Socioeconomics of Retinopathy of Prematurity Care in the United States

Transcription

1 Socioeconomics of Retinopathy of Prematurity Care in the United States Rebecca S. Braverman, M.D. Robert W. Enzenauer, M.D., M.P.H. ABSTRACT Background and Purpose: To elucidate the experience of pédiatrie ophthalmologists across the United States who care for infants with retinopathy of prematurity (ROP). Methods: Seven hundred and ten surveys were mailed to U.S. memhersof the American Association of Pédiatrie Ophthalmology and Strabismus, and 283 (40%) of 710 surveys were completed. Surveys were reviewed and statistical analysis was completed by the authors. Results: There was no uniformity of contract compensation or method for determining the value of ROP care. Almost half of the respondents felt they would generate more income if they did not perform ROP screening. Eighty percent of respondents that were happy with their ROP compensation had a contract for those services. One third of respondents had their malpractice insurance provided by the hospital. Retina specialists performed 40% of inpatient ROP screening and 53% of treatment. Most respondents continued to care for infants with ROP once discharged. Conclusions: In the United States, there is no uniform experience regarding compensation for ROP care, or a methodology for determining the value of services and coverage of liability insurance. These findings are consistent with previous studies. Lack of uniform compensation and high liability pose a threat to the future of ROP care. INTRODUCTION Retinopathy of prematurity (ROP) is a potentially sight threatening disease that affects all nations of the world. ROP screening and treatment has been found to be a cost effective endeavor.^ Reimbursement for providing ROP screening services tends to be less than From the Children's Hospital of Colorado, Aurora, Colorado. Requests for reprints should be addressed to: Rebecca S. Braverman, M.D., Children's Hospital Colorado, E. 16th Ave, Box B430, Aurora, CO 80045; rebecca.sandsbraverman@ucdenver.edu what would be generated by providing outpatient clinical care or performing ophthalmic surgery. A pilot study published by the authors queried ophthalmologists who provided inpatient care for premature infants with ROP, and they found that there was no uniform method of determining the value of services provided to hospitals for ROP screening/treatment, in the presence or absence of contracts or malpractice coverage.^ Inpatient ROP care tends to be time consuming, often requiring ophthalmologists to travel to various hospitals away from their regular worksite. Additional costs to the physician are often in Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 63,2013, ISSN X, E-ISSN

2 BRAVERMAN curred for compensating administrative staff members to coordinate outpatient care once the infants are discharged from the hospital. Compliance with follow-up appointments tends to require significant time. Support staff are often required to make the follow-up ROP appointments and contact the families of those who fail to make their scheduled appointment. There is no question that screening and treatment of ROP is an essential service to society, and can significantly decrease morbidity and severe eye complications. Our goal for this survey was to further delineate the ophthalmologist's experience across the United States relative to ROP care. METHODS A questionnaire was developed by the authors and mailed to active U.S. members of AAPOS in A total of 710 questionnaires were mailed, and 283 were returned to the authors. Responses were categorized by geographic location (North/ East, South, Midwest, West) and by tjrpe of practice (academic, private, or a combination of the two). Statistical analysis was completed by the authors. RESULTS Two hundred eighty-three (40%) of 710 questionnaires were returned to the authors. Some questions were left unanswered on questionnaires. The demographics of the respondents were as follows: ninety (32%) North/East; seventyone (25%) South; sixty-six (23%) West; fifty-three (19%) Midwest; and three (1%) were not available. Most respondents were in private practice: 163 (58%); in academic groups: eighty (29%); or a combination: thirty-seven (13%). Two hundred eleven (75%) had been in practice for more than 10 years; forty-seven (17%) in practice for 4-10 years; and twenty-five (9%) less than 4 years. The majority of ophthalmologists, 115 of 227 (51%), performed screenings at one NICU; forty-nine (22%) at two NICUs; thirty-eight (17%) at three NICUs; and twenty-five (11%) at four or more NICUs. Eighty-eight of 224 (39%) spent less than 2 hours a week away from their primary practice to perform ROP screening; seventy-nine (35%) for 2-4 hours; and fifty-seven (25%) for a half a day or more. Most respondents, 113 (50%), performed screening examinations every 3-7 days; seventy-six (33%) every 1-2 weeks; and twenty-six (11%) greater than every 4 weeks; and thirteen (6%) every 3-4 weeks. One hundred sixty-three of 242 (67%) traveled less than 30 minutes to the NICU and their final destination to perform screening exams; sixty (25%) traveled between minutes; and nineteen (8%) traveled greater than 60 minutes. Twenty-two of 226 (10%) were compensated for their travel time. Only 105 of 263 (40%) responses of respondents stated that retina specialists performed ROP screening exams in their area. Treatment of ROP was performed by a retina speciahst 53% (128 of 243) of the time; 32% (78 of 243) by the respondent; and a combination of the two in 15% (37 of 243) of cases. Fifty-two percent (125 of 239) of all respondents did not have a contract to perform ROP services. Most individuals, 54% (62 of 114), with contracts were in private practice; academic 24% (27 of 114); and combination academ^ic/private practices 22% (25 of 114). Twenty percent (39 of 193) used a lawyer to negotiate contracts. Forty-five percent (98 of 219) felt they were adequately compensated for their ROP screening services. Of those who were happy with their compensation, 80% (78 of 98) had a contract with the hospital to provide ROP screening services. Ninety-eight of 207 (47%) felt they would generate more income if they would not perform ROP screening services. Some respondents had American Orthoptic Journal 93

3 SOCIOECONOMICS OF ROP TABLE MONTHLY ROP CONTRACT RATES All Respondents* Midwest South North/East West # Respondents Median Maximum Mean 71** $4,166 $17,083 $4, $6,000 $15,166 $6, $4,172 $16,666 $4, $3,750 $17,083 $4, $3,500 $12,500 $4,190 *There was no statistical significance found between geographic regions and contract income using the unpaired t-test. **Demographic information not available for one subject. more than one source of reimbursement for their services. One hundred ninety-one of 231 (83%) billed insurance companies for their services. One hundred one of 223 (45%) respondents also received compensation directly from the hospital for their services, but did not necessarily have a contract. Respondents had no uniform method to determine the value of their ROP screening services. Several different methods were noted, including: billing insurance companies, hourly rates calculated by the amount of revenue one could generate seeing patients in the office, "fair and reasonable price," portion of lost revenue while out of their primary practice location, "word of mouth," and charging flat fees. Seventy-one respondents from all regions reported their monthly contract rate to perform ROP screening. The mean monthly contract rates were $4,930 for all respondents, $6,477 for the Midwest, $4,946 for the South, $4,551 for the North/ East, and $4,190 for the South. For a summary of mean, median, and maximum monthly contract incomes, see the Table. There was no statistical significance found between the regions using the unpaired t-test. Fifty-six percent (127 of 225) of respondents were responsible for their own malpractice insurance to cover their performance of inpatient ROP screenings, whereas seventy (31%) had their insurance paid for by the hospital, and twentyeight (12%) had a combination of both. Seventy percent (167 of 237) of individuals were responsible for providing inpatient consultation services in addition to ROP screening. Thirty-six percent (81 of 224) were required to provide emergency room on-call services as part of their ROP screening. The vast majority of respondents (233 of 235) continued to care for infants with ROP once they were discharged from the hospital. Coordination of follow-up outpatient ROP appointments was a joint effort between the physician and the NICU for 151 of 236 (64%) of respondents; sixtythree (27%) NICU alone; and twenty-two (9%) by the physician only. Thirty-six percent (83 of 228) spent more than 2 hours per week of administrative time coordinating ROP services, and 64% spent less than 2 hours per week. DISCUSSION This is the largest survey to date conducted to evaluate the socioeconomics of ROP care in the United States. There was an equal distribution of survey respondents among the nation's major geographical regions. The majority of individuals (74%) had been in practice for more than 10 years, and greater than half (58%) were in private practice. Most screened at one NICU and 75% spent 4 hours or less each week away from their primary practice to do so. However, a number of individuals 94 Volume 63, 2013

4 BRAVERMAN noted they did their screenings after hours or on days when they also did surgery. Only 10% reported that they were compensated for their travel time. The majority of the burden of ROP screenings was born by pédiatrie ophthalmologists. Only 40% of respondents reported that retina specialists in their area performed screening services. However, over half (53%) of the respondents reported that treatment of ROP was done by retina specialists. Less than half of individuals (45%) were happy with the compensation they received for providing ROP screening services. The majority of those who were happy with their compensation (80%) had a contract to perform these services. Fiftytwo percent of all individuals did not have a contract to perform ROP screenings and almost half (47%) felt they could generate more income if they did not perform ROP screening services. In addition, there was no uniform method used in order to determine the value of screening services performed. Additional financial liabilities and clinical responsibilities exist for those who perform ROP screenings. Greater than half (56%) of respondents reported they were responsible for providing malpractice insurance to cover their ROP screening services. Seventy percent were responsible for providing inpatient consults, and 36% were required to provide emergency room coverage in addition to ROP services. Ophthalmic consultations performed on the inpatient ward and in the emergency room^ tend to be time consuming and can add significantly to the length of the workday. The majority of ophthalmologists continued to care for infants with ROP after they were discharged from the hospital. Fortunately, most (64%) reported a cooperative effort between the NICU and their practice to coordinate outpatient follow-up appointments. The authors previously published their findings of an online survey of pédiatrie ophthalmologists in the United States who performed inpatient ROP care.^ The survey was limited by the small number of respondents (twelve), but several facts were consistent with this current study. There was no uniform method of determining compensation for inpatient ROP screening services. In addition, there was an equal distribution between individuals who were financially responsible for their own malpractice insurance coverage and providing inpatient and emergency room consultation services. The current study was limited by a survey format that allowed respondents to skip certain questions, which sometimes resulted in a lower response rate. ROP screening and treatment is a costeffective endeavor. However, there are many logistical, financial, and medical/ legal challenges that the ophthalmologist must bear.^'* Challenges include traveling to the NICU, time away from their primary practice, and coordinating continued care of the infants in the NICU and after their discharge. A survey commissioned by the American Academy of Ophthalmology (AAO) completed by a consulting firm, Bruno and Ridgway of Lawrenceville, New Jersey, sent surveys by mail to pediatric and retinal specialists selected by the Academy. Thirty-seven percent (224 of 600) responded to the survey. Only half of the respondents cared for premature infants with ROP at the time of the survey, and a fifth of respondents were planning to stop doing so. The top two reasons cited for discontinuing ROP care were medical liability and complexity of scheduling care. Other reasons for discontinuing ROP care included: poor insurance reimbursement, lack of hospital support for tracking and follow-up care, and developments in the management of ROP patients.^ Reimbursement for services are not uniform across the United States based on the current findings. Many ophthalmologists carry American Orthoptic Journal 95

5 SOCIOECONOMICS OF ROP the financial burden of providing- their own malpractice insurance while generating less income performing ROP services. Financial and legal habihties pose a threat to the future of ROP care. REFERENCES 1. Dunbar JA, Hsu V, Christensen M, et al.: Costutility analysis of screening and laser treatment of retinopathy of prematurity. J AAPOS 2009; 13: Braverman RS, Enzenauer RW: Socioeconomics of retinopathy of prematurity in-hospital care. Arch Ophthalmol 2010; 128: Reynolds JD: Malpractice and the quality of care in retinopathy of prematurity. Trans Am Ophthalmol Soc 2007; 105: Day S, Menke AM, Abbott RL: Retinopathy of prematurity malpractice claims: The Ophthalmic Mutual Insurance Company experience. Arch Ophthalmol 2009; 127: Roach L, Francis BA: ROP crisis near, survey says. Eyenet 2006; cations/eyenet/200607/news.cfm Key words: retinopathy of prematurity (ROP), retinopathy of prematurity screening, retinopathy of prematurity malpractice 96 Volume 63, 2013

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