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Affordable Care Act: A work in progress


The Affordable Care Act continues to change and ophthalmology must change in order to adapt.



The Affordable Care Act continues to change and ophthalmology must change in order to adapt.

Dr. Clarkson

By Lynda Charters; Reviewed by John G. Clarkson, MD

Miami-When change is instituted, affected parties always wonder how they will fare. Ophthalmologists are no different, and they are preparing to adapt to changes resulting from implementation of the Affordable Care Act (ACA) as they affect the specialty.

“The future of the ACA is likely more questionable than the future of ophthalmology,” said John Clarkson, MD, dean emeritus and professor of ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami. “We don’t know how the act will continue to evolve.”

The goals of the legislation were insurance coverage for the uninsured population, cost-containment, comparative effectiveness, quality of care, and value-based as opposed to volume-based payment. However, while some of these goals may be achieved, the process currently is incomplete.


Physician workforce

Regarding graduate medical education (GME), the ACA calls for re-allocation of unused slots. The payments for GME are fixed and certain sections of the country benefit more than others. For example, payments per population in the Northeastern states of Ohio and Michigan are significantly higher (range, $39.08 to $172.85) compared with, for example, states such as Texas, Idaho, and Nevada, among others, where the range is $1.94 to $12.20.

“Not only are the payments fixed, but 20% of the GME positions are in New York alone,” Dr. Clarkson said. “States such as Texas and Florida do not have enough GME positions funded to provide funding for the graduates from the medical schools in those states. Because this was not addressed, it perpetuates an inequity.”

Other workforce issues include the American Medical Association prediction of a physician shortage by 2025 due, in part, to increased utilization under the ACA.

“It is clear that to provide vision care to our aging and expanding population that care will need to be delivered by a team, led by ophthalmologists working with optometrists, technicians, nurse practitioners, and physician assistants,” Dr. Clarkson said.

He suggested the potential for home-based care using smartphone technology, which should eliminate some office visits.



The effect of the ACA on research is uncertain. Sequestration appears to be having more of an effect due to decreased support for the National Institutes of Health, he explained.

“The ACA is emphasizing outcomes research, which may impact traditional research, the area where we have made our groundbreaking discoveries,” Dr. Clarkson said.

The ACA model

Institution of the so-called “Romney Care” appears to have had a positive effect in Massachusetts. Ninety-eight percent of the state’s population has medical coverage, the rate of increases in medical expenses has decreased, and health care is the largest employer in the state. In fact, recent analysis indicates that having more people insured has improved the health of the population of Massachusetts.

On the heels of that observation, the AMA Morning Rounds reported in early May 2014 that a study reported in The New York Times found the death rate in Massachusetts dropped substantially since the law was enacted in 2006-a 3% decrease during the first 4 years.1

Although ophthalmology administrators indicate sequestration has negatively impacted research funding, that is not the case for clinical ophthalmology.

“Academic and private practice ophthalmologists believe they are better off than before ‘Romney Care’ began,” Dr. Clarkson said.



A couple of areas that have not received a great deal of attention will affect physicians. Some states previously turned down federal assistance for Medicaid, which, according to Dr. Clarkson, may have a real impact, leaving many patients unfunded.

“Medicaid will not be available for the uninsured in almost half the states, because of the refusal of federal funding,” he said.

Another disparity results from decreases in disproportionate share payments-i.e., government funding of public hospitals or hospitals that provide an unusual amount of care to unfunded or underfunded patients. It was presumed that the ACA was going to provide either Medicaid or medical insurance for many of the uninsured, Dr. Clarkson explained, and the hospitals agreed to a reduction in disproportionate share payments.

“Hospitals in states that refused the federal Medicaid subsidy may be impacted heavily by decreases from $50 to $100 million annually because of the decrease in the disproportionate share payments,” he said. “This clearly will impact the care of those who need it the most.”


Bundled payments

The primary-care specialties are receiving the emphasis with bundling, not specialty care, Dr. Clarkson noted.

“There are lost opportunities for bundling regarding diabetic retinopathy, for example,” he said. “Ophthalmologists probably see diabetic patients more frequently than endocrinologists or internists. Bundling payments also should be considered for glaucoma and cataract care, but these are being ignored.”

Dr. Clarkson advised ophthalmologists to emphasize the fact that vision care results in actual cost savings by improving patient quality of life. He said he believes that home monitoring may be prominent in future eye care, and by working in ophthalmologist-led teams, vision care may be provided more efficiently to a larger number of individuals.

“The emphasis will continue to move toward quality outcomes through organizational practice and tele-ophthalmology,” Dr. Clarkson said. “The future of ophthalmology continues to be bright and is in our hands. Ophthalmology’s future clearly is brighter than the future of the ACA.

“However, ophthalmologists must be proactive by recognizing that change is inevitable and making positive improvements while adapting to those changes,” Dr. Clarkson concluded.



1.              Tavernise S. Mortality drop seen to follow ’06 health law. The New York Times. May 5, 2014. http://www.nytimes.com/2014/05/06/health/death-rate-fell-in-massachusetts-after-health-care-overhaul.html


John G. Clarkson, MD

E: JClarkson@med.miami.edu

Dr. Clarkson has no financial interest in any aspect of this report.

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