EyeNet Magazine


Is It a Picture?

Define Ophthalmology’s Future

Is It a Picture?

When is a picture not a picture? John M. Haley, MD, presents a compelling analysis of fundus photography and dilated retinal examinations in “Coding for New Technology: The Optos Dilemma” (Savvy Coder, November/December).

He asserts that the Optos product cannot be billed to insurance as fundus photography because the “pictures [are] obtained by scanning lasers.” The implication is that the image is either not “photography” or not a true or complete representation of what’s being examined.

The Merriam-Webster’s Dictionary defines photography as “the art or process of producing images on a sensitized surface (as a film) by the action of radiant energy and especially light.” By that definition, no digital camera product should be approved for billing to insurance as fundus photography.

We should be equally concerned about our ability to bill for dilated retinal examinations performed by indirect ophthalmoscopy. This device produces an upside-down and backward image with an exaggerated sense of depth—not a true image of what is being examined.

Without the Optos product, we would miss the opportunity to examine and document the peripheral retina in patients with miotic pupils due to posterior synechiae, extensive pterygia or advanced cataracts, or who are unable to tolerate 20 or more flashes of light (enough to obtain enough retinal photographs to assemble into an almost complete view of the retina).

To address Dr. Haley’s concerns, do we want to rewrite the CPT and E&M code definitions to include the dilated retinal exam, including a 360-degree view of the ora serrata as one of the examination elements? Do we want the Academy to educate members about daguerreotype plates and flash powder? Or, we could all recognize that a picture is a picture, and that a view of most of the peripheral retina is a view of most of the peripheral retina, by whatever means it was obtained.

Donald J. Mirate, MD, FACS, MBA
Valdosta, Ga.

Dr. Mirate has no related financial interests.

Define Ophthalmology’s Future

Like many of my colleagues, now a few years into practice, I often reflect fondly on life as an ophthalmology resident.


Then, newly minted into the clinical workforce, I quickly realized that the rules had changed. Incomprehensible government mandates, declining fee schedules, uncooperative insurance companies, looming threats of malpractice claims, and perennial optometric scope of practice expansion efforts intrude upon our primary goal of providing the very best care for our patients. While our predecessors flourished, rewarded for their hard work with good pay, respect, and relative autonomy, our careers will be defined quite differently.


If your training was anything like mine, exposure to the business and politics of medicine was somewhat lacking. In that respect, we as a profession are partly responsible for the present state of affairs. Fortunately, we can accept that responsibility and work to be part of the solution.  While most of us would prefer to simply care for our patients, we must also learn to be active in the business and political arenas. Our optometric colleagues have long taken this view, and now have an extensive track record of achieving their goals via organization, activism and financial commitment. Only by confronting our challenges personally and collectively, can we hope to regain control of our profession.


While there are many issues currently demanding attention, I believe that three are of serious concern to the young ophthalmologist: medicare physician reimbursement, medical liability reform, and optometric scope of practice expansion continue to erode our ability to practice effective, safe medicine. Declining payments and rising insurance premiums are forcing many physicians to change their style or location of practice. Some are leaving medicine, and others are choosing never to enter. Optometric expansion is indicative of a trend throughout medicine, that of nonphysicians expanding clinical privileges via legislative fiat, devaluing medical education and jeopardizing patient safety. The remainder of this letter will discuss these issues and the role of political activism in ophthalmology.


The Medicare Pay Fix

Significant concern arose when, in 2002, the Centers for Medicare and Medicaid Services (CMS) announced a 5.4 percent decrease in physician reimbursement, refocusing attention on the method CMS employs to establish its payment schedule. Troubled by uncontrolled spending, the government initially implemented cost containment measures in 1992, leading to the establishment of the current Sustainable Growth Rate (SGR) formula in 1998. The SGR determines the allowable increase in spending by estimating the anticipated costs of administering Medicare physician services for the year ahead, attempting to keep pace with the gross domestic product. If actual expenditures exceed the yearly target, reimbursements are cut the following year to bring spending back into long-term balance.


This method is clearly untenable, failing to adequately reflect the true costs of providing medical services, which do not necessarily correlate with the economy. After fees dropped in 2002, further reductions in physician reimbursement were averted by Congressional interventions, including the Medicare Modernization Act of 2003, which replaced anticipated cuts with a 1.5 percent increase for both 2004 and 2005. However, this legislation failed to address the fundamental flaws in the SGR and did nothing to alter the existing deficit. Beginning in 2006, unless further acts of Congress are forthcoming, reimbursement is expected to decrease by approximately 5 percent per year until 2012, accounting for a nearly 30 percent decline in physician payments. As a specialty caring for a relatively large percentage of Medicare patients, ophthalmology faces difficult days ahead unless changes are made.



Medical Liability Crisis

Contributing to the escalating costs of practicing medicine are even more rapidly rising malpractice insurance premiums. While medical liability concerns are not new, few physicians would deny that a crisis currently exists. Many in high risk specialties, such as obstetrics, neurosurgery and pediatric surgery, are relocating to states with reforms in place or are simply leaving medicine. In states which have produced such reforms, including caps on noneconomic damages, the benefits to patients and physicians are clear—lower malpractice premiums, fewer lawsuits and lowered costs, all resulting in greater access to care. Despite these advances, efforts to effect such changes in many states remain stymied by the powerful trial attorneys’ lobbies.


While continued work at the state level is vital, federal policy regarding medical liability is clearly needed. Over the past three years, the U.S. House of Representatives has repeatedly passed legislation to reform the medical tort system. Unfortunately, the Senate continues to impede the process, refusing to allow similar legislation to move forward despite the support of the House, the President and the majority of the American people. We must continue to pressure Congress, particularly members of the Senate, to address this vital issue before more physicians are forced out of practice, leaving patients without access to needed care.


Optometric Scope of Practice Expansion

While ophthalmology has not yet suffered the extreme increases in malpractice premiums seen in other specialties, our profession has been shaken by the recent optometric advances in Oklahoma and the Veterans Affairs medical system. Through extensive lobbying, Oklahoman optometrists have convinced the state legislature of two fallacies—that they are trained and capable of performing both laser and non-laser procedures, and that failure to afford them such privileges would deny patients access to surgical care. Clearly, optometrists do not have the appropriate surgical training, nor do they have the medical foundation to support such training. Furthermore, no study has ever demonstrated a patient harmed by the inability to obtain ophthalmic surgical care, particularly the non-urgent procedures many optometrists hope to perform.


The recent decision by the Department of Veterans’ Affairs to limit eye surgery to ophthalmologists was a hard-fought, essential win for patient safety, reversing a dangerous precedent which legitimized surgery performed by non-physicians at the federal level. However, this decision will only serve to energize organized optometry’s quest to push the limits. Further expansion of optometric surgery is a losing proposition for patient safety. We must continue to fight aggressively on both the state and federal fronts to block the optometric lobby’s efforts to obtain privileges through legislation rather than proper education and training. Unchecked, organized optometry will insidiously creep toward its goal of total parity with ophthalmology.


What Can We Do?

Clearly, there is much work to be done. As young ophthalmologists, we have the most to gain or to lose. The American Academy of Ophthalmology, the American Medical Association and other specialty societies are diligently working to achieve solutions to the many challenges we face.  These organizations’ strength is derived directly from the efforts of their members.


We are the future of the Academy, and the success of its advocacy hinges on our willingness to give our time, creativity and financial support. This may seem like much to ask at a time when our attention and resources are already focused on building practices, raising young families and repaying student loan debt. How simple it would be to simply defer responsibility for these issues to our more established colleagues. I believe, however, that change must begin at the bottom.


Involvement need not be inconvenient or unaffordable. Simply being a member of the Academy and, just as importantly, of your state ophthalmologic society supports the goals of those organizations. Increase your involvement by volunteering to serve on a committee, or consider an executive board position or another leadership role. 


Become active politically. As noted previously, most of the issues before us require Congressional intervention. Write, fax, e-mail or call your members of Congress and state your positions. When appropriate, ask that your friends, family and patients do the same. If you are fortunate enough to have an existing relationship with a congressional member or aide, take the time to educate them regarding the relevant issues. Often they do not have enough information to make an informed decision, and the personal attention of an involved, knowledgeable constituent can be very influential. Should time permit, attend the Academy’s Advocacy Day for the best opportunity to interact directly with members of Congress.


Remember that advocacy starts at home. Many issues, including tort reform and scope of practice concerns, are decided in our state houses. Join your state ophthalmologic society and take the time to meet your local legislators. Attending local political meetings, fundraisers or state “physician for a day” programs are great ways to connect. That small effort can lead to lasting, mutually beneficial relationships which will continue to prosper as many of these individuals move on from state legislatures to the U.S. Congress. 


Finally, contribute to OphthPAC, state ophthalmology political action committees (PAC) and the Surgical Scope Fund (SSF). This financial commitment is vital to achieve the goals of our advocate organizations. For young physicians, money is often in short supply. Give what you can afford—every dollar counts and more are needed. For those concerned about public access to information regarding PAC contributions, remember that funds given to the SSF are not subject to FEC reporting requirements and are therefore, completely anonymous. These monies are used to support individual state societies in their fights against optometric scope of practice expansion, and are now needed more than ever.


The future of ophthalmology is ours to define, but only if we are willing to commit the resources necessary to overcome the challenges before us. I urge all young ophthalmologists to become more involved.  Our time, effort and financial commitment will be repaid with greater autonomy and more fulfilling careers as well as better access to good care for our patients. And those are goals worth fighting for.

Jeff S. Maltzman, MD
Tucson, Ariz.

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