Florida ophthalmologist and retina specialist Salomon Melgen billed Medicare nearly $21 million in 2012, his most lucrative year in a five-year stretch in which he collected a total of $90 million from the federal government. The retina specialist attracted the attention of the U.S. Department of Justice, which charged him with submitting false claims and doctoring patient charts. In April of 2017, Melgen was convicted on 67 criminal counts of Medicare fraud.
Melgen wasn’t alone. During his heyday, the Office of the Inspector General of the U.S. Department of Health and Human Services identified a pattern of improper billing by many ophthalmologists. Specifically, the OIG found that 1,726 ophthalmologists nationwide “demonstrated at least one of our nine measures of questionable billing” during 2012 alone.
How did they do it? In Melgen’s case, he billed Medicare mostly for injecting a drug into the eyes of 645 patients with the wet form of age-related macular degeneration. He was paid for 37,075 injections that year — more than 100 per day, every day. His average haul per patient was more than $23,000.
The OIG found “over half of Medicare payments associated with questionable billing” by ophthalmologists in 2012 were for this same treatment. As a result, of Medicare’s 25 highest paid physicians that year, 12 were ophthalmologists. A total of 879 ophthalmologists billed Medicare at least $1 million that year.
Ophthalmologists may be doing thousands of medically necessary injections a year, but many appear to be billing for more than they’re doing. Given how lucrative Medicare can be, it is no coincidence that organized ophthalmology is fighting to ensure it is the only profession that can perform this type of procedure, preventing other qualified health care professionals from doing so.
The OIG also found numerous instances of ophthalmologists billing Medicare for an unusually high number of “complex” cataract surgeries, which pay significantly more than standard cataract surgery. “Approximately one-third of the providers demonstrating questionable billing on any of the OIG measures (580 of 1,726) did so for billing an unusually high percentage of their overall claims for cataract surgery as complex cataract surgery,” the OIG reported. Medicare paid those 580 ophthalmologists $39 million for this procedure. Many ophthalmologists may exhibit questionable billing for surgery because of limited competition.
To maintain dominance at the cost of patient access and care, ophthalmology objects every time states consider allowing doctors of optometry to perform additional procedures commensurate with their education and training.
Excessive billing by some ophthalmologists is not only an egregious misuse of taxpayer dollars but also creates a distortion of the free market for medically necessary eye care services. The ophthalmology lobby manipulates its artificially inflated rates to scare legislators away from allowing other doctors to provide this care. What lawmakers need to understand is that doctors of optometry can perform intraocular injections and other services. And a competitive health care ecosystem that supports competition among clinicians would ultimately drive lower costs and improve quality.
Every day in my four-doctor practice in Oklahoma, I collaborate with ophthalmologists on eye health issues affecting our patients. We focus on quality care and serving in our complementary physician roles — optometry providing primary care and ophthalmology offering surgical and tertiary care — the model for patient-centered, team-based health care.
As forward-looking as some ophthalmologists may be, there is an active segment that will not accept any advances over the last 30 years in how doctors of optometry are educated and practice. They distort and mislead, and seek to instill fear with assertions that go beyond “alternative facts.” It is these ophthalmologists, who want the system to serve them, that are the leading example of exactly what’s wrong in health care today.
The doublespeak of ophthalmology about optometry is incredibly contradictory. Optometry and ophthalmology work hand in hand in many medical settings to provide patients with quality eye care. Yet when it comes to scope-of-practice legislation, ophthalmologists continually claim that they are the only qualified profession to provide eye care services. Although Melgen and the OIG findings singling out ophthalmology are outrageous and extreme examples, they are indicators of a profession that’s driven by finances and eliminating competition, not by a concern for patients or taxpayers.
Doctors of optometry learn focused primary eye care skills and more conservative treatments, knowledge ophthalmologists do not acquire in their training. Ophthalmology’s formative training focuses on using tools such as a needle or a knife, so it’s no wonder that some overuse those services while they underrecognize the ability of others to use them just as well, even if not as often.
Doctors of optometry are the gatekeepers of primary eye care and pre- and post-operative surgical care, providing more than two-thirds of those services for Americans. As some ophthalmologists artificially inflate their services, they suppress competing optometrists from expanding their scope of practice to include more medical procedures, such as injections. Yet, ophthalmologists often keep a stranglehold on primary eye care services in their clinics, and they restrain competition for other medically necessary eye care services in state legislatures.
Ultimately, patients suffer most. Wait times are up, quality is down and patients are not getting enough time with their doctors. This is a huge disservice to taxpaying Americans who require eye procedures but cannot obtain them because of burdensome restrictions imposed by ophthalmologists.
In its 2012 report, the OIG recommended, and Medicare officials agreed, to increase monitoring of billing for ophthalmology services and investigate providers with questionable billing for ophthalmology services. These are positive and necessary steps.
Meanwhile, state lawmakers should understand that the massive income realized by some ophthalmologists is unjustified, and that organized ophthalmology is committed first and foremost to preventing or eliminating any competition in the market. Melgen and others take advantage of a monopoly in eye care services that need not continue.
David Cockrell, O.D., practices in Stillwater, Okla., and is a past president of the American Optometric Association and chairman of the AOA Advocacy Group.
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