Having survived a congressional vote, a Supreme Court challenge and a presidential election, the Affordable Care Act continues to roll out, with most provisions enacted by the end of 2014. Focused on reducing health-care costs while increasing quality, ACA aims to revolutionize the way America’s health-care system functions. Understanding what the future holds will allow ophthalmologists to shape their practices and adapt quickly to the new environment.

Health policy experts believe that physicians will feel the most impact in the following areas.

30 Million New Patients

With the individual mandate to purchase insurance and the Medicaid expansion, most project 30 million newly-insured patients, all seeking primary-care providers. Insurance will not have lifetime reimbursement caps and must provide, at minimum, basic “essential” benefits in 10 categories. Insurance companies cannot deny patients with pre-existing conditions, cannot cancel policies at whim, must use at least 80 percent of premiums towards patient care and end co-pays for numerous preventive services. For 2013 and 2014, Medicaid reimbursement rates will rise to match Medicare reimbursements so that primary-care providers welcome all. Ophthalmologists should continuously educate primary-care doctors, hospital systems and insurance plans that patients at risk for such conditions as macular degeneration, glaucoma and diabetic retinopathy should be referred for full eye exams. 

Practice Efficiency

By analyzing and improving practice efficiency, ophthalmologists will be able to accommodate many of the newly insured. A 3:1 exam room to physician ratio, with a 2:1 ophthalmic technician to physician ratio, optimizes patient flow. Focusing on ways to improve the patient visit, ophthalmologists should investigate their patient no-show rates, length of time until the next available appointment and cycle time from when patients enter the office to when they leave. Maximize patient satisfaction by updating the look of the waiting room and restrooms, training front desk staff to be exceedingly polite and helpful, and taking time to listen to and acknowledge each patient’s medical complaints. All of these have a stronger correlation with high satisfaction rates than health outcomes.

Medicare Fraud

ACA places enormous emphasis on exposing Medicare fraud and reimbursement recovery. Medicare is training more than 2 million senior citizen beneficiaries to report fraudulent billing, and partnering with private auditing firms, which are allowed to keep a percentage of what is recovered. All Medicare providers will be revalidated through licensure checks, site visits and audits. Penalties for fraud are severe, particularly if the crime garners over $1 million. Physicians must reassess all billing practices to be sure they conform to Medicare rules exactly. Medicare’s allowing questionable practices in the past is not an acceptable excuse for providers to continue. Code strictly based upon the documented complexity of the patient. If billing for a specific process (i.e., interpreting test results), that process must be written out clearly in the medical record if the ophthalmologist expects remuneration for it.

Rise of Mid-levels

Because America faces a shortage of doctors to treat the newly insured and a rapidly aging population, mid-level professionals like optometrists, physician assistants and nurse practitioners will gain more prominence and responsibility as primary-care providers. A traditional of rivalry and competition between doctors and mid-levels must change to a partnering relationship. For maximum efficiency and better use of limited specialists, primary-care physicians and mid-levels should be trained to use non-mydriatic ophthalmic cameras to triage mainly patients who may require procedures or eye care specialized to ophthalmologists. Every image can be read by an ophthalmologist via telemedicine to determine if a referral is warranted. Your practice can replace the yearly normal diabetic visits, for example, with patients who need interventions. Refractions and contact lens care can be left to optometrists.

Practice Mergers

ACA promotes the Patient-Centered Medical Home model where patients can find a one-stop shop for complete care. An example is the establishment of accountable care organizations, health systems in which physicians focus on care coordination while reducing unnecessary costs. Successful ACOs will share the savings. With ACA favoring large interdisciplinary provider structures, the inevitability of lower per-patient reimbursements, the high costs of buying and maintaining medical technology, and the cost of malpractice insurance, solo and small group practitioners will stand at a disadvantage. Payment schedules will favor large medical ophthalmology practices that channel procedures to the super cataract surgeon and the super retina injectionist. Within three years, 75 percent of practicing physicians will be employed by health-care systems. Every solo practitioner should consider whether selling or merging his practice may ultimately bring more rewards.

Electronic Health Records

While most physicians are early in the steep learning curve with electronic health records, 75 percent of practices have already computerized. The potential for this technology seems vast: improved coordination among treating providers; reduced testing and treatment duplication; fewer medical mistakes because of misread prescriptions and adverse drug reactions; more accurate and timely billing; improved quality measurements; ability to track patient flow; less paperwork and chart storage; and protection in malpractice lawsuits.

Often, ophthalmologists connected to a PPO or hospital system are tied to EHRs that document eye exams poorly. The next step in the EHR progression is to improve interoperability among different computer systems. Once that occurs, ophthalmologists should move to hardware and programs more suitable to the field. For example, a handheld tablet with a pre-populated eye exam may make documentation faster and easier. 

Reimbursement/income

The future holds lower reimbursements, particularly for specialists. The payment system will move away from fee-for-service, which incentivizes increased testing, to bundled payments per episode for both hospitalizations and outpatient visits. For example, currently, for each glaucoma patient, ophthalmologists are paid for each exam, gonioscopy, visual field test and OCT. After a number of pilot studies to ascertain the advantages and risks to this payment approach, in the future Medicare will likely move to a model of reimbursing a fixed amount for each patient to cover as many visits and tests as the doctor feels are necessary for each diagnosis. 

New Research and Guidelines

Much of a physician’s knowledge comes from experiences and opinions of mentors, teaching attendings, colleagues and pharmaceutical representatives. Thus, many health-care practices proliferate without unbiased scientific evidence of effectiveness. ACA creates the Patient-Centered Outcomes Research Institute to oversee research comparing drugs and procedures to determine which lead to the best outcomes.

The recent National Eye Institute-sponsored bevacizumab vs. ranibizumab comparison for age-related macular degeneration is an example of such “comparative effectiveness” investigations. This research should not only help physicians make more informed practice choices but it will protect in malpractice cases if recommended processes are followed. The influence of pharmaceutical companies will be minimized as medical companies must report publicly any payments of over $10 made to physicians or hospitals. These payments include every form of payment: gifts; consulting fees; travel; grants; royalties; entertainment; etc.

As part of a new movement to reevaluate what has become standard of care, 17 medical specialty groups collaborated to release a list of 90 common tests and procedures that have not improved health. Decrying the value of such tests as routine EKGs in low-risk, non-symptomatic patients, imaging for nonspecific low back pain or uncomplicated headaches and standard admission or preoperative chest X-rays, this “Choosing Wisely” Campaign also includes five recommendations from the American Academy of Ophthalmology:

The future of health care will revolve around extending care to those who have little or no access currently, improving quality and bringing down costs dramatically so they stop overtaking personal and governmental budgets. Medicare and private insurance companies will be scrutinizing physician practices for better health outcomes and proper billing procedures while offering less in reimbursements.

Ophthalmologists can prepare to capture this enlarged patient market by retooling their office efficiency and esthetics, evaluating payment coding, firming relationships with other providers, implementing new technology and employing new practice guidelines.  REVIEW