You can thrive in this new-world order

Our experts discuss the ophthalmic trends that will lead practices from reimbursement reliance, towards self-reliance.

From the earliest days of his campaign, Donald J. Trump vowed to “get rid of Obamacare.” Now elected, Trump has nominated six-term Congressman and Affordable Care Act critic Tom Price, MD, to head HHS, so he seems on track to fulfill that commitment. But it may also signal dramatic changes to the Medicare program.

A Georgia Republican, Dr. Price favors privatizing Medicare, a program that, by at least one estimate, accounts for 60% of the cash flow for the average ophthalmic practice. Add in revenue lost by the ACA’s imminent repeal and that figure climbs a few percentage points more.

But, this is Washington we’re discussing, so there are reasons galore — legislative, legal, political, practical — why change won’t come overnight. Yet come it will, so practitioners, consultants, researchers and academics, at least interviewed for this article, say that ophthalmologists who want to thrive must embrace medicine’s new-world order.

“I think we’re all scratching our heads and wondering what a post-Trump ophthalmic America is going to be like,” says John Pinto, president of J. Pinto & Associates, Inc., an ophthalmic practice management-consulting firm. “It is time to be light on your feet and be ready for anything.”

What follows are the trends, good and hazard-ridden, that you should know about.

Baking and channeling

Some things — cost containment and consolidation — are already baked into the cake. So it’s likely that fewer small, private practices will survive as the demand for care rises and reimbursements stagnate, or worse, fall. Even larger groups will have to channel their inner entrepreneur to exploit fresh business opportunities to supplement revenues. Many have already done so, and are reaping that benefit. (Please visit page 24.)

“That is the inevitable path that we are already on,” says Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona. “There is no way to stop it. That first domino was pushed years ago, and we’re in the middle of this big change.”

On the bright side, new, innovative technologies, therapies and pharmaceuticals should come online by 2020, ushering in the era of personalized medicine with a side benefit of reined-in costs.

The art of the practice

Thanks to demands from an aging population, Mr. Pinto and others believe ophthalmology should fare as well as, if not better than, other medical specialties in 2020. But the push to privatize Medicare is a wildcard, especially for ophthalmologists.

It’s too soon to say when, or if, the air in the privatize Medicare balloon escapes. Seniors are the country’s largest voting block and they don’t like politicians messing with their hard-earned benefits. Dr. Price’s ambition aside, the smart money says Medicare remains a federal program with lower reimbursements. Of course, we’ve all recently learned that smart money isn’t always, well, smart.

“I would be surprised to see a voucher system passing Congress absent a frank national emergency,” Mr. Pinto says. “And efforts to materially reduce fees will be fought by well-connected health-care systems that now employ an increasing percentage of providers.”

Mark Packer, MD, president of Mark Packer Consulting, agrees, adding that the only way Medicare privatization passes is if it improves the quality of care and increases cost-effectiveness.

“We saw the same kind of thing tried before with Medicare HMOs and now the Accountable Care Organizations,” he says. “Regardless of the exact form it takes, the end result on the ophthalmic practice is reimbursements are going to be less. That’s what I would prepare for.”

A new business plan

One way to prepare is to benchmark your practice. Benchmarking shows you revenues and expenditures, overhead costs, a year-to-year fiscal comparison, and where your practice ranks against other practices. In a cost-conscious health-care system that is becoming more restrictive and monolithic, understanding those financial details is important.

“We are going to have to learn to work within that kind of [restrictive] system,” Dr. Dugel says. “That system will reward people who are efficient, people who are adaptable, people who are foresighted. Those are the kind of groups and individuals that are going to win in the era of consolidation.”

Winning will require a diversified business plan that creates income from other medically-related ventures. For instance, some ophthalmologists are adding aesthetic services — skin and facial products, chemical peels and vitamins — to their practices or expanding into premium channels like ocular plastic surgery. Others are investing in medical office buildings or surgery centers.

For Dr. Packer, revenue is also driven by premium channel procedures that patients pay for out-of-pocket.

Eric Donnenfeld, MD, also sees this in his practice, Ophthalmic Consultants of Long Island. His group is now providing more of these premium channel procedures to more patients. Because technology has increased the types of vision improvements for patients, ophthalmologists who can perform these surgeries will earn more.

(Dr. Donnenfeld made his comments in the Roundtable discussion, page 24.)

But it’s not advanced technology alone, he continues, that has brought more patients looking for these services. Society is changing; the generations are not in sync with how they regard aging, how they value money. The Greatest Generation, whose members either grew up in or felt the impact of the Great Depression are good with “whatever the insurance covers.” The “self-actualized” boomers, he continues, loathe aging. For them, cataract surgery is “a way to restore their youth.” And hence it is the boomers who are driving the so-called shared billing market.

More business trends

Another business trend: Some small practices are saving money by moving a few procedures out of surgery centers and into their offices. Dr. Packer says it’s just a few practices, but the “economics of that [move] are very favorable.”

“They have grown from doing LASIK in the office to doing refractive lenses in the office, to now doing premium cataract surgery in the office.” Even Medicare is looking into it. “It’s an interesting trend that I see as growing,” he adds.

The reason, again, is advances in technology. A cataract surgery suite connects an imaging/measurement device with a femtosecond laser and operating microscope. These systems give surgeons a free flow of information from the clinic to the operating room and back to the clinic postoperatively.

“I think automated transfer of information is going to be an increasing feature,” Dr. Packer says. “It is sort of early and it needs to be refined, but I think that is kind of a definite direction in terms of what we’ll see in cataract surgery technology.”

Another way to steel your practice for lower reimbursements, he says, is to stay abreast of technology so you can take advantage of the next big thing.

“There is always a window of opportunity when something new arrives,” Dr. Packer says. “Be involved even on the clinical research side so that you learn about it before everyone else.”

RPE research

According to the NEI, about 10 research groups are trying to regenerate retinal pigment epithelium (RPE) using myriad cell sources. This type of regeneration started in 2011 when an AMD patient received the first injection of stem cell-derived RPE cells; the lab of Robert Lanza, MD, led this research. In 2014, Japanese researchers led by Masayo Takahashi, MD, PhD, treated a patient’s wet form of AMD by using scaffold-less sheets of RPE that originated in induced pluripotent stem cells (iPSCs). Stadtman Investigator Kapil Bharti, PhD, and others at the NEI intramural research program are now using these (iPSCs) RPE cells seeded onto scaffolds. For more of Dr. Bharti’s work, visit:

The art that is science

The collaboration of technology and science is ushering in the era of personalized medicine as we begin to understand that people respond differently to treatments for the same disease.

Dr. Dugel says studies have found that while macular degeneration patients clinically present alike, 40% respond differently to the same drugs and dosages. Personalized medicine may be the answer to containing costs while improving the quality of care.

“What we’re realizing is that we need to look at the genome type of the patient and personalize the diagnostics and therapeutics for that particular person,” he says.

Doctors can identify the subtype of each patient’s disease and choose therapies accordingly. So, the plan for a patient with diabetic retinopathy would include seeing an ophthalmologist every six months but only visiting a foot or kidney specialist yearly or less.

“Rather than shotgunning it and having everybody see somebody every year, we can concentrate on a particular subtype of that disease based on that patient,” Dr. Dugel says. “If you can deliver the best personalized medicine, that will also be the most cost-effective medicine there is.”

Cost-effective though it may be, personalized medicine will still be expensive. Managing costs while improving quality will take a concerted effort among physicians, pharma and med industries and government institutions, which is happening in some areas of ophthalmology.

Dr. Dugel says that when he was in training, few drugs were available for patients with retinal issues. However, over the past few decades, retinal surgeons have worked closely with pharmaceutical companies to develop a new generation of drugs for macular degeneration.

“That kind of collaboration is going to produce the next paradigm shift in ophthalmology, specifically retina, which is the personalized delivery of care,” he says.

The NEI has several cell therapies on track to enter clinical trials in the next couple of years. “If they prove successful, they stand to revolutionize AMD treatment,” says Paul A. Sieving, MD, PhD, director of the NEI.

As for cataracts …

It’s the same. Only different.

The future of cataract surgery “revolves around integration of technology and customizing patient outcomes,” says Kendall E. Donaldson, MD.

New topography and tomography devices, along with new formulae, lead to more accurate measurements and better outcomes for cataract patients, Dr. Donaldson says. By 2020, she expects new 3-D techniques will more accurately measure the cornea, allowing surgeons to “more precisely correct astigmatism.”

Continued IOL improvement will also mean better quality vision for patients, says Dr. Donaldson, medical director of the Bascom Palmer Eye Institute.

“IOLs like the Calhoun light-adjusted lens [LAL] give us a glimpse into this future technology, which will someday become commonplace,” Dr. Donaldson says. “Additionally, presbyopia correction will provide more natural range of vision, more accurately approximating the behavior of a youthful lens.”

The buzz

Of ophthalmology’s subspecialties, glaucoma has the most buzz. “These next five years will be the biggest years in history for glaucoma,” says Robert Noecker, MD. “This is like glaucoma’s time in the sun.”

Besides new devices and surgical technology that will make traditionally risky glaucoma much safer, Dr. Noecker, director of glaucoma at Ophthalmic Consultants of Connecticut, says new classes of glaucoma medications will help physicians to mix and match therapies. “We have a few new molecules that are becoming available that work differently than the rest of the drugs that we currently use. That’s an opportunity because [now, there is a] tendency that their drugs work and then they don’t, at least not as well.”


As to how our health care system will look, function and respond in four year’s time is the stuff of crystal balls and Tarot cards. But what is real — innovations in personalized patient therapies, surgical technology and techniques, and targeted pharmaceuticals, let alone the American spirit — leaves Dr. Packer optimistic about the future of medicine.

“There are so many people with so many great ideas, and those things are going to come to market eventually,” he says. “I don’t think anybody is going to stop that. There will always be a way for innovation to move ahead.” OM