On July 29, the Centers for Medicare & Medicaid Services (CMS) released its proposed 2020 Physician Fee Schedule. For many ophthalmologists, nothing in the report seemed as important as the 15% drop in payment for cataract surgery.
The physician fee schedule determination process depends upon the principle of relative value. This relative work value is established by determining the time, intensity, and other resources needed to do the procedure.
An initial work value is proposed by the specialty based upon a survey of its members. The value is then accepted, refined, or rejected following debate in the AMA-convened Relative Value Scale Update Committee (RUC), which involves physicians of many specialties. The entire payment determination process is dependent upon the data that come from the physician survey process.
Based on survey results, ophthalmology was facing much, much more significant losses to cataract services. We were able to maintain a value higher than other procedures with similar times because we were able to convince the RUC of the intensity and complexity of cataract surgery. On a minute per minute basis, cataract surgery remains more highly valued than carotid endarterectomy, coronary artery bypass graft, or craniotomy with resection of a brain tumor.
Critically, the survey showed little support for the current four post-op visits in the 90-day global period for a typical procedure. A significant majority of the cataract surgery payment decrease is due to loss of this fourth post-op visit.
What about the point that cataract surgery is getting more technical and producing better results, which greatly improve patient quality of life? It’s a totally legitimate argument for better payment. It is also one made equally legitimately by most other specialties. And since payment is “relative,” we don’t gain ground in a budget neutral environment.
It comes down to the size of the pool of money to pay for physician procedures. And this, naturally, is a political decision—not one governed by regulations, CMS, or by the RUC process itself.
No one believes that the rising total cost of American health care is sustainable. To subject physicians to effectively zero annual payment updates when other components of the health care system receive 2%-3% and higher annual updates is poor policy and just plain unfair.
During CMS’ official public comment period for the proposed fee schedule, the Academy will be working with ASCRS and other societies to implement some payment changes that will blunt the payment decrease. We will also be providing relevant courses on related subjects at AAO 2019. We view this very much as an active issue!
What can the Academy and all of us do going forward?
First, we must realize that trivializing ophthalmic surgery accelerates the fall to the bottom.
Second, characterize yourself as what you really are—a physician who is trained in ophthalmology and has the additional skills of an ophthalmic surgeon. We are not just “retina surgeons” or “cataract surgeons.” We didn’t go from college to fellowship training.
Third, recognize that the Academy and other ophthalmic societies have your back. We may not always win each battle, but we win a lot of them. During the next several months the Academy will be working with the surgical community on several specific initiatives that may blunt the negative economic impact of the proposed cataract surgery devaluation.
Fourth, remember that the Medicare budget is a product in part of the political process. And advocacy requires cogent arguments and policy, access to decision-makers, and personal engagement.
Finally, we must continue the focus to earn and retain the trust and respect of our patients and to enhance the quality of their lives. It is that honor that enriches us above all things.
View a video from Dr. Parke on this topic at aao.org/eye-on-advocacy-article/video-cms-cut-cataract-medicare-payment-fee.