m retired, so why should this concern me?
There is a push from the American Medical Association, interest groups and some politicians to weigh physician time with the patient in the calculation of any encounter to better compensate primary care physicians. This is a noble goal, but the budget for paying doctors is basically fixed, so any economic enhancement for one group comes at the expense of another. The reward for making cataract surgery faster, safer, more reliable and successful is a major hit to our reimbursement. And who said no good deed goes unpunished?
For any medical diagnosis, a code must be assigned to a combination of the complexity of the history and the exam, medical decision-making, the disposition of the problem and the resources required to deliver the service. These resources, including practice expense, medical liability insurance expense and regional costs for office space, form an integral part of the formula for every diagnosis and procedure code. Only fractions of percentages for increases in reimbursement have been added over the years to the “conversion factor” that forms the basis for relative value units that cover all medical specialties. It is, in essence, a zero-sum game whose rules become increasingly complicated. Recent changes in methodology have been applied to reward “value” rather than “production” so that fee-for service is on the wane. Since the definition of what constitutes “value” keeps changing, physicians must continue to lobby for the value of their services through their professional societies, through their elected representatives and at the RUC meetings where all medical specialties participate.
What does all this mean for doctors in general and for my specialty in particular? The stress of increased administrative burdens, combined with fee cuts and higher practice expenses, will prove for some doctors to be just too much to bear. In my blog I highlighted the issues of Burdens and Burnout. With the coming changes to physician reimbursement policy, many doctors will lick their wounds and continue to practice medicine, while others will elect to become non-participating doctors in Medicare and Medicaid. Some will simply quit practice altogether. Saying goodbye to my patients, my staff and fellow physicians was difficult for me, but looking ahead makes me realize that it was a timely decision, indeed.