Eyeworld

EW NEWS & OPINION 19 S omething you will never see: Sasquatch, D.B. Cooper, an "average" doctor. I'd wager 90% of physicians consider themselves "above average." An eye surgeon's self-assessment surely meets that estimate. Who wants their baby blues impaled by an "average" eye surgeon? Such magical thinking is statisti- cally impossible. But doctors are a self-selected, competitive group. Re- member medical school orientation? Look to your right, look to your left, one of you won't be here at gradua- tion. No longer expressed explicitly, that old chestnut lurks in backwaters of admission offices. The demo- graphics of medical school have changed, its culture remade to reflect political correctness, but competitiveness vanquished? I think not. The release of physicians' Medicare payments is humbling. Only 49% of doctors can be above average. A mere 2% of ophthalmolo- gists breathe the ether of the govern- ment's reimbursement stratosphere. Oh, the dissonance! Relax. For most doctors, the information's release is a non-event. Patients think you make more, probably a lot more. At best, some well-meaning geriatrics might tack toward sympathy for the hard-work- ing if somewhat overpaid surgeon who saved their eyesight. Ophthal- mologists are more likely to be derided by their colleagues; hospital- employed cognitives abhor greed and avarice especially when disap- pointing paystubs accurately reflect their flexible workweeks. Money ranks high when it comes to enflaming righteous indignation. Ophthalmologists earn a lot of money; they spend a lot for the privilege. Get over it. The Wall Street Journal worked obsessively for release of data the American Medical Association wished to keep private; a federal judge enjoined such action during the Carter administration. In 2013, a different federal judge under the administration that swore unprece- dented transparency finally vacated the 1979 injunction. Like time, transparency seems relative. The media enjoyed the windfall of numbers. Websites of the New York Times and the Washington Post offer sophisticated search functions that can pinpoint a physician's reim- bursement by state, town, specialty, and, seemingly, color of reception- ist's hair. The Columbus Dispatch published a local million-dollar club, and 3 of the 5 charter members were retinologists. In Ohio, a retinal specialist topped the state's charts at $3.2 million. Cleveland.com's headline boldly encouraged folks to "Find how much your doctor received from Medicare (database)." Thirty- five thousand Ohio doctors received a headline-grabbing $2.5 billion in Medicare payments in 2012. What did the public notice, the $2.5 bil- lion or the 35,000? More relevant is $71,428, the average reimbursement per provider before expenses; a pre- owned BMW is likely out of reach. A Tesla? Be serious. But the data is problematic. It includes podiatrists, optometrists, chiropractors, nurse practitioners and anesthetists, physical therapists, physician assistants, psychologists, and social workers. No denigrating these caregivers, but they are scarcely mentioned when the system's alleged rapaciousness is scrutinized. Secondly, reported dollars bundle the cost to the doctor of expensive drugs such as Genentech's Lucentis. Without context, ophthalmologists appear overpaid. According to the Centers for Medicare and Medicaid Services, 880,000 doctors and other medical providers earned $77 billion dollars in 2012. Ophthalmology ranked third behind hematology/oncology and radiation oncology according to CMS data published in the Wall Street Journal. If you received less than $330,000 from Medicare in 2012, you, dear doctor, were indis- putably below average. According to the New York Times, retina specialists received a prodigious portion of ophthalmol- ogy's gaudy reimbursement. Treat- ment of wet macular degeneration cost $1 billion. Media sources noted that "at least 20%" of these dollars went to the purchase of expensive, low margin injectables like Lucentis. For a subspecialty that once cele- brated 20/200 outcomes, the mavens of the posterior segment are doing fine ... before expenses. So, class warfare and profes- sional envy have evolved to this: Highly trained specialists whose clinics serve the oldest, whose serv- ices require well-compensated staff, complex facilities and expensive drugs and technology, and who perform the now quotidian miracles of staunching age-related vision debility and enhancing quality of life are paid a lot of money by a mistrusting bureaucracy that administers healthcare for an entitled elderly. Is there a problem? Maybe. My own 2012 Medicare reimbursement was embarrassingly below average. I plead complacency, old age, prudent lifestyle, kids out of college, and a low-maintenance spouse. The New York Times data re- vealed that 2,995 ophthalmologists were paid $3.32 billion. The Wall Street Journal data showed that 1,000 providers, about a third ophthalmol- ogists, received $3.05 billion in payments. At $3,000,000 per provider, that's some serious smack. The Washington Post reported that nearly 4,000 physicians were paid more than $1 million tax-payer dollars in 2012; 879 were ophthal- mologists. These doctors are smart, hard working, highly skilled, and mostly honest. Because of a few egregious outliers, many find themselves in the crosshairs of the OIG's 2014 Work Plan. The "winner" of Medicare's lot- tery? According to the Los Angeles Times, a Florida retinologist was paid "more than $26 million dollars to treat fewer than 900 patients." It's never a good day when the FBI commandeers your clinic's records and computers. But on the bright side, you won't need that Tesla any time soon. 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 June 2014 by J.C. Noreika, MD, MBA Below average and doing just fine Insights J.C. Noreika, MD, MBA 11-19 News_EW June 2014-DL_Layout 1 6/3/14 12:16 PM Page 19

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