Many ophthalmologists share a sense of frustration and sometimes helplessness over internally inconsistent, ambiguous, and seemingly capricious government regulations. I do. So whenever anything good (or even “not bad”) happens, individuals and organizations not uncommonly try to claim frequently undeserved credit.
Why “undeserved”? Very rarely can one individual or organization claim to have single-handedly unwound complex regulations—given the multiple vested interests and general unwillingness to reverse a policy decision. Success requires a clear plan, lots of oars rowing in the same direction, and much work by local boots on the ground. And it helps to have a valid position.
This is why all of ophthalmology (and all physicians) should legitimately celebrate a win with the recent CMS reversal of fee cuts affecting some glaucoma and retina codes. This victory has an impact far beyond just these codes’ payments—it affects the very process of assigning payment. And we should take credit for it, because it wasn’t going to happen by itself.
Basically, the Relative Value Scale Update Committee (RUC) recommended to CMS some data-driven changes to the work component value of selected glaucoma and retina codes. These values were based on survey data, adjudicated by physicians, and included considerations of time and intensity of service. In a precedent-setting move last November, CMS rejected the RUC recommendations and slashed the payments based strictly on time, with no or little consideration of intensity. The implications were profound: The RUC process could devolve to just counting minutes, with no consideration for complexity or risk! Glaucoma and retina today; cataract, neurosurgery, and urology tomorrow.
The American Glaucoma Society, the Retina Society, the American Society of Cataract and Refractive Surgery, and the American Society of Retina Specialists all partnered with the Academy in a unified effort to reverse this policy.
In December, Academy staff and leaders, along with leaders from the glaucoma and retina communities, met with CMS leadership and submitted extensive written comments pointing out flaws in the offending Final 2016 Physician Fee Schedule. We all called for and presented to CMS refinement panels made up of outside experts who opposed the CMS recommendations in favor of RUC recommendations.
The arguments we raised included a 60-day notice without the opportunity for professional input and failure to adopt recommended values; and that failure to recognize intensity of service appeared to violate the existing statute.
We then worked together to educate Congress. Academy staff with invaluable support from physicians generated a bipartisan letter to CMS signed by 82 House members. Similar letters came from Senate members and from the Congressional Doctors Caucus. And D.C. office staff made countless trips to Capitol Hill.
Individual ophthalmologists engaged key members of Congress and a grassroots appeal (led by the American Glaucoma Society), contacted members of important caucuses, including the Congressional Black Caucus and the Congressional Hispanic Caucus, pointing out impacts on access to, and disparities in, care. Finally, the Academy worked with other major medical societies to engage their support for the value and integrity of the RUC process.
In early July, CMS bowed to the validity of ophthalmology’s case and, in a rare move, reversed its prior rulings and its methodology. Payments for these codes in 2017 will be based on the original RUC recommendations. More important, CMS recognized that relative value should be based on factors other than simply time. This is both an economic win for ophthalmology (hundreds of millions of dollars annually) and a victory for fairness and integrity of process.
So it’s more than fair for ophthalmology to take credit for this “W”—a win benefiting all of us. And it is shared by many individuals and a small group of engaged organizations.