New world order of glaucoma presenting strong challenges

Changes in both technology and the healthcare policy are presenting new challenges for glaucoma specialists. As the demand for eye care surges, ophthalmologists are struggling to keep up–despite the availability of better tools for diagnosis and treatment.

“There is a real crisis ahead of us,” said Andrew Iwach, MD, who outlined the situation in his presentation, “Glaucoma: Managing the Odds,” during the Glaucoma Symposium at the 2017 Glaucoma 360 meeting.

Trends in diagnosis and treatment

Medicare data shows that clinicians are billing almost as often for optical coherence tomography as for visual field tests in glaucoma. “This is the pattern,” Dr. Iwach said. “We’re still doing photography a little bit and pachymetry.”

Citing data from Novartis Alcon, Dr. Iwach noted a dip in prostaglandin analogs (PGAs) and an uptick in beta blockers to control intraocular pressure. “Is cost a factor?” he asked. “I don’t know the reason.”

On the other hand, a survey by Market Scope found that about 65% of prescribers were using PGAs and only 11% beta blockers as first-line medication treatments for glaucoma. “As to what agents are being added second, the fixed combinations come in quite high,” Dr. Iwach pointed out.

Allergies to the medication preservative benzalkonium chloride (BAK) remain a concern. Alternatives include stabilized oxychloro complex (Purite) found in Alphagan-P (Allergan) and ionic-buffered preservatives (sofZia) found in Travatan Z (Alcon Laboratories), according to the Glaucoma Research Foundation. Timolol, a dorzolamide/timolol fixed combination, and tafluprost, a PGA, can be obtained in preservative-free forms, the foundation said.

It is worth noting that the volume of medication in a preservative-free bottle maybe different from the standard formula, Dr. Iwach said.

MIGS soaring

MIGS soaring

When it comes to glaucoma surgery, “the big change is the significant drop off in the number of trabeculectomies that are being coded and I assume being done since 1995-1996 when PGAs were introduced.”

Microinvasive glaucoma surgery (MIGS) is soaring in popularity, Dr. Iwach noted. As of 2016, the number of iStents placed exceeded the number of trabeculectomies, he said. Market Scope projects a continued rise for MIGS.

The new devices do still face some hurdles. “For example, with the Cypass (MicroStent, Alcon Laboratories) at our surgical center we’re having trouble getting reimbursement figured out,” Dr. Iwach said. “If the hospital doesn’t get paid, it’s hard to do some of these new procedures.”

Demographic stressors

Stress on providers is rising. “We’re busy, we’re doing more cases, and down the road the demands for eye care are going up,” Dr. Iwach said.

By 2025, the demand will have increased by 25% while the number of ophthalmologists will have dropped by 8%, he said, again citing Novartis Alcon data. “These patients are coming so we need to make sure we take a leadership role to make sure we guide them to the right place for the care at the right time,” Dr. Iwach added.

The deficit is projected to occur even though more women are coming into the profession. While about 22.5% of ophthalmologists are now women, 44% of those in training are women, Dr. Iwach said, while already 42% of optometrists are women.

Perhaps because of the intense work load, many ophthalmologists are reporting musculoskeletal injuries. Over the course of 16 or more years, about 30% of ophthalmologists have neck injuries, he said. Others are experienced repetitive motion injuries to their hands and back pain.

Reimbursement complexities

Reimbursement complexities

Electronic health records (EHR) are another “pain in the neck,” Dr. Iwach opined. “My understanding is roughly 50% of practices don’t use EHR.”

Not only is there an upfront cost, “you have to maintain it,” he said. “Then, you have to calculate the impact on your ability to see patients and to talk to them and to develop relationships.

“Especially in glaucoma even if you do everything right, some things go wrong,” Dr. Iwach added. “That lack of relationship can end up biting you down the road.”

The American Academy of Ophthalmology is working on tips to ease the burden. “For a glaucoma specialist’s office which does not have EHR but wants to avoid a penalty, there will be a little bit of a recipe because you have all these different options,” said Dr. Iwach.

Likewise, negotiating the Centers for Medicare and Medicaid Service’s Merit-Based Incentive Payment System (MIPS) can be complicated, Dr. Iwach said. The system offers physicians incentives to show evidence that they are providing high-quality, efficient care.

“The way I understand it is you can do a little bit and try to avoid the penalty,” Dr. Iwach explained. “You can do a little bit more to try to get the bonus. But the bonus is influenced by the amount of people who don’t do the minimum work. The more people who do the minimum, the smaller the pie for the potential bonus. So you really have to look at what are the economics that really make sense.”

Dealing with private insurers can be just as difficult, he added. Dr. Iwach cited a recent letter from Aetna demanding that his practice pay a $3,000 refund based on an error that the insurer made a year ago.

Ophthalmology goes online

Ophthalmology goes online

Meanwhile, physicians must grapple with new technologies for delivering care, Dr. Iwach said. Younger people are willing to visit their doctor by video, and many are seeking eye care from primary care physicians in this way. The company, Doctor on Demand, offers medical consultations, including for some eye symptoms by video within minutes.

“In the Bay Area, there are companies putting serious money into this and we need to know how to respond,” Dr. Iwach said.

Ophthalmologists may need to answer questions about data on their practices that is online as well, he said. He cited the example of ProPublica, a public interest news site offering a data base that links individual practitioners with amounts of money purportedly received by industry. In Dr. Iwach’s case, information on the site was incorrect.

Information collected on practitioners through the Physician Quality Reporting System (PQRS) is also public. “I started scanning it and it just didn’t make sense,” Dr. Iwach said. “So that’s the upside or downside of participating in all these programs.”

One product cures all?

Ophthalmologists also have to answer questions about products advertised on the internet, Dr. Iwach said. A website advertising one product claims they can help with glaucoma, cataract, corneal disorders, eyestrain, dry eye, retinal diseases, and other disorders, but disclaimers make it look suspicious. “I don’t think it’s ready for prime time, but this is what’s out there,” he said.

Internet misinformation got Dr. Iwach thinking about bizarre aspects of ICD 10 codes. One code covers being bitten by a parrot, he noted. Another covers being sucked into a jet engine – for a second time.

“These are not made up,” Dr. Iwach said. “It’s extraordinarily frustrating for the clinicians. We’re here to help patients. We understand the issues of cost, but we are not the main cost factor in this whole picture. If you feel frustrated, you’re not alone.”