DEC 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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16 EW NEWS & OPINION December 2013 Insights Cheer to the New Year by J.C. Noreika, MD, MBA J.C. Noreika, MD, MBA I n the spirit of good cheer and hope for the coming year, consider this contrarian's review of the current drama. For ophthalmologists, auld lang syne has been "times that try men's souls." Acronyms—IRS, OIG, EEOC, DOJ, HHS and CMS enforcing HIPAA, MU, ACA, ACO, ICD-10, RUC, SGR, IPAB, and RVU—call into question the wisdom, as Bob Dylan once sang, "to keep on keeping on." Take heart for here's a New Year's toast to the re-emergence of private practice, fee-for-service, and the pleasures of practicing ophthalmology. Skeptical? This essay is microeconomics and Charles Darwin, not Norman Vincent Peale. American pragmatism and demographics interdict conventional wisdom that ophthalmologists are on the road to perdition. The Affordable Care Act's conception, "we have to pass the bill so that you can find out what is in it," its three-plus year, multibillion dollar gestation and its inglorious website launch may be remedied by Washington's apparatchiks. But its reality is incontestable: Even if an inalienable right, healthcare isn't free. The system is evolving. Physicians who exhibit a capacity for risktaking and a modicum of business acumen will seize advantage. As colleagues seek shelter in bureaucratic hospital-led consortiums, some critical specialties in the peripheral isopters of medicine will strategically innovate and thrive independently. Why? Baby Boomers are aging—fast. There are an awful lot of them. These folks were suckled on "screens," first TVs, then technological relics like PDAs, PCs and laptops, now smartphones and iPads. Surveys reveal people would rather die than go blind. Pixels are life. Supply and demand rules. There simply aren't enough of us and there won't be enough anytime soon. According to a 2013 Medscape survey, 54% of ophthalmologists are aged 50 or older. Organized optometry plots incursion onto ophthalmology's turf but the leap from desire to implementation is broad, late, and perilous. The McDonald's generation? Americans are an impatient people. They want it yesterday. Companies that provide ease of service— FedEx, Apple, Amazon, Google, and Netflix—thrive. Europe's socialized healthcare systems are decades old; their citizenry is inured to long queues at the clinic. In comparison, even America's underclass can get care when it wants it, the longest delay usually in the emergency room's waiting room. Americans will pay for a product perceived necessary and desirable. According to the International Bottled Water Association, we spend more than $15 billion dollars per year on its products, the same as spent on eyewear. My advice? Hang in there. Ophthalmologists are well positioned to take advantage of this remodeling's inevitable unintended consequences. The slumbering public will awaken and the market will work. In the foreseeable future, I envision patients paying for their eye exams when performed. I see ophthalmologists competing on price, convenience, service, technology and outcomes. Medicare will stay. But patients will file their own claims to reimbursement, learn personally that their deductibles have not been met and find that co-pays aren't the result of their doctor's conceit. Practices' websites will assist patients with step-by-step instructions and hyperlinks to file their claims. No longer delimited by insurance companies' or Medicare's fee schedules, the price of an eye exam will decline. Sloughing the costly administrative work third-party payers unilaterally impose, practices will dramatically reduce their overhead burden. Competition would inspire innovative pricing. A full year's follow-up of the glaucoma patient for a subscription fee of, say, $300? Your practice has a thousand patients with glaucoma? Do the math. Concierge practices sell meds in-house at modest markup with savings accruing to the patient. Glaucoma patients may save enough in drug costs to cover the annual subscription. How about preventive care? Americans buy $30 billion worth of products of questionable efficacy per year from the vitamin and supplement industry. Might a patient whose father lost vision from macular degeneration invest $120, the equivalent of a trip to the salon, for a biennial SD-OCT analysis of her maculas? The Affordable Care Act may occasion the very opposite of what it set out to effect, viz., the consolidation and centralization of medicine. This would be the legislation's quintessential irony. Innovations like ASCRS' IOL Calculator and AAO's Iris Registry enhance clinical acumen by collating real-world digital results. Some best practice initiatives of the ACA could also be adopted. Doctors might realize the act's loftiest intentions by pricing their services with flexible discretion when providing quality care for society's neediest. Most importantly, practitioners would cast off the chains of thirdparty payment restoring the doctorpatient covenant. The art and practice of medicine is theirs to enjoy. Quixotic? Thomas Paine didn't think so. In his soul-trying times, he went on to state "what we obtain too cheap, we esteem too lightly: it is dearness only that gives everything its value." And what is dearer than sight? How's that for hope … and change? EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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