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    COVID-19 and Ophthalmology: The Pandemic’s Impact on Private Practices

    Written By: Evan M. Chen, BS, and Ravi Parikh, MD, MPH

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    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.
    Clinic
    % of pre-COVID volume % of survey respondents
    0-25% 7%
    26-50% 13%
    51-75% 31%
    76-100% 49%
    Operating Room
    % of pre-COVID volume % of survey respondents
    0-25% 21%
    26-50% 15%
    51-75% 28%
    76-100% 36%
    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.

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    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.

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    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.

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    BOOKMARK AAO.ORG/CORONAVIRUSThe 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.