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Letter to the Editor: The Winning Save

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It amazes me that the government’s plan for healthcare reform has not involved more input from physicians and other health care professionals. This would be like politicians designing a high-speed underground train from New York to San Francisco without the input of architects, engineers, and builders. Cost containment strategies that focus on regulations have unintended consequences and cost a fortune to implement. This does nothing for quality of care. Can’t we try something different?

The 2017 ASRS meeting debuted a brilliant contest entitled “The Winning Pitch,” which followed a similar model to the entrepreneur contest TV show “Shark Tank.” The ASRS membership was asked to present ideas, projects, and devices that would advance eye care, for a first prize of $10,000. I propose the same be done to stimulate improvement in quality and cost of retina care: “The Winning Save” contest. The ground rules for entries to this contest would be as follows:

  1. There is no outside interference between the physician and patient. Whatever is decided must put the patient’s welfare first.

  2. It is up to the physician, with the patient’s input, to determine what is best for the patient.

  3. The concept must require minimal oversight by a third party; if it is a win/win you don’t need MIPS, BIPS, TIPS, IRIS, Sunshine laws, and so on.

  4. The concept requires minimal if any paperwork, utilization review, explanation of benefits, and the like. It works because all incentives are aligned. It is cost effective because the right thing is done correctly the first time.

In my opinion, government policies are penny wise and many pounds foolish, creating systems that actually encourage expensive care. The following are my own ideas for cost savings in retina care.

Cost Containment in Medical Retina

A major expense in retina care is delivering sight-saving drugs into the eye. In my career, these drugs have done more to improve these patients’ quality of life and prevent the despair, hardship, and global expense of blindness than perhaps even cataract surgery. We all should be indebted to the pharmaceutical industry for developing these amazing drugs.

On the other hand, these drugs are very expensive, and rightly so. Many take a billion dollars to bring to market. But, about 20% of the pharmaceutical dollar goes to research and development, and 40% to marketing. The physician now has become the “middle man” who must pay for, order, catalog, store, and administer – with some risk – these drugs with pass-through dollars. For this management we are paid a percentage of the average wholesale price, which via sequestration was decreased from 6% to 4.5%. If the dollars are mismanaged and the physician cannot pay for the drugs used, then, besides facing bankruptcy, the physician might not be able to administer the drugs to the patient in a timely way and sight could be jeopardized. A small bonus is the physician could pay for the drugs with a credit card and accrue airline mileage or even credit card cash back.

Although the ASRS Preferences and Trends survey consistently indicates that, in most cases, retina specialists still start with the least expensive drug, there is temptation and at least an air of impropriety about our selecting the more expensive drugs for other reasons (Congress created the Sunshine Act to make financial relationship information available to the public, but in effect legislators are shaming physicians into not attending the sometimes informative dinner meetings held by drug companies). The wide variation in practice patterns suggests that we are not fully data driven in clinical decision making.

There is a simple way to obviate temptation of economic gain. Instead of paying the physician $60 for the least expensive compounded drug bevacizumab (Avastin; Genetech), pay the same dollar amount the physician would receive if he or she used ranibizumab (Lucentis; Genentech), or Aflibercept (Eylea; Regeneron) or about $166 (4.5% of the average wholesale price $2,100 = $94, plus 2% credit card cash back, $42, plus the cost of compounded bevacizumab, $30).

This would eliminate any economic incentive to use one drug over another. It would not encourage the use of bevacizumab, nor discourage the use of ranibizumab. It would encourage the physician to do whatever he or she feels is best for the patient. If evidence-based medicine clearly shows a difference, the better drug will win.

Appropriate Payments to Physicians

Payments should be fair for the services and treatments we provide, and should not encourage gaming the system. Modifiers are not a fair method of payment. If a patient comes to the office for a visit to determine if treatment is needed for AMD, pay a reasonable amount for the examination, testing, clinical decision making, and treatment. There is no rational explanation except to cut costs for denying payment for reasonable and necessary testing or services, or not paying for an examination if one is needed at the time the injection is given.

If bilateral injections are needed and acceptable to the patient, there is no rational reason to pay less for the second eye injection. Can you imagine if a plumber came to your home to search for a leak beneath the slab your home is built on, tested to find the leak, after an hour found the leak, fixed it in 5 minutes and you told him you would only pay for the time it took to repair the leak? Or if the same plumber came to your home and found 2 leaks and you told him that you would pay him half to repair the second leak? It’s preposterous, and surely you'd end up in small claims court, and lose!

Of course, we can game the system: do the exam and testing on one day, bring the patient back another day and treat one eye and then bring her back yet another day to treat the other eye. This is a waste of the physician’s time and money, not to mention the time off the family must take to bring their grandmother back and forth to your office, loss of wages, wasted gas, and auto expenses.
On the other hand, if the physician does break up the treatment into parts, he or she should not be paid for a visit at the time of the injection. Let’s keep it simple, give the injection the same day as the visit and testing, pay for the total services rendered and if the patient desires to have both injections done the same day, pay the same for both injections.

Payments for Tests

Payers should pay only for testing that is necessary and let clinicians use the technology as they see fit. My practice hired a consulting firm, and after days of review they came to the conclusion that we were not doing “enough testing” (not as much testing as our colleagues). My argument is that the additional tests frequently don’t provide information that will change my care of that patient. All patients receiving AMD intravitreal injections require at least an OCT. Except for end-stage disease, both eyes should be tested, symptomatic or not, because the incidence and recurrence rates are very high in the fellow eye.  

OCTA is a new, noninvasive, safe, way of performing an angiogram at each visit. It is not an OCT, it is an angiogram. Payers should not distinguish among angiograms using dye (FA, ICGA), from OCTA. Some practices do both FA and ICG at almost every visit for AMD. OCTA, in my experience, obviates the need for dye in 90% of AMD cases. With OCTA, there is no dye exposure, so no chance for a catastrophic allergic reaction. OCTA better distinguishes types 1, 2, and 3 neovascularization and polypoidal than FA/ICG, and combined with the OCT B scan, it will show leakage. Yet the payers pay less than half for the angiogram generated by the more expensive OCT instrument. An angiogram is an angiogram, regardless of how it is generated. OCTA in most cases provides more information, is a safer study, requires a considerably more expensive OCT machine, and much more training and experience. It may detect disease sooner, resulting in better outcomes and alter our practice patterns such that fewer injections are needed overall.

Color, red-free, and AF imaging are also important to document the extent of hemorrhage, lipid, drusen, and geographic atrophy, which are not imaged as well as with OCT. All necessary testing should be part of the evaluation. It is an insult to our intelligence to suggest that color imaging is the same as an OCT B scan or an OCT Bscan is the same as an OCTA. But don’t let us take advantage of the system by performing FAs and ICGs for AMD when they add little to clinical decision making. Give us a flat fee (not a bundled fee) for imaging at each visit, for all the testing we do. Cut out these modifiers that no one understands and that billing programs often get wrong, driving billing staff and clinicians crazy. If the clinician sincerely believes an ICG is necessary, he or she can do it but the physician will get paid no more than if doing just an OCTA. If the clinician really feels the ICG is necessary, payers should allow physicians to bill the patient separately for the expense and to let the clinician explain to the patient why she must have the test and why the patient should pay out of pocket for it. Incentivize good behavior, not more unnecessary testing.

Compounding

I can't comprehend how ordering a separate patient prescription for bevacizumab will make it safer for the patient than using a nameless syringe. Strict compounding rules are needed, but let the compounding industry set its own standards. They know where corners are cut. Then, if violated, let the lawyers seek their pound of flesh.

Surgery

I'd be a much richer man if I took every retinal detachment to the operating room and never did pneumatic retinopexy (PR). Also, the government would be a lot poorer. I perform PR because I believe it is the best way to reattach the retina, allows for the best vision, and causes no harm if it is done properly, even if it fails. However, the payers see it differently. Because PR is apparently so “simple” to do in the office, they pay about two-thirds for it compared to a vitrectomy. This is another example of the system being penny wise and pound foolish. The government assumes that paying the surgeon less money saves money, ignoring the costs of the surgical suite, ancillary testing, preoperative examination, morbidity of surgery, anesthesia, surgical/postoperative nursing care, and the inevitable return to the OR for cataract surgery.

My solution? Pay the physician 25% more for a PR than a vitrectomy. To prevent gaming the system (ie, the Friday night pneumatic and the Tuesday morning scheduled vitrectomy), do not pay for any subsequent operation within 90 days. The government will save millions by letting the market forces work and will not have to “keep score.” If cases are properly selected, PR is successful 70% or more of the time.1 If we even assume PPV is successful 90% of the time (and there is no return to the OR for the cataract surgery) with PR, 3 of 10 patients go to the OR, instead of the 11 times for the vitrectomy group vitrectomized eyes. The physician is rewarded for properly selecting and performing the least invasive procedure, the patient benefits from a less traumatic procedure, and morbidity and risk of the OR are avoided. The government is rewarded by avoiding all the costs associated with OR surgery. Paying for one surgical procedure (remember the second retinal operation is not paid) overall keeps the costs down and discourages gaming the system.

Facilitating Office-Based Retinal Surgery

Allow office-based retinal surgery without multimillion-dollar start-up costs. A recent Kaiser Permanente study showed that 4,000 cataract operations performed in a clean room without an anesthesiologist was as safe and efficacious as going to an OR.2 What advantage is there of going to an OR for eye surgery? Unlike orthopedic cases, air flow is not a factor. Is it safer to do a vitrectomy in a hospital OR after an infected bowel operation than in the office clean room where only eye surgery is performed? We enter the eye all the time in the office exam chair, giving intravitreal injections and performing paracentesis. Is a nondrainage scleral buckle more safely done in the OR suite?

Expiration Dates

The FDA asks drug companies how long they wish to test their drug to determine the expiration date. For example, the expiration for C3F8 and SF6 is 1 year. Really. I suggest the expiration date of these gasses be re-evaluated for at least a 2-year expiration date.

Conclusion

I don't believe any of these suggestions jeopardizes patient care. They don’t incentivize more expensive care, or limit quality care. They encourage doing the right thing correctly the first time.

The Winning Save contest can be done for each of our subspecialties and can apply broadly to other medical fields. The government should ask us how we could make things better.

References

  1. Tornambe PE, Hilton GF. Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96(6):772-783.

  2. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-based cataract surgery: population health outcomes study of more than 21,000 cases in the United States. Ophthalmology. 2016;123(4):723-728.