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September 2007

Our Dream Team: How Do They Keep the Lights On?
By Richard P. Mills, MD, MPH
Chief Medical Editor, EyeNet

The day before yesterday, there was a loud bang and the lights went out. It wasn’t hard to figure out why. On the street in front of my house lay an electrical wire the size of a hawser, sizzling next to the tree branch that had felled it until the circuit breaker up line kicked off, quieting the commotion. A couple of hours later, after a call to the power company, three bright yellow trucks arrived. It was a nice day, so I took a journal out to the deck, but instead of reading watched the line crew at work. Unlike a lot of road construction I’ve driven by, with two guys actually doing the work and five supervising, all seven linemen performed a carefully choreographed routine. Ground the lines, install a new insulator, stretch the line taut, attach it to the pole, splice the connection, detach the grounding, radio ahead to flip the breaker. Voila! The lights came back on. I recalled how many times my lights have gone off, and somewhere out of my awareness, often in the rain at o’dark hundred, a different line crew had repeated this dance.

Naturally, my thoughts turned to reimbursement (didn’t yours?). Getting paid fairly for the services we provide is not automatic. It takes constant, creative effort by extremely knowledgeable people working on our behalf. Somewhere out there, ophthalmology’s hardworking linepersons are keeping your lights on. They are working in a high-voltage environment where a misstep can be disastrous. And most of us have no clue how they do it—unless you have a front-row seat at the Academy’s board of trustees meeting. Your 2007 president, C. P. Wilkinson, MD, has the best seat in the front row, and he’ll be presenting a Special Recognition Award to our “Dream Team” at the Opening Session of the Annual Meeting in New Orleans.1

CMS sets its fee schedule using a Resource-Based Relative Value Scale (RBRVS), implemented in 1993. Recognizing that the RBRVS needs ongoing tweaking to accommodate changes in medical practice, the AMA hosts a group of representatives from each medical specialty. The Relative Value Update Committee (RUC) annually recommends to CMS changes to the RBRVS, which CMS usually accepts. What’s remarkable about the RUC process is that it converts what could easily be a political struggle into an arena where data trump muscle. What’s even more remarkable at the RUC is that good data can sway even cynical internists and neurologists. (Try that at your local hospital medical staff meeting!)

Armed with data and cogent arguments about work relative value units (RVUs), our Dream Team won RUC approval this year for changes to the eye visit codes (e.g., 92014) and the Evaluation & Management codes (e.g., 99214). Sound arcane? Barring CMS revision of the 2008 fee schedule, the bottom line to ophthalmology annually = + $154,000,000. And that’s just one example among many.

And remember, when you receive a request from the Academy or occasionally even from the AMA to complete a survey, doing so thoroughly and honestly to reflect your efforts helps ophthalmology and the Academy to represent the realities of practice.

By the way, if you happen to meet up with Dream Team members at home or in New Orleans, thank them for keeping your lights on.

1 AAO’s Dream Team: Gregory P. Kwasny, MD, OCS, George A. Williams, MD, Stephen A. Kamenetzky, MD, Trexler M. Topping, MD, Michael X. Repka, MD, Cathy G. Cohen, Cherie McNett, and Koryn Rubin.