The Patient Shared Billing Ruling That Got Things Rolling!

JoelOphthalmologyLeave a Comment

In May of 2005, The Patient Shared Billing ruling passed the US Congress and got things rolling. Patient Shared Billing was quietly enacted and changed the landscape of healthcare.

As I was cleaning out some files today, I came across an interesting piece of history that I had saved.  Below is an article from OSN about the ruling from CMS that gave patients the ability to pay for an uncovered service (Presbyopia correction) and still receive their covered benefit (cataract extraction with IOL implantation).  The legislation also gave physicians the opportunity to receive remuneration for the additional testing and cognitive work associated with offering this service.  In addition, IOL manufacturers could realize profits that sated the appetites of the manufacturers for R&D spending.

2005 CMS Ruling PSB

Our industry owes a tremendous debt of gratitude to Andy Corley and the team from Eyeonics for the work that they did to move this legislation through the system.  I was fortunate enough to be associated with the sales team that launched Crystalens and the Eyeonics team was an exciting group of talented, driven and creative thinking people to be around.  During meetings, Andy talked a lot about success requiring a change to the mindset of physicians whom have been told for a long time by a third party payor that their services were worth less each year.  He was accurate in his assessment about attitude and I think that we still fight that battle of the mind today.

Another common roadblock to success with the Advanced Technology IOLs (ATIOLs) in ophthalmology today relates to the perceived performance of the technology.   When this legislation was approved, many predicted a 30-40% penetration of the market by 2011 and here we are in 2014 sitting at about 18%, depending on whose data you study.  The stated reason for this shortfall by many is that the technology has not performed.

Performance as compared to what?  A mono-focal IOL? For the patient sitting in the chair, right now, with a once-in-a-lifetime chance to restore their youthful vision, what we have today is the best option available to that person.  Will it improve?  Of course.  And that’s the age old dilemma with anything technology related, things will always get better.  Yet why cheat the person sitting there today, they only have one chance?  Author’s note, my mother has two Crystalenses in her eyes from 2007 and she loves them….

Economists talk a lot about trade-offs, and that phrase is apropos with ATIOLs.  There are some really good things and some things that can be a challenge.  The interesting thing about this, to me, is that if the patient is given the right information to make an informed, thoughtful and consultative decision they will choose what is right for them, achieve their desired visual outcome and happily pay extra for that service.  Sadly, many are never offered the choice or are offered it in such a manner that it mostly talks them out of it.

I believe that in May of 2005 the greatest opportunity for patients, industry and surgeons became available to those who are willing to think and act differently.  I am amazed at how few really do and humbled by those who make it an art.

The rest of this decade is going to be a really exciting time for all of us in ophthalmology!

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