WASHINGTON—With huge reimbursement challenges ahead for ophthalmology in 2005, payment issues will dominate the American Academy of Ophthalmology’s federal advocacy efforts on behalf of all Eye M.D.s in the coming year.

The Academy’s aggressive agenda includes addressing the Medicare payment cuts scheduled for all physicians in 2006, making sure ophthalmology can compete for pay-for-performance Medicare funds, and protecting ophthalmology payments under the Five-Year Review. The Academy’s Federal Affairs Secretariat met Jan. 22, 2005, in Washington, D.C., to determine how the Academy will respond to these issues.

“While our goals are ambitious, we are confident ophthalmology will be successful if we stay focused and engaged,” said Michael Repka, MD, Academy secretary for federal affairs. “Our extensive knowledge, pioneering work by the Academy in preferred practice patterns, and understanding of these issues makes us confident that ophthalmology will prevail.”
 
Targeted issues include:

Fixing the SGR Formula – Efforts are already underway by the Academy and others to derail scheduled annual cuts of 4 percent to 5 percent due to the Medicare physician payment update formula. Ophthalmology will be fighting along side the AMA and the rest of organized medicine for a formula fix in the sustainable growth rate (SGR) calculation before January 2006, when the next round of cuts is expected to start. While a long-term solution remains elusive due to costs and the budget deficit, the Academy is fighting for fairness. MedPAC recommends physicians receive a 2.7 percent update. The president’s budget proposal is sure to include cuts, and entitlement programs may not be spared. If Medicare is targeted, ASC and imaging reimbursements may be on the table.

Pay for Performance – With P4P, the question is no longer if it will happen…but when and how. Both Congress and MedPAC are supportive of an incentive pay program for physicians aimed at improving quality in the Medicare program. It is anticipated that the process may first require a simple reporting of efforts and then gradually move into collecting more meaningful data. The real questions are how it will be paid for (i.e., budget neutral) and will all specialties have equal opportunities for the money.

Five-Year Review – The Centers for Medicare and Medicaid Services (CMS) and organized medicine will spend the next two years looking at work values of many codes during the Congressionally mandated Five-Year Review. Ophthalmology’s effort in the required review will continue as a major focus for the Academy. To date, the Academy has identified 15 codes whose physician work values appear undervalued. In addition, the Academy plans to work with specialties to defend any ophthalmic code work CMS targets as overvalued “because technology made it easier or faster to perform.” As part of the five-year review, the Academy will call on selected members to complete surveys. The Academy will use data obtained from the surveys to support its argument for increasing or retaining the value of ophthalmology codes before the RVS Update Committee (RUC).

Surgery by Surgeons in VA Facilities – Efforts to protect the eye health of our nation’s veterans were given a major boost in December 2004 when the Veterans Health Administration (VHA) issued a directive banning laser surgery by optometrists in its facilities. The Academy looks forward to working with the new leadership at the Department of Veterans Affairs (VA) to provide quality eye care for those served by the VHA, and will continue to monitor the situation closely. While the VHA’s recent directive is a decisive victory for veterans and patients, a challenge to patient safety persists in Oklahoma. Oklahoma continues to be the only state in the nation that licenses optometrists to perform laser surgery and now allows them to perform eye surgery with a scalpel. A great deal is at stake, because if this issue is not resolved, it will continue to plague the VHA and other federal health programs.

Other issues requiring the Academy’s attention include: Medical liability reform, children’s vision legislation, plano contact lenses and the “Fairness to Contact Lens Consumers Act.”

Medical Liability Reform – Both the president and senate leaders are giving greater priority to reforming current liability limits and statutes, including setting caps on non-compensatory claims. Greater headway could be made, however, in the states as excess damage suits that are pushing key specialists out of some areas of the country.

Children’s Access to Vision – Legislative efforts continue to increase access to eye exams and treatment for children who need it. The Academy will work the American Academy of Pediatrics and the American Association for Pediatric Ophthalmology and Strabismus to boost vision services for those children who are most in need. The Academy is working for the reintroduction of its bill from the 108th Congress, which called for grants to states to provide eye exams and follow-up treatment to uninsured children when the child fails vision screening.

“Fairness to Contact Lens Consumers Act” – Since this became law in August 2004, practitioners have faced implementation problems. Some dispensers are making it difficult if not impossible to respond to prescription verification requests as outlined in the law and subsequent regulations. The Academy will provide ongoing information to the Federal Trade Commission, whose enforcement could get at those problematic dispensers who are negatively impacting ophthalmologists and their patients.

Plano Contact Lens Legislation – Legislation was introduced this month similar to last year’s House and Senate bills to amend the “Federal Food, Drug and Cosmetics Act” to recognize and regulate both corrective and non-corrective contact lenses as medical devices. In the last Congress, a unanimously passed House bill died in the Senate. With a new Senate committee, the Academy will renew its effort to pass the legislation.