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Ophthalmologists to see new payment models, increased patient access


Increased patients and patient access, new payment models, and the rise of comparative effectiveness research top the list of challenges that ophthalmologists will face in the future, according to William L. Rich, III, MD, FACS.

By Liz Meszaros

Of the many challenges ophthalmologists will face in the future­, increased patients and patient access, new payment models, and the rise of comparative effectiveness research top the list, according to William L. Rich, III, MD, FACS.

“I’m usually known as the doctor of doom, but today, I’m going to give you some hope,” said Dr. Rich, medical director of health policy for the American Academy of Ophthalmology. “If you look at the rapidly changing environment in healthcare, there are some distinctive opportunities for new innovations and new payment models to finance them.”


Increased access

The Protection and Affordable Care Act (or Obamacare) will expand insurance coverage for 33 million Americans by 2017, but experts anticipate that by 2014, there will be 11 million more individuals added.

William L. Rich, III, MD, wants ophthalmologists to think of the opportunities of new payment models, the perils of bundled payments, and know that with comparative effectiveness, they can either win or lose. (Photo by Stevan Nordstrom)

“The question is: if all of these people are coming into our offices, how do we take care of them?” Rich pointed out. “Ophthalmology has one of the most serious workforce shortages in all of medicine, along with cardiology, general surgery, and cardiovascular surgery. We have no chance of increasing the number of residents who are trained now, or fellows for that matter. “

This increasing number of patients and shortage of ophthalmologists, Dr. Rich predicted, will result in the use of more extenders, optometrists, and technicians. More importantly, this will result in what may be the biggest opportunity–an increased emphasis on remote monitoring and the treatment of patients with chronic disease.


“This opens opportunities for new technologies that have never been there before because there was no way to pay for them,” he noted. “We will have to look at quantitative measurements of things that are of importance in monitoring glaucoma in large populations. We have to convert the beautiful images of OCT and visual fields into significant data points that can be entered into an EHR or a clinical registry.”

But, the conversion of ophthalmic markers into digital form will prove challenging, Dr. Rich added. 

“The biggest challenge in front of us now . . . is in getting digital data out of our diagnostics and therapeutics,” he explained. “For instance, give me a number for retinal nerve fiber layer, give me a number that is repeatable, and can be entered electronically into the EHR. For those who can do this, there are huge opportunities. There is a huge payoff in this.”

Who will pay for this?

New payment models will enable this to happen, continued Dr. Rich. For example, the Medical Home Initiative pays providers fee-for-service, but will also pay a monthly per capita payment for the remote monitoring and the coordination of care.

“This creates a huge opportunity for those of us who deal with chronic diseases,” he noted.

Bundled payments will also become common, and organizations will be reaching out to ophthalmology to design bundle payments for ophthalmic indications, such as cataract surgery, new subretinal neovascular membranes, diabetic macular edema, and glaucoma.


“Why play in this arena? With cuts to fee-for-service payments and the great variation in the resources used to treat chronic diseases, there is a potential for greater revenue,” said Dr. Rich. “If you look at healthcare reform now, payment reforms all contain bonuses for physicians who participate in new payment models. Participation in the bundle gets you in the door and helps you avoid paying a lot of penalties.

“This is another way the Feds are looking at. They’ve failed in micro-managing costs and payments. They’re looking to make us the prudent utilizers and purchasers of care,” he predicted.

Future research approaches

Comparative effectiveness research is also part of Obamacare and the Patient Centered Outcomes Initiative is now open for proposals. With the collection of aggregate data specifically looking at new types of scientific inquiry, including elements of correlation and causation, clinical registries will offer research and device surveillance at a fraction of the cost of current studies.

The Academy has started an IRIS outpatient registry, with the ability to follow patients longitudinally using probabilistic matching,” he said. “All other registries look at the short-term impact of a device on the patient. We have no idea of the long-term impacts of interventions on patient quality of life or on the course of the disease. Longitudinal clinical registries, like the IRIS registry, will.”


The IRIS registry was launched April 1, 2014. The goal is to acquire 2,000 ophthalmologists and 18 million patients by 2016.

“In summary, think of the opportunities of new payment models, the perils of bundled payments, and know that with comparative effectiveness, you can either win or lose,” Dr. Rich concluded.


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