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Providers navigate effects of 'Obamacare' with steps for increased efficiency


Negotiating the twists and turns that will be inherent to the Patient Protection and Affordable Care Act (PPACA)-commonly known as the Affordable Care Act (ACA) or “Obamacare”–could be tricky, said Terri Pickering, MD. In order to succeed, ophthalmologists must be aware of and ready for the inevitable changes.

By Liz Meszaros

Negotiating the twists and turns that will be inherent to the new healthcare reform act could be tricky, said Terri Pickering, MD. In order to succeed, ophthalmologists must be aware of and ready for the inevitable changes.

The Patient Protection and Affordable Care Act (PPACA)-commonly called the Affordable Care Act (ACA) and “Obamacare”- was signed into law March 23, 2010.

“It is the most sweeping regulatory overhaul of the Unites States healthcare system since the passage of Medicare and Medicaid in 1965,” said Dr. Pickering, who is in private practice at the Glaucoma Center of San Francisco. “In fact, it is so sweeping that it is predicted that over 1 million people will actually give up the jobs that they hate and are only hanging on to get healthcare by 2021.”

The goals of the ACA include:

• Increase the quality and affordability of health insurance;

• Reduce the number of uninsured by expanding public and private insurance coverage;

• Reduce healthcare costs for individuals and the government via Accountable Care Organizations (ACOs);

• Reduce the number of medical bankruptcies (the leading cause of bankruptcy in the United States).


Benefits also extend to younger patients. In 2005, it was estimated that there were about 9 million uninsured children. Vision benefits are extended to all children up to 19 years old, and parents will no longer need to avoid getting a child’s vision checked or corrected due to cost concerns. (Ophthalmology Times, November 2013, “How childrenbenefit from Obamacare.” http://bit.ly/1hsC9SS)

“The biggest benefit that we can see, especially from ophthalmology, is to children,” said Dr. Pickering. “Pediatric vision services have been designated one of the 10 essential health benefits, and this is really beneficial for youth.”

Shifting the burden of cost

Currently, there are about 6 million enrollees, with a high number of Latinos and African-Americans. About 80% of enrollees chose bronze or silver plans with higher, out-of-pocket expenses.

“These may give fewer expenses to the insurers, but may be a higher burden and a barrier to healthcare for patients,” Dr. Pickering noted.

In addition, not enough young adults are singing up. The goal is that 40% of enrollees should be between ages 18 and 34 years, and only 24% are.

“This has caused some of the insurers to take a step back,” said Dr. Pickering. “Aetna is expecting to lose money, and may drop out entirely because of the previous factors. Humana is also raising some issues. They expect their enrollees to be less healthy and more expensive than they anticipated. So the insurers say they want quality care, but in really, they really want low unit costs.”


One of the reasons the costs for Obamacare are shifting is that unlike individuals and unlike physician practices, the insurers have a bailout, which is why they signed on to participate in this plan in the first place, she said. It is written within the law and for some of them, may be upwards of $450 million.

“This has led to some pessimism regarding this law, that it may be just a very costly entitlement plan, adding layers of bureaucracy,” she added. “Ultimately, for patients, our concern is that it’s low-quality insurance, which may lead to patients having difficulty finding doctors who will even accept these plans.”

In California, for example, enrollees are hitting snags where the insurer websites say they have a certain panel of physicians. When the patients go to these physicians, the physicians tell them “no,” that they haven’t agreed to participate in that network.

Insurers have shifted the financial burden imposed by the ACA from themselves to patients and physicians, not just in terms of high deductibles, but also in cutting doctors from networks and limiting panels available to patients.

This has led a group of New York physicians to sue an insurer for wrongful termination. Certain attorneys are saying fixes within the plan are illegal.

“This all has created a perfect storm for us,” Dr. Pickering said. “In looking forward to our practices as ophthalmologists, what we can predict is more pediatric patients but also more adult patients. Regardless of how many people sign up for Obamacare, it will add on to the increased burden presented by the Baby Boomers.”


Further possibilities include:

• The Patient-Centered Outcomes Institute will give new guidelines to ophthalmologists.

• Ophthalmologists will be working closely with primary care physicians.

• Electronic health records will be a big issue.

• Practice mergers will occur.

“The ACA favors ACOs and large interdisciplinary provider structures, which will inevitably lower costs per-unit patient,” said Dr. Pickering. “This factor, including the increasing cost of medical technology and malpractice insurance, means private single practice will become a vanishing entity. Some predict that 75% of physicians will be employed by healthcare systems in the next decade.”

• ASCs may become more attractive to hospitals.

• Reimbursements will drop, especially for specialists. Payment plans are changing, moving toward more bundled payments and less fee-for-service.


Medicare vigilance

Medicare will be another big feature. In 2010, ophthalmic services accounted for about $6.8 billion for Medicare, and now the ACA has placed an enormous emphasis on Medicare fraud.

“These two factors mean that for the first time, ophthalmology will be targeted by the Office of the Inspector General for fraud investigations,” said Dr. Pickering. “Once you get on that listing, you basically never get off.”

Medicare is also training 2 million senior citizens to report fraudulent billing. There will be more fraud investigations and more government penalties.

Another factor that will be huge for ophthalmologists is the rise of mid-level practitioners. This is now occurring because there is a shortage of physicians and nurses throughout the country.

“The Department of Health and Human Services and state legislators tend to regulate healthcare willy-nilly,” explained Dr. Pickering. “They have to fill a gap in care; they have to provide services; and they just put bodies in to do the care. There is no consensus across the country as what an optometrist, a nurse practitioner, or a physician’s assistant can do versus and MD or an RN.”

In particular, nurse practitioners and optometrists are moving to increase their scope of practice to include surgery.


“How do we stay afloat in this perfect storm?” Dr. Pickering pointed out. “The reality is that we have to increase our patient efficiency. It is important to define medical efficiency as maintaining or developing high-quality care in the shortest amount of time, but without accepting unnecessary risks.”

Dr. Pickering shared some suggestions to help ophthalmologists accomplish this:

• Reduce office bottlenecks;

• Streamline lanes–for an ideal ratio of 3 lanes:1 MD;

• Automate using EHRs to reduce no-show rates, length of time until next available appointment, patient time in the office, etc;

• Be proactive with brochures;

• Consider the possibility of home or remote disease monitoring;

• Do not try to work faster to increase efficiency - this will only increase mistakes;

• Delegate to techs; 2:1 ratio;

• Cross train techs;

• Optimize optometrists’ productivity;

• Constantly communicate from the top down and the bottom up;

• Create an integrated eye care team, in which optometrists, assistants, and staff support the ophthalmologist in assessing data, diagnosis, and counseling patients;

• Be open to new ideas and remember the power of incremental advantage.


The American Academy of Ophthalmology (AAO) is helping as well, with the creation of the IRIS registry. Additionally, the AAO and the American Academy of Optometry met last summer to create a joint educational initiative. The goal is to prepare for the delivery of the highest quality eye care and to foster a mutual approach to serve the growing population of patients expected in the near future.

“We have to take care of more people. We also have to take better care of more patients and provide care for an expanding population,” said Dr. Pickering.

“We are in the midst of a healthcare revolution, which is really a continued

re-invention of the American healthcare system,” she concluded. “The interesting thing is that this bill is changing as we speak, and the end product has yet to be determined. Stay tuned! And remember, anything can happen.”

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