Stephen Kamenetzky, MD
A professor of clinical ophthalmology and visual sciences at Washington University School of Medicine, Dr. Kamenetzky is the Academy adviser to the AMA Relative Value-Scale Update Committee, which advises CMS on physician payment rates. He is also a consultant to the Academy’s Health Policy Committee and teaches coding courses at the Annual Meeting. The opinions expressed herein are his own.
“There they go again,” to paraphrase the famous retort of Ronald Reagan during a 1980 presidential debate. Once again, the consultants and policy wonks have banded together to provide the next sure-fire recipe to tame the rising health care cost trend in the United States: the accountable care organization (ACO). It matters not that all of the demonstration projects using the most experienced group practices in the country have not produced overall meaningful savings for the Medicare program. Some groups even had higher costs than standard Medicare. Ditto for the same experiment in the commercial market in Massachusetts, conducted by Blue Cross Blue Shield. To someone who has been around for a while, it is clear that this is at least the third attempt in the past 30 years to recycle this failed model.
Nevertheless, it appears that the parade will continue for a while and ophthalmologists are going to need to decide what to do. The ACO model, stripped bare, really works by capping the dollars available for care and forcing those delivering care to battle amongst themselves to develop a way to distribute the money. Whoever gets the money and is in charge of passing it out will be in the driver’s seat. Initially, large hospital systems and physician groups will probably control the funds. Specialists like us who deal primarily with elective, outpatient procedures will be very low on the food chain. Hospitals will pit primary care against specialists and specialists against each other for what is left after the system has taken its share.
With payment pools fixed for patients needing eye services, say goodbye to branded drugs for which suitable and equivalent “generic” alternatives exist. Want high-priced toys that produce vivid images of the inside of the eye in living color and three dimensions? It’s on you. You won’t get paid a nickel extra for using them. Price competition will rule and the competition will get downright nasty. Medicare payment scale might be the ceiling, not the floor.
The ACO model will force physicians to quench their thirst with what is left in the glass after everyone else has had their fill (as opposed to the current model of getting paid every time you take a sip). Moreover, in the current system, the more sips of water you take, the more water is left in your glass, since the supply of water is essentially unlimited. However, in the ACO model, once the sips empty the glass, there is no more water until next year. You spend the rest of the year dry.
What to do? Dive in headfirst? Jump in feet first? Toe the water? Or how about just read a book until the storm blows over? Time is on your side. This process is not going to get up and running overnight. Groups of ophthalmologists will have more power than individuals, so stay in touch with your colleagues. Follow what is happening in your local community. But for now at least, there’s still time to read a good book.
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