Ophthalmic medical practices in the United States are under unprecedented pressure to care for a rapidly growing population of patients, even as Medicare reimbursement levels continue to decline and payers are implementing payment programs based on cost and quality metrics. The Centers for Medicare and Medicaid Services (CMS) has continued to enact significant cuts to payment rates for a range of ophthalmic procedures, from glaucoma surgery to retinal detachment repair and various diagnostic imaging procedures. These are only the latest changes to the economics of care delivery to which ophthalmologists must rapidly adjust. More than ever, the financial viability of the ophthalmology practice depends on its ability to deliver efficient care – integrating cost, quality, outcomes, and patient satisfaction – within an ever-changing landscape of medical innovation, government regulation, payer intervention, and patient expectation.
Several years ago, we formally evaluated the relative efficiency of academic hospital center and small group practices by applying activity-based cost analysis to both settings.1 We found that the small group practice outperformed the academic medical center on nearly all markers of efficiency. In the latter setting, only four service lines – non-laser surgery (e.g., pneumatic retinopexy, pars plana vitrectomy, scleral buckling surgery), laser surgery (e.g., pan-retinal photocoagulation, retinal tear repair), non-optical coherence tomography (OCT) diagnostics (e.g., other forms of multi-modal imaging such as color, red free, autofluorescence, fluorescein angiography [FA], ultrasound), and injections – were profitable, with profit margins ranging from 62% for non-laser surgery to 1% for intravitreal injections. The largest negative profit contributions were generated by office visits and OCT imaging. The continued reduction of reimbursement rates for both diagnostic services and therapeutic injections in the intervening years has made conditions even more challenging for both types of practice and has increased the critical importance of evaluating and improving efficiency. Various models for measuring and comparing practicing efficiency are in development. For example, an efficiency index, calculated as a function of cost, number of patients receiving care, and the quality of care, has been proposed to measure the care delivery process for a given intervention within the ophthalmic practice.2 As such models are expanded to include outcome measures and are validated in larger inter-practice comparisons they may be useful in efforts to improve both the quality and efficiency of care.
Regardless of how efficiency is measured, it is increasingly clear that one key to the challenge of simultaneously improving practice efficiency and quality of care amid relentless financial pressure is the use of advanced technology – diagnostic and treatment systems that provide more useful clinical information, more rapidly, and with greater comfort or convenience for patients. An example along these lines is the positive impact on efficiency and quality of care in cataract and refractive practices produced by the integration of wavefront technology. The impact of this technology for digital refraction and optical path diagnostics was recently described, with the authors noting that the
speed and comprehensiveness of total visual system assessment improved outcomes, patient satisfaction and cost-effectiveness.3 We have seen analogous benefits in our practice from the routine use of ultra-widefield (UWFTM) retinal imaging using the Optos system. This paper will describe how the integration of UWF retinal imaging improved efficiency and quality of care, enhanced patient satisfaction, and allowed more patients to be examined during a fixed time interval in our practice. We show that the resulting increase in patient volume can improve cash flow irrespective of reimbursement rates or how payments for testing are bundled.
Elements of efficiency for diagnostic imaging The unparalleled field of view (sometimes called “pan-retinal” imaging), rapid, patient-friendly image capture, high-resolution, and easy transmission of UWF optomap® (Optos, plc. Dunfermline, Scotland) imaging make it well suited to enhancing the efficiency and quality of ophthalmic care. The Optos system provides the widest field of view of any retinal imaging platform.4 The high-resolution digital image it produces is obtained in a single, non-contact, often non-mydriatic capture lasting about a second; the image is immediately available for evaluation by the clinician and review with the patient on a computer screen or tablet. Cross-registration of different imaging modalities or prior images is instantaneous, supporting comprehensive evaluation of retinal pathology or disease progression. The systems are DICOM compatible and utilize cloud-based transmission and storage to facilitate image sharing with other offices and practices, as well as archiving as part of the medical record.