HEALTH REFORM IN PRACTICE IN US OPHTHALMOLOGY

Come 2014, about 14 million Americans will gain health insurance, rising to about 30 million by 2022, thanks to health reforms passed by the Obama administration. But since reform is largely a joint project of the federal and state governments, the details of coverage and how they will affect ophthalmologists will vary greatly by location. “Decisions made in Washington DC and in state capitals today will have an impact on how we care for our patients,†said Susan K Mosier MD, MBA, an ophthalmologist and Medicaid program director for the state of Kansas. However, the overall direction is clear. Payment will move away from fee-forservice reimbursement toward managed care approaches. “There is a lot more performance monitoring and recording on the way.â€

The federal Medicare program, which covers those 65-years-of-age and older, already has adopted strict performancebased payment rules, said William L Rich MD, medical director of health policy for the American Academy of Ophthalmology (AAO). In 2015, practices that fail to meet quality and medical record use requirements will lose up to 3.5 per cent of Medicare revenues, rising to 7.0 per cent or more by 2018.

AAO is developing a registry that is designed to enable participating practices to meet the quality reporting requirements, which will tie payments to indicators such as providing screening and prevention services, Dr Rich said. While switching to electronic records can be costly, participating in registries has clinical benefits, including auditing practice performance and monitoring long-term effects of drugs and devices. About 35 to 40 per cent of US practices have converted to EMR. From state-run insurers, ophthalmologists can expect a variety of managed care approaches, Dr Mosier said. Most feature greater involvement of primary care physicians in controlling specialist service use, and restrict patient choice of physicians.

The most common is a comprehensive risk-based plan, in which a contracted network is at risk for care quality and outcomes. Plans support members with health assessment and care coordination, and must report performance and quality measures and submit to external quality reviews to obtain payment. Nearly half of state-run programmes already use this model, and they will likely be greatly expanded under reform, Dr Mosier said. She also expects private insurers to follow suit. Driving it all is reduced funding, said Michael X Repka MD, MBA, AAO’s medical director of governmental affairs.

For decades, total government expenditures on ophthalmology have grown year to year, but they are about to level off even as patient demand grows. He noted, for example, that the advent of intravitreal injections for AMD and other retinal conditions has dramatically increased procedure volume in retinal offices. Technological advances such as implants that reduce the number of injections required may help relieve this particular problem, Dr Repka said. However, the larger issue is finding ways to deliver services more efficiently and effectively. “We have to find savings in healthcare delivery. More quality and less cost is no longer a mantra, it is a need.â€