CAPE CORAL, Fla. - Private practitioner Don E. Williamson, OD, enjoys several long-standing comanagement relationships with cataract surgeons here. While he knows that ophthalmologists will receive a lower Medicare reimbursement for cataract surgery beginning this year, he expects it to have little, if any, impact on the quality of comanaged care.
"I do not see fees being an issue," Dr. Williamson said. "We have an obligation to take care of the patient, and the ultimate interest for both the surgeon and comanaging doctor is the best care for the patient."
Specifically, 1998 ushers in a lower Medicare reimbursement fee for cataract surgery due to a redistribution of dollars and a fundamental shift of reimbursement from surgical specialties to primary care. The cataract fee, which varies slightly across the country as it reflects geographic differences and other factors, averaged approximately $960 in 1997. In 1998, it will be about $805.
The comanagement portion of the fee will remain 20%, which is about $161 of the new surgical fee, prompting New Jersey practitioner Christopher J. Quinn, OD, to note, "From a strictly financial point of view, the optometrist is assuming a level of responsibility, as is the surgeon, that is not being compensated the way it was previously. So, optometrists are sharing the pain of their ophthalmologic colleagues."
New fee schedules
Dr. Williamson, who serves on the American Optometric Association's (AOA's) Federal Relations Committee, said many dynamics are affecting 1998 surgical fees for all specialties, not just ophthalmology.
"The Health Care Financing Administration (HCFA) has just completed a 5-year review of nearly all procedure codes," he said. "They have looked at things like practice cost, geographic location, physician time and direct contact time with patients, and they're adjusting fee schedules as a result."
Also, three elements of the new federal budget agreement - adjustments to practice expense reimbursement, the shift of reimbursement funding from specialty to general medicine (the so-called "down-payment") and the transition to a single conversion factor - have contributed to the reduction in fees for surgical specialties.
The Practice Expense Coalition, a group of more than 30 medical specialty groups, was successful in obtaining a 1-year delay in the implementation of the practice expense rule with a 4-year phase-in period. The down-payment became effective in January.
David Crist, OD, chair of the AOA's Federal Relations Committee, said the HCFA continues to meet with representatives from provider groups on the practice expense issue. This may impact Medicare fees in the future.
"I think one of the concerns is that there may be a point where cataract fees get low enough that an ophthalmologist is going to find that economically it's not in his or her best interest to comanage these patients with the optometrist," said Dr. Crist. "There are those in ophthalmology who forecast unbelievably large cuts in cataract reimbursement. If that happens, I think cataract comanagement will be endangered."
In New Jersey, Dr. Quinn echoed that same concern. "As the surgical fee comes down, surgeons who thought they could allow optometrists to perform postop care might feel they can't afford to do that anymore," he said. "Overall, I think there may be ophthalmologists who will stop comanaging because they just can't afford to give 20% away."
Dr. Quinn works in a referral center that restricts patient care to only those patients who have been referred to the center through their optometrists. All types of ophthalmic surgical procedures are comanaged at the center, he said, and cataract patients comprise the single biggest portion at 40%.
Dr. Quinn said 75% to 80% of ODs who refer to the center choose to comanage the cataract patient after surgery. The remaining 20% to 25%, he said, choose to leave both surgery and postoperative care to the
center, preferring "to get patients back when they have healed," he said.
Committed to care
Despite concerns that lower surgical fees may eventually negatively affect comanagement relationships between ODs and MDs, both Drs. Quinn and Williamson agree that financial reimbursement is not the reason they comanage cataract patients.
"We've made a commitment to comanagement and feel it's important to the relationship with our referring doctors," said Dr. Quinn. "We're not going to decrease our comanagement because the fees are lower. That fee is secondary to the importance of the comanagement relationship."
Dr. Quinn said comanagement leads to better patient care, but also feels lower surgical fees will present a challenge to doctors. "I would be disappointed to see doctors decide it wasn't worth their while to provide postop comanagement, because it's good for the doctor, the patient and the surgeon," he said.
Dr. Williamson said comanagement allows for continuity of care as well as patient convenience and comfort. "Doctors have always worked closely with surgeons. They understand what results are expected, and they identify areas that need to be seen by the surgeon," he said. "This relationship works well."
Dr. Crist said while ODs may not want to expand their comanagement practices in the face of reduced fees, it is in their best interest to continue to nurture the relationships they have with ophthalmologists.
"I have always thought that, hopefully, these relationships are based on providing quality, continuous care for the patient and not just on reimbursement," he said.
For Your Information:
- David Crist, OD, may be contacted at (303) 757-3311; fax: (303) 757-3692. Dr. Crist did not disclose whether he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any company mentioned.
- Christopher J. Quinn, OD, may be contacted at Omni Eye Services, Metropolitan Corporate Plaza, 485 Route 1 South, Building A, Iselin, NJ 08830; (732) 750-0400; fax: (732) 750-1507.
- Don E. Williamson, OD, may be contacted at 3218 Del Prado Blvd., Cape Coral, FL 33904; (941) 542-3101; fax: (941) 542-5633. Neither Dr. Quinn nor Dr. Williamson has a direct financial interest in any of the products mentioned in this article, nor is either a paid consultant for any company mentioned.