Ophthalmologists, whether generalists or subspecialists, face an increasing number of barriers to the effective practice of medicine. With decreasing reimbursements, increasing cost of equipment and a changing economy, many are finding it hard to keep their heads above water. Others manage to keep their chins up despite reform. This article discusses some of the common challenges facing ophthalmologists today. The information is derived from various subspecialists from around the nation who have contributed their thoughts on the matter.
There are challenges that are common amongst ophthalmology subspecialties and those that are unique. The field of oculoplastic surgery, for instance, has its own set of barriers. Dr. John Fezza is an oculoplastic surgeon on the west coast of Florida. Although primarily in private practice, he still dedicates time to the teaching of residents and fellows at the University of South Florida, the Veterans Administration, and Vanderbilt University. With experience in both a private and academic setting, he finds private practice to be less distracting, more efficient, and more lucrative and he can practice with much more autonomy.
On the other hand, physicians in private practice tend not to have residents and fellows, so they must take call themselves or rotate with other physicians in the group or geographic area. The challenges Dr. Fezza faces are with the other specialties, primarily plastic surgeons, where there is an overlap in the treatment of many conditions, such as blepharoplasty and brow lifts. Since the American Board of Medical Specialties (ABMS) does not recognize any ophthalmology subspecialties, including oculoplastic surgery, competing specialties use this fact to argue that the quality of care they offer is superior. There has been a long battle over board certification for oculoplastic surgeons for the past several years for these reasons and more. Progress has been made though, with Accreditation Council for Graduate Medical Education (ACGME) recognition as of this summer which will hopefully lead to board certification in the next decade.
Coding presents another challenge while it continues to evolve, forcing some physicians to be 'creative' and others to simply 'under code' to avoid controversy. Often the necessary creativity of a specific surgery is difficult to code appropriately as fixed codes and guidelines may not accurately describe the work that was done.
Finding and keeping intelligent and motivated employees is always challenging. Some have better luck than others. It becomes a vicious cycle because with the cutbacks, it is harder to compensate an employee the way one might want to. This may foster lack of enthusiasm on the employee’s part. Less effort equals fewer patients and so on.
Across the board, the most common complaint is the decrease in reimbursements. Physicians are forced to see as many patients as possible to make ends meet. Insurance companies do not see many of the ophthalmic procedures as 'valuable', especially with competition willing to perform the same procedures for less. Some procedures reimburse so little that surgeons are not willing to perform them because they become 'money losers'. In the end, the patient becomes the loser. To compensate, physicians will focus on self-pay procedures. For oculoplastic surgeons, botulinum toxins, dermal fillers, lasers and cosmetic surgeries help to compensate for the loss in reimbursement. For cornea and refractive surgeons, it is the premium intraocular lenses and refractive surgery that helps. But even with self-pay procedures, the money coming in is less. For instance, Dr. Tatiana Lee-Chee, a cornea specialist in south Florida, discusses the trend with LASIK. This procedure started out as a high-end product where every doctor would benefit. With growing competition, some physicians decided to drop the prices considerably and now patients shop for bargains for their eyes!!! Dr. Jeffrey Maehara, an anterior segment specialist in Hawaii, mentions that on top of low reimbursements, the cost of equipment is outrageous and it is no longer financially sound to spend money on updated equipment since it will take far too long to make your money back. "Ultimately, patient care is compromised", he says.
With the pending 21% Medicare cut, physicians don't know whether to hold claims or not and some threaten to cut back on the amount of Medicare patients they accept, a situation that will be devastating for the population that needs health care the most. As well, Medicare has become stricter with compliance, including fraud regulations and HIPAA, says Dr. Lee-Chee. Maintaining compliance can be very costly with the loads of paperwork that patients are now forced to fill out at each visit, hiring of compliance officers and now the move toward electronic medical records, another costly adventure. Many private ophthalmology practices are 'mom and pop shops' that are finding it harder and harder to survive. In 2007, the Centers for Medicare and Medicaid Services (CMS) developed the Physician Quality Reporting Initiative (PQRI) as a voluntary pay-for-reporting program that provides a 2% financial incentive payment to eligible professionals for reporting data on quality measures for covered services furnished to Medicare beneficiaries. This process takes a long time and the returns are not as big as one would expect, says Dr. Lee-Chee.
On top of the growing challenges with decreased reimbursements, the legal environment in general is heating up. Patients are often heard complaining about physicians and expressing their desires to sue, sometimes over an incident that hardly seems malpractice.
So what to do in this era of increasing challenges? Realize what the challenges are, band together to change them for the better, keep your chin up, and most importantly, have passion for the career you choose so that it makes it all worthwhile!