LETTERS

Medicare Cuts: A Time for Introspection

I read with interest the article “Blinding Ignorance,” by Dr. Peter Kaiser in the January/February 2016 issue of Retinal Physician and would like to offer the following comments.

I share Dr. Kaiser’s pain and frustration over steep cuts in Medicare Allowable payments for most of the surgical procedures performed by us, including a 31% cut for the code 67108 (repair of retinal detachment by vitrectomy, with or without scleral buckle) diminishing total allowable payment to slightly more than $1,000. You can expect half of that if you accept Medicaid or some of the Affordable Care Act–related plans, for a complex procedure performed for a blinding disease that takes “two to three hours.”

I commend Dr. Kaiser for his honesty in admitting the duration of the procedure, which is similar to mine and doesn’t include approximately one hour of nonsurgical time per case in preop evaluation, site marking, interval history and physical, administration of block, surgical prep, dressing, postop paperwork, dictation of the operative report, talking to the patient and family, time for turnover of the operating room, etc.

Nevertheless, I am mindful of the statements made by prominent and well-known retinal surgeons at various meetings claiming that they can perform a core vitrectomy in “four minutes,” pucker surgery in five, and a vitrectomy buckle procedure in eight.

When I challenged a speaker that it was not possible to do a vit buckle procedure in eight minutes, he scoffed, “A lot can be accomplished in eight minutes.” (Seriously!)

Our reimbursement for a procedure is determined by the product of Relative Value Units assigned to that procedure, multiplied by a Conversion Factor, the latter of which, at $35.83, is only 0.02% less than in 2015, whereas the former at $30.83 is 32% less compared to $45.39 in 2015.

While the Conversion Factor is beyond our control and has actually increased from $34.04 in 2012, the Relative Value Unit largely represents the amount of work involved in a procedure. (Sorry, no points for skill.) Falsely trivializing our own work by irresponsible statements like the one above is one of the reasons for the relentless downward adjustment in Relative Value Units for our surgical procedures, as we are well aware from the example of cataract surgeons.

Perhaps we need to start being more honest and truthful in our talks regarding the actual surgical time and in surveys performed to determine Relative Value Units. In the meantime, it may be wise to dictate in our operative reports actual surgical time taken in the procedure to give our professional organizations the data they need to present the real time and effort involved in our cases to regulatory bodies.

As Benjamin Franklin remarked at the signing of the Declaration of Independence, “We must, indeed, all hang together, or else we shall all hang separately.”

Kamal Kishore, MD
Peoria, IL