Speakers Highlight Opportunity Cost of Vitreoretinal Surgery and Lost Reimbursement During the Pandemic

A recent change to CMS’ reimbursement rate that resulted in an adjustment to clinical reimbursement but not surgery was effectively a decrease in surgical compensation, explained Ella Leung, MD, of Georgia Retina, during a session at the American Society of Retina Specialists 40th Annual Scientific Meeting. Leung presented research comparing the Medicare physician reimbursement for common vitreoretinal surgeries with equivalent office-based patient care to identify the opportunity cost of these surgeries.

Leung and her colleagues performed a theoretical model comparing the reimbursements for the 10 most common vitreoretinal surgeries with the equivalent office-based work relative value units (wRVUs) that could have been generated during the same time period. During her presentation, she presented the reference case: a surgeon seeing 50 patients per 8-hour clinic day, who instead performed a vitreoretinal surgery and postoperative care within the 90-day global period.

The clinical wRVUs during 90 minutes of surgery had a weighted median (IQR) of 2.7 wRVU (2.44-3.00) per clinical encounter. The clinical wRVU for each postoperative encounter was 1.3 (0.92-1.42). Looking at the 10 most common single-code vitreoretinal surgeries, Leung and her colleagues found CMS’ surgical reimbursement has a weighted average of 15.6 wRVU for surgery—in the reference case the surgeon could have made 46 wRVUs from office-based care in the same global period, which is a 65.8% opportunity cost.

For each of the 10 Current Procedural Terminology codes for surgery, CMS reimbursements were less than what could have been made in the clinic at the same time. Evaluating the threshold times for surgery to equal clinical reimbursement, the reference case had a weighted average surgical time of –0.9 minutes, which meant surgery never equaled clinic time.

“So, these numbers are hard to achieve, if at all possible,” Leung said.

During the question-and-answer period, one member of the audience presented a flip side to the work presented: CMS view the findings as physicians being overpaid for office visits.

In the presentation following, Shriji Patel, MD, MBA, of Vanderbilt Eye Institute, presented findings on the economic impact due to reduced retina procedures during the COVID-19 pandemic based on an analysis of 2020 Medicare data.

“It’s undeniable that the COVID-19 pandemic significantly impacted random procedure volume and reimbursement during its peak in 2020,” he said. Although all fields of medicine were impacted, and the American Medical Association estimated there was a $13.9 billion reduction of reimbursement across fields with ophthalmology affected more than most with a 19% decrease in reimbursement.

Patel and his colleagues studied CMS data on 12 commonly performed procedures and were able to see that despite a steady and predictable increase from 2017 to 2019, there was a steep decline in 2020. The average decrease in retina procedure volume was 16% (range, –5.1% to –25.4%) compared with 2019. While some procedures were not affected much because these were urgent indications that patients required care, nonurgent indications dragged down the average, he explained.

“Certain codes…they hardly went down at all because of the urgency with which our patients required those procedures,” Patel explained.

Similarly, there had been a steady incline in reimbursement from 2017 to 2019, which fell sharply in the early months of 2020. According to Patel, there was a $42 million reduction in total reimbursement to retina specialists in 2020. On average, there was $13,514 less in CMS reimbursement per provider during early 2020.