Reimbursement policy creates a conflict of interest for patients and physicians

In 2009, the Centers for Medicare & Medicaid Services (CMS) modified the reimbursement policy for blepharoplasty and blepharoptosis repair, the two most commonly performed eyelid operations, to prohibit separate payment for blepharoplasty and blepharoptosis repair if both are performed on an ipsilateral upper eyelid within a 90-day period.

The National Correct Coding Initiative (NCCI) mandate was intended to prevent "bundling" — improper payment for procedures that are considered to be components of a more comprehensive process.

Elizabeth A. Bradley, M.D., with the Department of Ophthalmology at Mayo Clinic's campus in Rochester, Minnesota, speculated whether such changes in physician reimbursement, however, might also alter patient and physician behaviors and, if so, mitigate health care savings.

Many patients who present with visually significant eyelid droop require repair of both dermatochalasis and ptosis. Dr. Bradley and her research team questioned whether the financial disincentive of bundling might encourage physicians to perform two separate surgical procedures outside the 90-day period, or instead deem the blepharoplasty component of combined surgery to be cosmetic, increasing patients' out-of-pocket costs.

"Bundling of payments is becoming a common form of reimbursement in an effort to curtail the costs of health care," says Dr. Bradley. "We weren't aware of any research that examined patient attitudes and physician behaviors after the introduction of a payment bundle mandated by the NCCI." Results of this study were published in Ophthalmology in July 2014.

Patient awareness and preferences

The team administered a five-question survey to 50 patients who presented to the Department of Ophthalmology for evaluation of ptosis and dermatochalasis in 2010 and 2011. English-literate adults with visually significant ptosis and dermatochalasis who were candidates for unilateral or bilateral blepharoplasty and ptosis repair were asked to participate after examination.

Questions elicited patient awareness of the new policy, preferences regarding payment for the surgeries, and opinions on the effectiveness and fairness of the new policy in reducing health care costs. Survey participants' responses indicate:

  • 90 percent were unaware of the change in reimbursement for blepharoplasty and blepharoptosis operations
  • 91 percent would be opposed to having to pay out of pocket for blepharoplasty or having to wait at least three months after ptosis repair to have a blepharoplasty
  • 62 percent said they would rather have the two surgeries performed separately than pay out of pocket

Physician practice habits

A five-question Web-based survey was distributed to 510 unique physician email addresses obtained from the American Society of Ophthalmic Plastic and Reconstructive Surgery in 2010.

The 198 physicians who participated in the survey represented office-based practices, freestanding ambulatory surgical centers, academia, nonprofit community hospitals and for-profit community hospitals. They reported receiving productivity-based payment, a combination of salaried and productivity-based payment, salaries only, and other self-employment, and retirement.

Their responses indicated practice change:

  • Before the CMS reimbursement policy change, 77 percent of oculoplastic surgeons performed blepharoplasty and blepharoptosis repair in the same sitting, whereas 37 percent did so after the policy change.
  • Compared with before the policy change, more surgeons performed the two procedures at least three months apart (4 percent before vs. 29 percent after).
  • Compared with before the policy change, surgeons billed patients for a cosmetic blepharoplasty more often (5 percent before vs. 12 percent after).

"The data support the speculation that changes in physician reimbursement may alter physician behaviors," says Dr. Bradley. "These surgeons made a significant change in the delivery of ptosis and blepharoplasty surgical services after the bundling of payment for these two procedures by the CMS. This change is not desirable to most of the patients surveyed."

In 2013, the CMS implemented the Bundled Payments for Care Improvement initiative, enrolling select organizations that receive bundled payments for acute and post-acute care episodes.

"Our study also indicates that such changes may ultimately mitigate the health care savings from bundling," says Dr. Bradley. "We estimate the CMS saves approximately $287 with the new bundling reimbursement for each case performed. If a physician performs a blepharoplasty and blepharoptosis repair 90 days apart, however, the cost increase to the CMS is approximately $1,500. Unbundling a single case negates the cost savings of approximately five bundled cases."

For more information

Bajric J, et al. Patient and physician perceptions of Medicare reimbursement policy for blepharoplasty and blepharoptosis surgery. Ophthalmology. 2014;121:1475.