September EyeNet, published ahead of print.
The COVID-19 pandemic has profoundly impacted the delivery of medical care in the United States. Clinics have seen a drastic decline in outpatient visits as well as procedures, and hospitals have experienced a significant loss in revenue despite overwhelming numbers of COVID-19 cases. Although the initial wave of the pandemic appeared to be subsiding in some regions of the country, a subsequent surge in cases suggests that COVID-19 will have a prolonged impact on medical practices in the United States.
Large financial losses for ophthalmology. Initial reports found that among all medical specialties, ophthalmology practices suffered the greatest decreases in patient visits.1 Reports from single institutions or health systems have highlighted similar trends with significant downscaling of ophthalmologic patient encounters and procedures as well as a shift toward telemedicine.2,3 Because a large proportion of ophthalmologists practice outside of hospital systems and are based in small practices, including many solo practices,4 interruptions in normal patient volume can have significant financial impacts on ophthalmology practices. In turn, this can lead to temporary and even permanent closure.5
Why the pandemic disproportionately impacts eye care. Ophthalmologists have been particularly impacted by the pandemic as the majority of ophthalmic surgical procedures are elective and a significant proportion of ophthalmologists’ patients are older, with greater risk for comorbidities.
Member Pulse Surveys. To examine the economic effects of the pandemic, the Academy has been sending Member Pulse Surveys to random samples of ophthalmologists in private practice. This article discusses the results of two surveys—one conducted in late spring (May 20-25) and one in midsummer (July 9-13). These had response rates of 10% and 7.4% as well as confidence intervals (and margins of error) of 95% (± 6 %) and 95% (± 5%), respectively.
Impact on Ophthalmology
The May and July surveys reveal some shifting metrics.
Renewed clinical volume in July. Beginning in June, state and local governments began initiating phased reopenings across the United States, and this is reflected in the survey results.
As of July, 92.1% of survey respondents reported that their practices were at that time scheduling patients for routine and/or elective ophthalmic care, an increase from 79.1% of respondents in the May survey.
Survey results suggest that practices also experienced increases in clinic volume with nearly half of those surveyed in July reporting patient volumes of more than 75% of pre-COVID levels (see table). However, OR procedures have recovered more slowly, with just over one-third of respondents scheduling 50% or less of normal OR volume. Generally, the July metrics for clinic and OR volume show an uptick from the May survey, which found that the majority of respondents had less than half of normal clinic and OR volume compared to pre-COVID levels.
Concurrent decline in telemedicine usage from May to July. Among July respondents with opened practices, 38.7% reported telehealth encounters compared to 55.7% in May.
|Patient Volume: Percent of pre-COVID volume seen by private ophthalmology practices in July.
|% of pre-COVID volume
||% of survey respondents
|% of pre-COVID volume
||% of survey respondents
|Source: Academy Member Pulse Survey, July 2020.
Many practices received federal aid. In total, 87.7% of July’s respondents had applied for federal aid through the Paycheck Protection Program (PPP) and 95.9% of those applicants successfully obtained PPP funding. This is an increase from the May survey, when 91.2% of PPP applicants reported successfully obtaining funds. (Note: In April’s Member Pulse Survey, 81.8% of respondents said that they had received payment from the Medicare Provider Relief Fund.)
Eye Care and Telemedicine
A wide variety of telemedicine codes have been used. On March 1, CMS included a large number of telehealth services in the list of examinations that would be covered during the COVID-19 Public Health Emergency. These newly covered services included virtual evaluation and management (E/M) examinations. On April 30, coverage was extended to virtual Eye visit services.
When asked which family of telemedicine codes they used most frequently:
- 40% of July’s respondents replied that it was telephone calls (CPT codes 99441-99443)
- 3% said virtual E/M exams (99201-99215)
- 2% said virtual Eye visits (92002-92014)
- 4% said e-visit online communication (99421-99423)
The 17.2% of July’s respondents who named Eye visits as their most commonly used family of telemedicine codes was a slight increase over the 14% who said so in May.
Why E/M codes are more widely used than Eye visit codes for telemedicine. During the COVID-19 Public Health Emergency, E/M levels for telemedicine exams can be determined by physician total time or medical decision-making, whereas Eye visit codes continue to require completion of specific components of an eye exam that are difficult to achieve remotely. For example, it might not be feasible to examine in an accurate and practical way the anterior chamber, lens, optic nerves, and retina and to test visual acuity, intraocular pressure, and confrontation visual fields. Furthermore, on April 30, CMS increased the allowable of non–face-to-face telephone encounters (99441-99443) to match their E/M level counterparts, which further disincentivized use of Eye visit codes. (Note: If an encounter took place over the phone, you can bill for a telephone encounter, but a virtual E/M or Eye visit service must include both audio and video.)
The shift to E/M codes, along with rising unemployment, is undermining practices’ financial stability. Difficulty in satisfying the requirements of the Eye visit codes has caused practices to use E/M codes instead. Small differences in reimbursement between Eye visit and E/M codes can compound, resulting in significant cumulative financial hardship on practices. Furthermore, rising unemployment is likely to increase the proportion of patients with federal health insurance coverage, effectively reducing the average revenue per examination. (Note: Although some insurers pay less for E/M codes than for Eye visit codes, CMS has indicated that there may be significant increases for E/M payments in January 2021.)
What can policymakers do to address telemedicine’s reduced usage of Eye visit codes? Policymakers could modify the existing requirements for Eye visit codes, which were designed for the in-person exam. They could, for example, develop standardized methods to complete eye exam components such as sending Snellen charts directly to patients to examine visual acuity or designing phone apps to accurately measure confrontation and visual fields. Indeed, mobile phones are capable of providing high-resolution direct ophthalmoscopy.6 Successful implementation of these tools would allow ophthalmologists to monitor objective exam parameters even in virtual settings. This would reduce unnecessary face-to-face visits, thus decreasing potential SARS-CoV-2 exposure for patients and practices.
Practices Face Many Challenges
Keeping staff and patients safe. Recent regional surges in COVID-19 cases emphasize the importance of continuing to monitor and adhere to safety protocols, such as those provided by the Academy (aao.org/coronavirus). At time of press, ophthalmology practices were seeing a significant increase in volume, which is associated with a greater risk of exposure and disease spread. Rapidly changing regional COVID-19 caseloads also call for practices to closely monitor guidelines of local, state, and federal agencies when calibrating clinic volume.
Reduced patient volume continues to hurt practice finances. Although recent surveys have shown encouraging trends, ophthalmology practices were still suffering from significantly diminished patient volume. A deeper dive into July’s data reveals that only 6.6% and 8.4% of practices had fully returned to pre-COVID levels of clinic and OR volume, respectively.
Federal assistance is critical. During the summer, as COVID-19 cases continued to increase, the Academy was concerned that the financial recovery of ophthalmology practices might be delayed or halted altogether. As part of its efforts to advocate for federal financial support for ophthalmologists, the Academy has been sharing data from its Member Pulse Surveys with policymakers.
Ophthalmology practices should continue to monitor eligibility for potential sources of financial aid as the pandemic progresses. The Academy maintains a list of resources and grants at aao.org/practice-management/resources/financial-resources-covid-19.
1 www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits. Accessed July 17, 2020.
2 Safadi K et al. BMJ Open Ophthalmol. 2020;5(1):e000487.
3 Williams AM et al. Ophthalmology Ther. 2020:1-9.
4 aao.org/practice-management/article/thriving-in-solo-small-practice-group. Accessed July 23, 2020.
5 Rubin R. JAMA 2020. doi: 10.1001/jama.2020. 11254.
6 Gunasekera CD, Thomas P. JAMA Ophthalmol. 2019;137(2):212-213.
Mr. Chen is a medical student at the Department of Ophthalmology & Visual Science, Yale School of Medicine in New Haven. Financial disclosures: None.
Dr. Parikh is at Manhattan Retina and Eye Consultants, New York, and is on the faculty at New York University School of Medicine. Financial disclosures: Anthem Blue Cross Blue Shield Empire: C.
See the disclosure key at www.aao.org/eyenet/disclosures.
BOOKMARK AAO.ORG/CORONAVIRUS. The Academy and the American Academy of Ophthalmic Executives have developed a wide range of resources to help you address the clinical and practice management challenges associated with the COVID-19 pandemic.