Neuro-Ophthalmology: Transitioning From Old to New Models of Health Care Delivery

In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD will discuss the following 6 articles.

Hoyt Lecture Williams F. Hoyt, MD The North American Neuro-Ophthalmology Society, in conjunction with the American Academy of Ophthalmology, established the annual Hoyt Lecture in 2001 in honor of William Fletcher Hoyt, MD, whose contributions to neuro-ophthalmology have spanned seven decades. A fellow of Frank Walsh, MD, the grandfather of clinical neuro-ophthalmology, Dr. Hoyt co-authored the 3rd edition of Clinical NeuroOphthalmology, the "bible" of our specialty. A faculty member of the departments of Ophthalmology, Neurology and Neurosurgery at the University of California San Francisco since 1958, Dr. Hoyt is world-renowned as a clinician, scholar and educator. He has published more than 300 scientific contributions and has trained more than 100 fellows, many of whom are senior professors in their own right, training the next generations of neuro-ophthalmologists on six continents. Neuro-Ophthalmology: Transitioning From Old to New Models of Health Care Delivery Larry P. Frohman, MD Abstract: In contradiction to fundamental laws of supply and demand, 2 decades of payment policies have led to some medical specialties experiencing declines in both manpower and reimbursement. This paradox has resulted in increasingly long wait times to see some specialists, some specialties becoming less attractive to potential trainees, and a dearth of new trainees entering these fields. Evolving models of health care delivery hold the promise of increasing patient access to most providers and may diminish costs and improve outcomes for most patients/conditions. However, patients who need care in understaffed fields may, in the future, be unable to quickly access a specialist with the requisite expertise. Impeding the sickest and most complex patients from seeing physicians with appropriate expertise may lead to increased costs and deleterious outcomes-consequences contrary to the goals of health care reform. To ensure appropriate access for these patients requires 2 conditions: 1. Compensation models that do not discourage trainees from pursuing nonprocedural specialties, and 2. A care delivery model that expediently identifies and routes these patients to the appropriate specialist. Journal of Neuro-Ophthalmology 2017;37:206-209 doi: 10.1097/WNO.0000000000000518 © 2017 by North American Neuro-Ophthalmology Society Departments of Ophthalmology & Visual Sciences and Neurology & Neurosciences, Rutgers-New Jersey Medical School, Newark, New Jersey. Presented as William Hoyt address, American Academy of Ophthalmology, October 18, 2016, Chicago, IL. The authors report no conflicts of interest. Address correspondence to Larry P. Frohman, MD, 90 Bergen Street, Newark, NJ 07103; E-mail: [e-mail] 206 S everal factors have converged to make neuroophthalmology an economically less viable practice, including underevaluation of nonprocedural encounters by Centers for Medicare & Medicaid Services (CMS) and other insurers, academic medical center overhead models where "one size fits all," and not reflecting lower resource utilization by neuro-ophthalmologists, and academic practices looking at individual profit and loss balance sheets without recognizing benefits of downstream revenue and freeing up time for larger income producers to be more financially productive. It has been reported that these economic issues are creating a human resource crisis in neuro-ophthalmology (1,2). In 2016, approximately 1 of 6 medical schools had been recruiting a neuroophthalmologist, often searching for extended periods. The demise of the ability of medical specialists to bill for consultative services using the "Consultation" CPT codes (9924x and 9925x) is an example of collateral damage to revenue for the practice of nonprocedural specialists. Consult code billing was eliminated because CMS believed that these codes were being used inappropriately by many physicians and CMS claimed that this action would have a very small financial impact. Yet this has disproportionately hurt specialities such as neuro-ophthalmology and other so-called "cognitive specialities" (Table 1). CMS thought that the economic impact of the loss of a consult code would be limited to the difference in payments between a consult code and the corresponding new patient code (i.e., 99245 vs 99205). However, depending on the way various members of a practice are structured Frohman: J Neuro-Ophthalmol 2017; 37: 206-209 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Hoyt Lecture TABLE 1. Cognitive specialty coalition member organizations American Academy of Neurology American Academy of Allergy, Asthma & Immunology American Association of Clinical Endocrinologists American College of Rheumatology American Psychiatric Association Coalition of State Rheumatology Organizations Infectious Diseases Society of America North American Neuro-Ophthalmology Society The Endocrine Society in the Medicare program, when someone within the practice refers a new patient, it may not be considered a new patient for the practice, limiting the consulting physician to billing a follow-up visit code, such as 99215. When this occurs, there is loss of perceived productivity (relative value units, or RVUs) and reimbursement dollars collected. What had been a 99245 now has to be coded as a 99215 with a 45% reduction in payment and a 42% reduction in RVUs. Thus, the specialist may potentially be seen as being less productive, when any change in "productivity" is nothing more than a consequence of coding regulations. As an example, in 2009, if a specialist solely did Level 5 consults on patients referred from within their own faculty practice on Medicare patients, and did 1,500 of these per year using code 99245, he/she would be credited with 8,055 RVUs. But in 2010, performing the same clinical case load, and only being able to use code 99215, the RVU total would drop to 4,695. Another downward pressure on neuro-ophthalmic income are the reports being sent out by insurance carriers indicating that neuro-ophthalmologists are coding at too high a level when compared to their peer group. The problem is that the carriers do not know who the peer group is, and all they can do is compare the neuro-ophthalmologist to the practitioners of the parent specialty, either neurology or ophthalmology. The North American Neuro-Ophthalmology Society (NANOS), working with a consulting firm (FTI Consulting, Washington, DC), analyzed every claim submitted to the CMS by a NANOS neuro-opthalmologist in 2014, and those by all ophthalmologists, neurologists, family medicine physicians, and internists. The results showed that for initial visits, neurologists coded at Level 4 or 5 about 90% of the time, whereas ophthalmologists did so 79% of the time. Neurology trained NANOS members coded an initial visit at Level 4 or 5 about 92% of the time, whereas ophthalmic trained NANOS members were at 84%. This was not very different from our "parent" specialties. Internal medicine's corresponding number was 67% and that of family medicine was 33%. For follow-up visits, neurologists coded Level 4 or 5 about 66% of the time and ophthalmologists did so 34% of the time. NANOS neurology trained members coded at this Frohman: J Neuro-Ophthalmol 2017; 37: 206-209 level 71% of the time, and the ophthalmology trained members did so 44% of the time, In contrast, internists were at 50% and family medicine at 48%. So for both initial and follow-up visits, neuro-ophthalmologists were not coding at significant different level than their parent specialty's practitioners. These coding profiles should be used by insurance carriers as an appropriate peer database. Another issue that has had a negative impact on the income of the neuro-ophthalmologist and other cognitive specialists is that CMS largely sees the world in 2 "buckets," primary care and proceduralist/surgeon. The undervaluation of financial reward for primary care was believed to be a causative factor for the perceived shortage of primary care physicians (PCPs). CMS redirected reimbursement dollars for clinical practice that were traditionally given to surgeons and proceduralists and gave them to PCPs. This tactic increased income for family medicine physicians and internists, who experienced 13% and 14% gains in salary, respectively, in 2016 compared to 2015 (3). Not only was this strategy not implemented for the cognitive specialists (where there are similar shortages of physicians) but also funds were taken from their fee schedules to help augment primary care reimbursement. The 2016 Medscape Physician Compensation Report did not identify neuroophthalmology as a distinct specialty for analysis but did identify all 6 of its brethren in cognitive specialties (Allergy, Endocrinology, Infectious Disease, Neurology, Psychiatry, and Rheumatology) as the 6 lowest paid medical specialties (4). Complicating the reimbursement issue is that approximately 75% of neuro-ophthalmologists are faculty members in academic medical centers. Even sympathetic department chairs are finding it hard to allocate departmental dollars to support their neuro-ophthalmologists. As the national trend is for control of practices to move from the department level to a centralized medical center practice plan, administrators reviewing productivity and compensation are further removed from the realities of neuro-ophthalmic practice and failed to recognize the vagaries of unusual specialties. So, we are erroneously labeled by the medical center practice analysts as less productive than our peers in procedural specialties. And similarly, if in the decentralized management model, a chair recognized an inequity on the expense side and alleviated it to support the neuroophthalmologist, the centralized practice plan rarely sees the value of doing so. One possible solution to increase financial compensation for neuro-ophthalmologists would be to promote dual discipline training (1). Recently, I have come to believe this would be a mistake and further threaten our discipline's supply of qualified clinicians. In the current environment, one can almost think of neuro-ophthalmology as a "nasty little habit" where one also must practice some other more highly compensated subspecialty to be able to afford being a neuro-ophthalmologist. Upon further reflection, this 207 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Hoyt Lecture approach might be good for the individual practitioner, but on a more global level, it is not ideal for delivering efficient and appropriate care. In the United States, there are about 250 fulltime clinical equivalents (FTE) of neuro-ophthalmology care providers (0.8 per million). You can achieve this with 250 physicians practicing only neuro-ophthalmology or with 500 who do it half-time. But if one trained in an additional subspecialty, it seems inevitable that clinicians would gradually spend more time in the more lucrative subspecialty and less in neuro-ophthalmology. If all neuro-ophthalmologists were to decrease their effort in clinical neuro-ophthalmology to 20% FTE, to fill those 250 clinical FTE, you now need 1,250 neuro-ophthalmologists. If you wanted 1,250 individuals each 20% FTE in neuro-ophthalmology, where would you find 1,250 interested people? If you could, do we have the manpower to train that many? And by what economic model could you support those spending more time engaged in neuroophthalmology education as fellowship preceptors? This is the potential death spiral of neuro-ophthalmology. To quote Dante, "Abandon all hope, ye who enter here" (5) (Fig. 1). This transformation to a neuro-ophthalmic community, practicing the discipline but for a smaller percentage of their time, will decrease access for patients with complex visual problems, lead to delay in diagnosis and treatment, with increased costs for inappropriate or unnecessary testing. Furthermore, as many neuro-ophthalmologists worldwide are trained in the United States, if there are fewer preceptors, then shortages of clinical neuro-ophthalmologists subsequently will develop in other countries. Our evolving US health care system, with a deficiency in PCPs, seems to plan to more heavily rely on nurse practitioners (NPs) and physician's assistants (PAs) as the future initial caregivers. The new world order also seems to be planning on using "big data" and evidence-based medicine to develop protocols of care for most conditions and most patients. To successfully do this requires that PAs and NPs have protocols for diagnosis and treatment for the conditions they will see. This may work well for most common and simpler medical disorders but likely not for the field of neuro-ophthalmology. Specifically, we see patients with less common problems, where there are unlikely to be accepted diagnostic/therapeutic guidelines to guide a less experienced practitioner. For example, in an ideal world, the clinician who initially evaluates a patient with an acute third nerve palsy should quickly refer the patient to a neuroophthalmologist, who can determine whether the patient requires urgent neuroimaging. It has been shown that prompt patient assessment by a subspecialist improves outcomes and saves resource utilization (6). Will a PA or NP know to do this or will they first refer to a general ophthalmologist or neurologist for evaluation of diplopia, delaying urgent management decisions? How is this idea of initial evaluation by someone with less training than a PCP going to jibe with increasing access by members of the public to their own medical conditions and their desire to see who they perceive is the right practitioner to evaluate and treat them? (7). Will patients, experiencing what they believe to be their first symptom of multiple sclerosis, accept seeing a NP or PA in lieu of a neurologist? Will not they get to the point where they may be asking for not just the neurologist or even the multiple sclerosis specialist, but rather for the neuromyelitis optica specialist? Our twin goals should be to alleviate an anticipated shortage of neuro-ophthalmologists, and to identify and expediently evaluate these patients who urgently need neuro-ophthalmic care, and improve their clinical outcomes. An obvious first step is to treat cognitive specialties as well as PCPs are treated in the reimbursement marketplace. In addition, there should no longer be further reductions in specialist reimbursement to support PCPs, a "budget neutral" arrangement by CMS for Evaluation and Management services. We need to create reimbursement/ productivity models that more accurately capture the contributions of cognitive specialists to patient care and outcomes. It seems that an RVU-based system inherently undervalues our efforts. An hourly compensation model might work if the time accrued included reviewing imaging studies, writing consults, and taking phone consultations from a wide range of physician. But this is complex to administer and monitor. How about paying neuro- FIG. 1. The spiral that potentially leads to a dwindling supply of neuro-ophthalmologists to practice and teach.*Adapted from (5). 208 Frohman: J Neuro-Ophthalmol 2017; 37: 206-209 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Hoyt Lecture ophthalmologists a set salary? In the current system, neuroophthalmologists have demonstrated that they work hard without large financial rewards. It could be argued that it is unlikely that a fixed salary would undermine productivity. Compensation must be fair and reflective of market supply and demand, allowing recruitment and retention of neuroophthalmic practitioners. This could be done by CMS on a national level or, for regional manpower disparities, states could develop similar programs. What can we do to identify and refer for neuroophthalmic care those patients where timely assessment is crucial to achieve favorable clinical outcomes with appropriate resource utilization? One solution might be creation of a new physician specialty, the referralist. Referralists would be senior, experienced clinicians who know their community and its providers. Some would be PCPs, and some would be specialists. They would function as a panel and direct patients needing out-of-the-ordinary care to the appropriate specialties or subspecialties. They might use decision aids, such as artificial intelligence, to help match the symptom complex to a particular physician's experience and expertise. These highly specialized physicians might be called Disease Specific Specialists (DSS) (Table 2). DSS will know their regional referralists and develop a relationship such that when a referralist needs a DSS to see a patient quickly, the DSS knows it is a reliable and reasonable request. This is not a health system telling a patient who they cannot see; it is a system telling them who they should see and making it happen faster so that diagnostic and therapeutic windows are not missed. In this model, the nature of the roles of the referralist and the DSS are such that no preauthorization is required for either the referral or for any testing that the DSS deems necessary. A final point regarding the evolving health care delivery system is that the core missions of medical schools/ academic medical centers are to train new physicians and to create new medical knowledge. Many medical schools are adapting to the new payment strategies by attempting to become part of a large integrated health care delivery system. The effort and resources for an academic medical center to evolve into such a provider of all services will inevitably dilute and defocus attention and resources away from the core missions of education, research, and translational care. We can just hope that this is not an irreversible path. If we do not take action, this poorly thought-out evolution of health care could leave future generations facing a shortage of DSS and, specifically, neuro-ophthalmologists. TABLE 2. Delineation of panel of certified specialists for each diagnosis REFERENCES PCP Does Not Need Referralist Lupus - Rheumatologist Duodenal ulcer - Gastroenterologist Macular degeneration - Retina specialist Gradual visual loss - Comprehensive ophthalmologist PCP Needs Referralist Rheumatologist interested in Cogan syndrome Gastroenterologist experienced in Whipple disease Retina specialist interested in retinal vasculitis Acute visual loss with pain on eye movement - neuroophthalmologist PCP, primary care physician. Frohman: J Neuro-Ophthalmol 2017; 37: 206-209 ACKNOWLEDGMENTS The author would like to thank Preston Calvert, MD, for his review and suggestions with this manuscript. 1. Frohman LP. How can we assure that neuro-ophthalmology will survice? Ophthalmology. 2005;112:741-750. 2. Frohman LP. The human resource crisis in neuro-ophthalmology. J Neuroophthalmol. 2008;28:231-234. 3. Merritt-Hawkins 2016 Review of Physician and Advanced Practitioner Recruiting Incentives. 37. Available at: https:// www.merritthawkins.com/uploadedFiles/MerrittHawkins/ Surveys/MH_Recruiting_Incentives_2016.pdf. Accessed September 16, 2016. 4. Medcape physician compensation report 2016. Available at: http://www.medscape.com/features/slideshow/ compensation/2016/public/overview#page=2. Accessed September 16, 2016. 5. Alighieri D. The Divine Comedy: Inferno. New York, NY: Simon & Schuster; 2005. 6. Dillon ED, Sergott RC, Savino PJ, Bosley TM. Diagnostic management by gatekeepers is not cost effective for neuroophthalmology. Ophthalmology. 1994;101:1627-1630. 7. Topol E. The Patient Will See You Now. New York, NY: Basic Books, 2015. 209 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.