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Reflections On ASRS and the Business of Retina

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The American Society of Retina Specialists 39th annual meeting was held in San Antonio, TX at the JW Marriot Hill Country Resort & Spa. Fortunately, San Antonio is my hometown, so the commute was easy. The meeting was the perfect combination of education, recreation, and socialization. Given the current COVID-19-related precautions, the ASRS took lengthy steps to minimize the risk of virus transmission. It made me feel safe to be there and encouraged me to attend the lectures in person, masked of course.

I was particularly interested in the session focused on the socioeconomics and practice management held on Sunday morning. Dr. Shriji Patel spoke about trends in Medicare reimbursement for vitreoretinal surgeries. Even though we are becoming more efficient surgeons, the adjusted reimbursement for our efforts continues to be cut. Over a 10-year span, the relative reimbursement for retinal detachment repair has declined 20%. Further, there have been no associated adjustments for inflation which continues to devalue the surgical efforts we make to save patients’ sight. Working harder for less money . . . it seems counterintuitive, but Medicare is a “zero-sum” system. We need to be more proactive about pointing out the value that people gain from our surgeries and the effort it takes to perform them.

Dr. John Thompson followed up with a discussion on the controversial use of the -25 modifier to justify payment for an office visit on the same day as an intravitreal injection. There has been a series of conversations as to when you should use this modifier and how its overuse might trigger a Medicare audit. He provided examples of how an audit can lead to extrapolation of error and result in an unexpected 6-figure fine. There is an appropriate time and situation to use the -25 modifier ... you are still examining your patients, but the exam must be for a separately identifiable reason, other than simply to guide treatment for the injection. 

Dr. Paul Hahn then proceeded to talk about the impact of the pandemic on the practice of retina. In an encouraging presentation of the data from the annual Preferences and Trends survey, retina specialists across the nation stepped up and continued to provide care despite the risks. It appears that although there were major initial setbacks in clinic volume, practices have rebounded and are providing retina care at pre-pandemic levels. I am encouraged by the efforts of my colleagues to be resilient in the face of something as destabilizing as a pandemic.

An expert panel, including Drs. Ankoor Shah, Paul Hahn, John Thompson, Geoffrey Emerson, and Camile Palma, weighed in on other issues that have permeated discussions since the conference started. Of late, we are seeing practice consolidation and acquisition by private equity groups. It is no surprise that businesses with capital are interested in a revenue generating model. There are many benefits and drawbacks. On the one hand, private equity seeks to increase a practice’s profitability by increasing margins, increasing billing and collections, and decreasing expenses. Some private equity firms can help physicians enroll patients in studies and increase overall efficiency. On the other hand, the sale to private equity comes with surrender of control. New expenses arise to fund these ventures and the administrative machines that come with them. The basis of these acquisitions is that profitability will continue to increase in the coming years and that a sale to a subsequent equity firm will allow for a greater profit. I am wary. Dr. John Thompson pointed out that this is a “house of cards” that does not acknowledge several threats. For those interested in an early exit strategy, the acquisition by private equity makes a lot of sense. Gain a huge payout at the beginning and use that toward retirement, but it devalues people at the midpoint of their career. The newer partners and non-partner associates end up becoming employees in a larger system that sacrifices autonomy in hopes of larger profits. This is a very real alternative to the current practice model and is very enticing. We are seeing it here in the San Antonio area with many of our smaller practices being bought out, but I am concerned by the autonomy sacrificed and the implications it has for our staff and our patients.

Another interesting topic brought up during this panel was the market entry of biosimilars and FDA approved bevacizumab. Retinal physicians will possibly need to contend with having limited access to compounded bevacizumab. This will likely change the reimbursement structure we are currently used to. Interestingly, this dovetails with the topic mentioned above: if private equity companies are basing purchasing valuations on potential profits, and the amounts of those profits significantly diminish (either due to decreasing Medicare reimbursement as mentioned by Dr. Patel or decreased payments for medications) then the foundation of these PE purchases might not be as profitable.

I think the overarching “take home point” for this year’s conference is that change is coming. Retina is a fantastic practice with huge tailwinds. You should ride these and let them carry you, but you should be ready for change. Judy Kim, MD closed the conference on Tuesday morning by stating that, “we are on the cusp of a revolution,” in retina. I could not agree more with the Program Chair’s sentiments as we look to the future. Dr. Kim did a fantastic job with this year’s meeting and kept it engaging, entertaining, and beneficial to those who attended. I look forward to future, in-person meetings, and further discussions about the business and practice of retina.

Dr. Friedman reports no conflicts of interest.

Image by UnitoneVector / Getty

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