BY CYNTHIA MATTOX, MD
“Trying to predict the future is like trying to
drive down a country road at night with no
lights while looking out the back window.”
—Peter F. Drucker
Although I do not have a clear vision of what the next
decade holds, clues can be found in the recently passed
(and now again contested) health care legislation and
today's economic climate.
THE BUSINESS OF GLAUCOMA CARE
We all know that Medicare spending is growing far faster
than the economy, a situation that is unsustainable for the
long term. Spending and utilization controls have not reduced
costs when applied to the aggregate of the health
care system. Individual providers, certain overspending geographical
areas, and hospital/physician organization systems
will therefore be targeted. The tools will be profiling and
value-based modifiers applied to individuals, reduced fee
schedules for outlying regions, and “global payments” or
capitation systems applied to Accountable Care Organizations
(ACOs). All of these are in the works for Medicare payment
structures that will begin in 2015. Many are already in
place from private insurers across the country.
In my opinion, it is mandatory to have a physician partner and administrator who will monitor and understand the impending rules and requirements from all insurers. Each of us should encourage our state's ophthalmological society to keep all members informed and speak with one voice to fight unfair programs.
Individually, we can also prepare for change. For profiling on quality and cost, I recommend participating in quality reporting programs. The somewhat revamped Physician Quality Reporting System (previously Physician Quality Reporting Initiative) program will now have public reporting in 2012 of individual physicians, based on their 2011 participation. Most likely, the Physician Quality Reporting System will be used to generate the value-based modifier differential in Medicare reimbursement that will be applied in the future, and glaucoma care may be targeted in the first wave of affected services, due to the large variation in costs. Also, we should expect more quality improvement programs from private insurers, which are now required to spend 85 cents of every premium dollar on actual health care. They are allowed to classify the cost of quality and profiling programs as “health care,” not administrative costs.
New Glaucoma ICD9 diagnosis codes that stratify severity for open-angle suspects and the most common types of glaucoma are likely to be approved for use in October 2011. These are add-ons to the original ICD9 codes for the type of glaucoma, so additional effort will be involved in reporting these codes. On the upside, it is to be hoped that cost efficiency analysis applied to our practices will reflect risk adjustment for more severe cases.
We need not limit ourselves to joining a single ACO. Ultimately, we will likely be part of several such organizations, as they proliferate. In past capitation schemes, organized ophthalmology has been able to negotiate “carve-out” provisions for surgical ophthalmology services, and this may be an appropriate strategy in the future. It is worth our while to educate primary care physicians in the ACOs about glaucoma and diabetes and to offer to help them meet their Healthcare Effectiveness Data and Information Set measures. This effort will show our value to the ACO and help us to share in quality-based payments going forward.
THE CLINICAL SIDE OF GLAUCOMA
PRACTICE
Clinical care will likely change in the next 7 to 10 years,
as we develop better algorithms for the timing and type of glaucoma intervention for various types of patients as
well as early- versus advanced-stage disease. Comparative
effectiveness research offers the hope of elucidating
the best intervention at certain stages of disease. The
cost of glaucoma care varies widely, making it a likely
target for comparative effectiveness research. The
Registry in Glaucoma Outcomes Research (RIGOR)
study of primary open-angle glaucoma awarded to the
AAO Hoskins Center for Quality Care and sponsored by
the Agency for Healthcare Research and Quality has
already begun, and it may guide care in the future. There
will be plenty of funding for future studies. After the initial
$1.1 trillion from the American Recovery and
Reinvestment Act, a tax on Medicare and private insurers
that begins in 2013 will annually provide an estimated
$500 million in funding for comparative effectiveness
research by 2015. The Patient Centered Outcomes
Research Institute will direct the research and will contract
with the National Institutes of Health, the Agency
for Healthcare Research and Quality, and private sector
organizations to conduct the studies.
Drug costs may be reigned in a bit as more generics become accepted and if Medicare gets more authority to negotiate drug costs for Part D. Still, as the cost of medications rises, patients may become more interested in pursuing surgical treatment for their glaucoma. I believe that the next generation of patients is already showing increasing confidence in technology for their care. Of course, we can all also hope for some type of disruptive technology to completely change treatment for our patients. Ten years is a long time!
THE EVOLUTION OF PRACTICE MODELS AND
TECHNOLOGY
The ophthalmic practice of 2021 will need to be lean,
adaptable, and flexible to incorporate cutting-edge
technology that will speed throughput, diagnosis, and
the use of treatment modalities. For example, I expect
that visual field testing will be able to detect stimulus
response directly from the visual cortex. Actual ganglion
cell viability will be assessed by new forms of retinal
imaging. We will have better algorithms to detect
and predict progression and visual disability. Computer
programs will analyze the constellation of tests to make
an initial assessment and speed our evaluations. Practices
will be larger with several surgical glaucoma subspecialists
on the team. Comprehensive ophthalmologists
and well-trained optometrists will supervise patients'
medical and postoperative care. Many surgical
consultations will occur through telemedicine setups,
where testing is reviewed, the patient is examined, and a
patient's interview occurs from a remote office location. The demands of an aging population will outstrip the
supply of surgeons.
Compared to our current practice models in which we often observe patients for years or have intense relationships throughout their surgical recovery, this model may seem less intimate and less satisfying. Out of necessity, the next generation of physicians and patients will be more comfortable with technology and fewer personal doctor-patient relationships. Practices and glaucoma specialists will evolve.
Compared to our current practice models in which we often observe patients for years or have intense relationships throughout their surgical recovery, this model may seem less intimate and less satisfying. Out of necessity, the next generation of physicians and patients will be more comfortable with technology and fewer personal doctor-patient relationships. Practices and glaucoma specialists will evolve.
Cynthia Mattox, MD, is the vice chair of ophthalmology at Tufts University School of Medicine and the director of the Glaucoma Service at the New England Eye Center in Boston. Dr. Mattox may be reached at (617) 636-8108; cmattox@tuftsmedicalcenter.org.
BY BLYTHE MONHEIT, MD
We stand on the verge of a new era of
medicine, one that is to be closely scrutinized
and regulated by government. We as
ophthalmologists and specifically glaucoma
specialists will face challenges and changes as never
before.
We rely heavily on functional and structural testing to assess disease stability or progression. In our current payer system, conflicts exist between what we need to manage disease and what the health care system will authorize (for example, limits on the number of functional and structural tests that are allowed). This kind of conflict may become more frequent with the proposed changes to the health care system.
While some aspects of the reform are uniformly positive (Patient Protection and Affordable Care Act), other changes are of concern. Many utilize the concept that cost savings in health care directly benefit the physician. The glaucoma population is particularly at risk in this scenario. Good care requires multiple high-level tests throughout the year to determine disease stability, often multiple medications to control the disease, and not infrequently surgical intervention. This may not align well with the proposed models.
Along with our professional societies, we should strive to educate policy makers that the cost of vision loss due to undetected glaucomatous progression will burden the country with providing higher-level and more frequent health care services. Patients with low vision are more costly (46.7% increase in Medicare claims) than those with no vision loss. Mean and total health care costs increase from disease onset with no vision loss ($8,157) to blindness ($18,670).1 Health care savings are the highest if vision loss is prevented.
In the current climate, innovations that will most affect our field include new technology to aid in accurately detecting progression and improved surgical techniques to attain IOPs that stop progression. Surgical options have increased, but the current devices and techniques do not yet offer a consistent IOP outcome in the low teens and are often more costly than the older alternatives.
When surgical innovations are able to attain longterm IOP control at a level that ensures disease stabilization, they will decrease the burden of medication costs on the patient and health care system. This will be the most important development in the field of glaucoma: the right surgical technique could change this from a primarily medically treated disease to a surgically treated one. Industry, clinicians, and research scientists actively pursue the development of the surgical technique that will change the landscape of our field.
Blythe Monheit, MD, is a glaucoma specialist in practice with The Glaucoma Institute of Austin in Texas. Dr. Monheit may be reached at (512) 452-8467; bmonheit@gmail.com.
BY RONALD L. FELLMAN, MD
The next decade will be one of evolution
as health care reform takes shape and the
medical community adapts.
HOW WILL HEALTH CARE REFORM AFFECT
GLAUCOMA PATIENTS?
The new health care legislation will have positive as
well as negatives effects. Welcome changes will include
the potential for more affordable medications, more widespread insurance coverage, better vertical integration,
coverage despite preexisting illness, and no loss of
insurance due to job changes. In addition, the preventive
push for screening and education of the new reform
package is a blessing for patients who have or are at risk
of developing a “silent” disease such as glaucoma—a
sneak thief of sight, especially in its early stages. The
community outreach programs will be heavily involved
in screening, and organizations like the American
Glaucoma Society must be active on a national level in
directing this difficult task.
A big negative will likely be the Centers for Medicare & Medicaid Services panel that rules by fiat and will ultimately dictate what will be paid for and what will not. We physicians will lose autonomy, entrepreneurial opportunities will fade, and cookbook medicine will predominate. Through the Accountable Care Organizations (ACOs), hospitals will have the most clout and will continue to dominate our work habits. As ACOs gobble up our practices, we will be forced to keep down costs and show accountability, and society will decide if it likes the model or not. Like most systems, it will slowly evolve.
Whatever health care reform package prevails, we must concentrate on affordability, accountability, and accessibility. To do so, we will need one more A: adaptability. In the past 3 years, my colleagues and I have integrated electronic medical records, electronic practice management, the Physician Quality Reporting Initiative, and compliance programs. In addition, we increased our research productivity, added a satellite office, built a new main office and ambulatory surgery center with all updated equipment, and hired new well-trained doctors. We also hired outside consultants to rethink our whole practice management style. All of these changes significantly increased our efficiency. In terms of clinical practice, efficiency means performing in the best possible manner while wasting the least amount of time and effort by having and using requisite knowledge and skill. It also means producing a positive effect that is satisfactory to both physicians and patients.
An essential is to use a commodity with maximum efficiency, and that commodity is one's medical practice. We now focus on the practice's identity, not individuals', because it is the practice that must be marketable to the new health care system. This will help us take on the government- mandated paradigm shift in medical care, which will ultimately be a change from volume based to value based, witnessed and facilitated by ACOs. Volume will become a secondary factor, a spillover from value-based care.
INNOVATIONS IN CLINICAL CARE
Pharmaceutical therapy will evolve along the lines of new
implantable drug delivery systems that will last the patient
several months and will be easy to replace. New compliance
algorithms will take shape to boost patients' awareness of
and success in dealing with their disease. A better understanding
of the genetics of glaucoma will lead to gene therapy
targeted against this difficult, relentless disease.
In diagnostics, we glaucoma surgeons will have the cardiologist's equivalent of their arteriogram (ie, a map of the patient's outflow system or “canalogram”). Patients with a repairable outflow system will undergo canalbased procedures. Those whose trabecular-canalicular system is beyond repair will be treated with a uveoscleral or external filtration procedure. Surgery will be tailored to the health of the remaining outflow system, not just to the diagnosis. In addition to a new emphasis on canal and uveoscleral surgery, newer means of less expensive filtration surgery will become available on a more global scale to relieve elevated IOP worldwide.
CONCLUSION
If we pay attention to the four As and our health care
system evolves into a program that emphasizes outcomes
and prevention, we will be able to efficiently take care of
the major increase in the number of glaucoma patients. A
better understanding of the etiology of glaucoma will
facilitate the development of new procedures that will be
simpler and less expensive to administer. As we tailor
therapy to the specific defect in the outflow system, outcomes
will vastly improve, and costs will decrease. It will
be a great time to be a physician taking care of glaucoma
patients, because we will have the means and the will to
create an upbeat environment for our patients, and they
will be better equipped to take care of themselves.
Ronald L. Fellman, MD, is a glaucoma specialist at Glaucoma Associates of Texas in Dallas and clinical associate professor emeritus in the Department of Ophthalmology at UT Southwestern Medical Center in Dallas. Dr. Fellman may be reached at (214) 360-0000; llman@glaucomaassociates.com.
