GUEST EDITORIAL

What Do I Think About 25% Vitrectomy Surgery Cuts — Bucket!

PAUL E. TORNAMBE, MD

In the 1990s, an anesthesiologist friend, trained in Canada but practicing in the United States, gave this analogy of government cutbacks.

“Think of a bucket filled with water; now, make a hole in the side of the bucket. The water drains out to that level. After a year or two make another hole further down towards the bottom of the bucket. The water again drains out to that level. Wait a few more years and do the same, pretty soon there is very little water left in the bucket.”

Unless someone says, “Stop making a hole in the bucket,” the process will continue until there is no water left in the bucket. Thus far, no one advocating for us has said “Stop.” They’ve just pleaded not to make another hole too far down.

THE RETINA BUCKET

In 1990, we received approximately $4,000 for a vitrectomy. As with all procedures that become more frequently performed, CMS decreased the reimbursement. Doctors have done pretty well, but the latest hole in the bucket is pretty far down. At $900 it may be hard to afford to continue to perform some vitrectomies.

Now, we and the government and insurance companies know that there will be more holes drilled into the side of the bucket. There will also be someone willing to do it for less. That is the capitalist way.

Rates will continue to decline until there is “push back.” The problem with doctors is that they agree to these lower rates because they really don’t know what it costs to do business.

Once you know what it costs to keep your doors open for one hour, it may be easier to say, “No, no more holes in the bucket, and maybe you should patch up a few of the last holes you made!”

No one can deny that vitrectomy surgery today is safer, less stressful, and faster than it was 20 years ago. As my father used to say, “Nothing is hard if you know how to do it!”

The technology has advanced, making the instruments more reliable; training new fellows has increased from one to two years and sometimes longer.

Mandated CME encourages us to continue to refine our skills by attending meetings, which are expensive, bringing in no increased revenue and compelling us to purchase ever more expensive instruments, which are reimbursed at ever lower and lower rates.

Employees’ salaries continue to rise, and significant costs and time are expended to keep staff up to date, well trained, and compliant with government regulations. Supplies, such as fluorescein and even dilating drops, increase in price, but none of these costs are considered when evaluating reimbursement for vitrectomy surgery.

THE TRUE PRICE OF SURGERY

The big problem willfully ignored by CMS and the Relative Value Scale (RVS) Update Committee (RUC) is that the time and cost of doing a vitrectomy does not start with the first incision; it starts when you leave the office for the OR. At that point, your office revenue stops.

The next time you leave the office to perform a case, start your stopwatch, and stop it when you return to the office. Then, you will know how much time you really expend doing surgery.

CMS refuses to consider travel to the OR, delays in starting the case, regulations mandating preoperative discussion with the patient and family in the preop area, teaching new techs — which prolongs the operation, postop paperwork and patient discussions, and of course 90-day follow-up care included in the price of the operation (which they feel is overpaid and are planning to reduce).

It doesn’t matter if the case is done on Monday morning at 7 a.m., at 2 a.m. late Saturday night, or at 11 p.m. on New Year’s Eve. The reimbursement is the same. Try applying that logic with your plumber!

But let’s look at the numbers. Twenty years ago, I determined that my hourly overhead was approximately $200/doctor/per hour; today, it is about $400. The ideal surgery day would be macular hole or pucker surgery in a facility near the office.

To avoid a second trip to the OR (and save the government and insurance companies significant money), in patients older than 50, we usually try to combine cataract and macular surgery in the same sitting by inviting the cataract surgeon to perform the anterior-segment operation during the same session.

This obviously extends uncompensated OR time by approximately 30 minutes. But to simplify things, let’s just assume we are going to operate on pseudophakic macular hole cases in an OR next to the office. Let’s assume these are routine, uncomplicated cases, and ours are the first cases of the day, so they hopefully start at the scheduled time.

Our surgery is performed at supersonic speed, but the OR turnaround is at biplane speed. The usual turnover time from when I put a patch on the last case and make the first incision on the next case is almost an hour.

We are planning to move to a surgery center to decrease this to the 15- to 20-minute range that my colleagues report, but that is the way it is now done, and I don’t think this is an exaggeration for most surgeons who use a multispecialty hospital-based OR.

I arrive at the hospital 15 minutes prior to the start time. At 7:40 a.m., the patient is blocked in the OR suite, and the incision is made at 7:50; surgery is completed between 8:30 and 8:45. After the surgery, I speak with the family and confirm the next day’s appointment time, dictate the OR report, and then wait 30-45 minutes to start the second case.

The second case begins at 8:45; we finish by 9:30. By 10 a.m., I have completed the postop orders, spoken with the patient’s family, and returned to the office to start seeing 12 patients before lunch, two of whom are no charge postops, with the rest being AMD patients to receive injections, as well as one or two consults.

PROFIT AND LOSS

Our medical office day usually starts at 7:30 a.m. In the 2.5 hours I was away from the office, I could have evaluated approximately 15 patients. The overhead time for performing the two macular hole operations is 2.5 hours at a cost of $1,000 (2.5 x $400).

I usually examine macular hole postops on days 1, 7, 14, 30, 60, and 90. The average visit, including charting, is 10 minutes, so each surgery patient receives about an hour of postop care.

Therefore, the total time I ideally spend with an uneventful macular hole patient (when two cases are done sequentially) from surgery to discharge is 4.5 hours/2 or 2.25 hours (x $400) or $900 in overhead dollars per macular hole surgery patient.

If paid $900 per operation, my profit is $0. I’ve covered my overhead, but there is nothing left to give my wife at the end of the month. If the case took longer, if it started late, or if there were postop complications — or if I had to drive a half hour to the OR, the profit (I mean loss) would be significantly reduced.

A good friend of mine recently gave his daughter a puppy. She dropped it and broke its leg. A Beverly Hills vet charged $7,000 to fix the fracture. A patient of mine had a heart transplant fives year ago; he said the surgeon was paid $3,500. Our practices have truly gone to the dogs. Bucket! RP