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  • Will Medicare Fee Cuts Change Glaucoma Practice?

    Aqueous shunt surgery, trabeculectomy and laser trabeculoplasty are the surgical foundations for preventing blindness in patients with glaucoma. Recent rulings by the Centers for Medicare and Medicaid Services, however, will significantly affect how ophthalmologists perform and are reimbursed for these procedures.

    What does this mean for YOs and what can you do to get involved? We spoke with a few experts on what looks to be an unprecedented assault on fair Medicare payment.

    The Background

    CMS pays for ophthalmology codes based on relative value units, compared to other medical procedures. The American Medical Association’s Relative Value­-Scale Update Committee (“the RUC”) advises CMS on physician work values.

    The RUC recently looked at several ophthalmology codes that haven’t been revalued for 20 years. Based on its surveys, the RUC determined that ophthalmologists were performing the intraoperative portion of certain glaucoma surgeries in less time than previously calculated. So, for example, if it now takes 45 minutes to perform a trabeculectomy rather than 60, the committee would recommend an appropriate reduction in relative value units for coding the procedure.

    However, when CMS released its final 2016 Medicare fee schedule, the actual cuts went well beyond RUC recommendations. In addition to significant cuts in for retina procedures, CMS slashed reimbursement for the following glaucoma procedures by up to 19 percent in 2016:

    • 65855 (trabeculoplasty by laser surgery)
    • 66170 (trabeculectomy ab externo in absence of previous surgery)
    • 66172 (trabeculectomy ab externo with scarring from previous ocular surgery or trauma)

    Additional glaucoma cuts of up to 33 percent loom in 2017.

    This move comes on the heels of CMS’ decision last year to prevent glaucoma surgeons from billing separately for aqueous shunts and patch grafts, which reduced surgeon reimbursement by up to 30 percent. In addition, beginning in 2016, CMS bundles the cost for all patch graft materials with the facility payment, reducing payment for ambulatory surgery centers, which receive about half the hospital operating room payment.

    What’s the Impact?

    “In the long run, the cuts are likely to change practice patterns, force some surgeons to give up surgical glaucoma care and reduce the numbers of residents choosing glaucoma as a subspecialty,” said Cynthia Mattox, MD, vice president of the American Glaucoma Society. She is also an Academy board member and serves on the Health Policy Committee.

    “YOs still in training at large academic teaching hospitals will remain somewhat protected from these policy changes,” said Jiaxi Ding, MD, a glaucoma fellow at the University of Iowa and YO Info editorial board member. “But the closer we get to leaving this buffer, the more we will feel the weight of these reimbursement cuts in terms of shaping sustainable practice patterns.”

    Dr. Ding said ophthalmologists currently performing aqueous shunts in ASCs, for example, now face three options:

    1. Continue using patch grafts per current techniques and swallow the cost;
    2. Adopt new techniques that may bring challenges of their own; or
    3. Change the surgery venue from an ASC to a hospital operating room, where the higher facility payment covers patch graft costs more adequately.

    Winston Garris, MD, a glaucoma surgeon in private practice at Carolina Eye Associates, said trying to stay profitable in this new environment could be very difficult.

    “People who operate at hospitals are in a better position because the institution absorbs a lot of costs associated with these reimbursement cuts to the shunt codes with grafts,” Dr. Garris said. But this may simply end up shuffling expenses rather than achieving the intended goal of cutting costs. “The result of CMS’ decision is not helpful for overall health care costs,” he said. “Surgeries in hospitals end up costing considerably more and burn through a lot more Medicare dollars.”

    What the Future Holds for Treating Intraocular Pressure?

    Given this situation, are there any alternatives to these surgical mainstays?

    “There are many up­-and-­coming glaucoma surgical techniques, particularly the minimally invasive glaucoma surgeries as well as canaloplasty and ciliary photocoagulation,” said Lindsay A. Rhodes, MD, an assistant professor of ophthalmology and a member of the YO Advocacy Subcommittee. “But, no, these are not as effective at reducing very high IOP in advanced patients.”

    For Dr. Ding, there is no current equivalent to trabeculectomy. “It’s the long­-proven ‘big gun’ to deliver potent IOP reduction and prevent blindness in advanced glaucoma,” she said. “This seems like absolutely the last procedure to slam with steep reimbursement cuts.”

    What Can You Do to Help?

    Ophthalmology hasn’t taken the cuts sitting down. After release of the final 2016 fee schedule rule, representatives from the Academy and other organizations held an emergency meeting with CMS, urging them to reconsider its decision. In addition, U.S. Reps. Peter Roskam, R­-Ill., and John Lewis, D-­Ga., have circulated a letter for Congress to send directly to CMS disputing the cuts.

    It’s not too late to join the fight.

    “This might be a discouraging climate for those of us just starting out in our professional career,” Dr. Ding said. “But we need to see these cuts as another lesson to be evermore proactive and protect ourselves and our patients from a future where physicians can’t afford to practice and students have no desire to train.”

    Here are a few ways to make your voice heard:

    “This issue came and went quickly, without the due process that’s been expected in the past,” said Diana Shiba, MD, chair of the YO Advocacy Subcommittee. “This only reinforces the need for everyone, including YOs, to be on top of their game — we must all be engaged.”

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    About the author: Mike Mott is a former assistant editor for EyeNet Magazine and contributing writer for YO Info.