UPFRONT

Blinding Ignorance

Peter K. Kaiser, MD

By the time you read this column, the new 2016 Medicare Physician Fee Schedule cuts to our services will have gone into effect because the codes were “misvalued,” according to the government.

Congress mandated this “correction” in the ironically titled Achieving Better Life Experience Act of 2014. The cuts were part of a 1% total physician cut in 2016, followed by another 0.5% in 2017 and 2018.

In case you did not hear about these cuts, they consist of a 33% reduction in reimbursement for a primary retinal detachment repair by vitrectomy, the main way that retina physicians operate on retinal detachments in the US.

Because the 1% cut was not met, the conversion factor was also reduced, so the 2016 fee for 67018 is $1,105. This reimbursement doesn’t even cover our time, let alone the overhead of being in an operating room. So, in other words, the government wants us to fix a blinding disease for free.

These cuts are far beyond what the AMA Relative Value Scale Update Committee (RUC) recommended. It is no surprise that ophthalmology codes were going to be reduced. Our improved surgical efficiency is an easy target. But the reductions went far beyond any reductions based on surgical time.

This systematic devaluing of retinal surgery is a disturbing trend. I am pretty sure none of the people at CMS who decided on these “misvalued” retinal detachment repair codes had a loved one with a retinal detachment, especially one that failed. I am sure they have not watched how complicated it is to repair RDs right the first time.

I routinely have to repair retinal detachments “repaired” by others, and the reason it is still detached is usually pretty obvious at the time of surgery. Often these surgeries take two or more hours and considerable technical skill, or the eye will become phthisical or, worse, enucleated.

Yet the reimbursement for this sight-saving (or even eye-saving) operation is being cut. Most doctors have no desire to repair these detachments because the extra ~$100 you receive for 67113 is simply not worth it.

Unfortunately, in 2016, it may not be worth it for anyone to repair a PVR retinal detachment or complex diabetic traction retinal detachment. The Cole Eye Institute will be losing money fixing these detachments, and I am sure we will see many more referrals next year, when retina docs realize it is a money-losing proposition to fix RDs and send patients more quickly to tertiary care facilities. Because most patients value their sight over many far worse health problems, this thinking is very backward.

It is unfortunate that the government is penalizing us for being efficient. They must think it is easy, forgetting that it takes many long years of practice. Even after the six years of postgraduate training, operating on the macula is very difficult and a tiny mistake is blinding.

Obviously this training, years of practice, and surgical skill do not matter to CMS. We cannot make up the cuts with better efficiency because we are all nearing our maximum efficiency, and we don’t get paid for the turnaround time between cases.

At some point something has to break, because I guess the government is telling patients that they can “Achiev[e a] Better Life” by not paying their doctors.