Funding for Ophthalmology Training

Of the federal programs that support Accreditation Council of Graduate Medical Education (ACGME)-sponsored residencies, the Center for Medicare and Medicaid Services of the Health and Human Services (CMS/HHS) contributes the most. Medicare underwrote $9.5 billion for the training of 100 000 residents in 2008: $3 billion in direct graduate medical education payments to partially support resident salaries and $6.5 billion for indirect medical education, a calculated value based on the additional costs of patient care associated with training. Based on the San Francisco Ophthalmology Residency Match for years 2007 to 2009, approximately 1363 residents filled positions at 115 programs. Assuming ophthalmology represents 1.4% of all residents, the cost for their training is approximately $131 million, based on cost of the Medicare budget. This does not include funding supported by the Department of Defense or the Department of Veterans Affairs.

The Balanced Budget Act of 1997 placed a cap on adding any new specialty residency positions and fixed the number of trainees at the 1996 level. Institutions that added new ophthalmology residents since then have done so at their own expense. Despite the cessation of new funding for specialty training, a recent movement has supported the growth of primary care trainees. The Resident Physician Shortage Reduction Act of 2009, which would have supported the training of 15 000 new residents in primary and specialty care programs, was not adopted. It would have added $12 billion to $15 billion to the Medicare program. Of the $787 billion stimulus package, $500 million was earmarked for training programs in health professions, of which the National Health Service Corps (which recruits primary care providers) received $300 million.

With the increasing incidence of age-related eye conditions in the US, such as cataract, macular degeneration, diabetic retinopathy, and glaucoma, lawmakers do not seem to understand the need for more ophthalmologists. Unless funding for expanded residency positions is approved, it seems unlikely that the current work force will be sufficient to meet the future needs. It is also ironic that providing visual-related health is not regarded as “primary” health care. Given the quality of life related to the maintenance of visual function and the economic burden of visual morbidity associated with systemic diseases, such as diabetic retinopathy, this position is unfounded.

Patient Choice for Eye Care

In 2008, an estimated 46.3 million US inhabitants were uninsured and 25 million were underinsured. The Patient Protection and Affordable Care Act (PPACA) (Pub L No.111-148) will expand health insurance coverage to approximately 34 million people by 2019; however, it will reduce the direct payments to hospitals for the care of uninsured and their Medicaid disproportionate share hospital (DSH) funding will decrease by $20 billion. Importantly, the PPACA will not provide for the care of undocumented immigrants. The PPACA will not alleviate the burden on safety net hospitals that currently provide the bulk of care for these patients. It is estimated that 23 million individuals will still remain uninsured even after the implementation of the PPACA. Of the 72 members of the National Association of Public Hospitals and Health Systems, 45 safety net hospitals receive DSH payments, including several public hospitals that are associated with large ophthalmology training programs, such as Grady Memorial Hospital, Ben Taub General Hospital, Los Angeles County Hospital, and Jackson Memorial Hospital. In fiscal year 2009, Miami’s Jackson Memorial Hospital incurred $619 million for all charity service costs, of which $268.2 million were unfunded, largely for the care of undocumented immigrants. In fiscal year 2010, the Anne Bates Leach Eye Hospital provided $22.9 million of unreimbursed eye care to Jackson patients through more than 29 000 encounters (personal communication, Michael Gittelman, September 1, 2010).

The PPACA mandates eligible individuals to enroll for health insurance and creates penalties for those who do not purchase insurance. If the penalties for not purchasing insurance are less expensive than the cost of buying coverage, then currently uninsured patients may elect to remain without health insurance. The largest group that will receive health care coverage are an estimated 16 to 20 million Medicaid recipients with incomes up to 133% of the federal poverty level. Where these newly covered Medicaid patients decide to receive eye care could affect the financial support of safety net and teaching hospitals for funding resident training. If patients elect to go elsewhere, then a potential new revenue stream for currently uncompensated care would be diverted to outside providers. If newly funded patients choose to receive care at teaching hospitals, then revenues could increase. Entering newly eligible young adult patients into a stable eye care environment could lead to an increased detection and treatment of potentially blinding conditions, such as diabetic retinopathy and primary open-angle glaucoma, especially in high-risk groups. Currently many older patients with cataracts, macular degeneration, or glaucoma are Medicaid or Medicare beneficiaries and children with strabismus and amblyopia are recipients of Medicaid. It seems unlikely that either group would migrate to other providers; however, this remains an unknown.

Patient Choice for Eye Care

In 2008, an estimated 46.3 million US inhabitants were uninsured and 25 million were underinsured. The Patient Protection and Affordable Care Act (PPACA) (Pub L No.111-148) will expand health insurance coverage to approximately 34 million people by 2019; however, it will reduce the direct payments to hospitals for the care of uninsured and their Medicaid disproportionate share hospital (DSH) funding will decrease by $20 billion. Importantly, the PPACA will not provide for the care of undocumented immigrants. The PPACA will not alleviate the burden on safety net hospitals that currently provide the bulk of care for these patients. It is estimated that 23 million individuals will still remain uninsured even after the implementation of the PPACA. Of the 72 members of the National Association of Public Hospitals and Health Systems, 45 safety net hospitals receive DSH payments, including several public hospitals that are associated with large ophthalmology training programs, such as Grady Memorial Hospital, Ben Taub General Hospital, Los Angeles County Hospital, and Jackson Memorial Hospital. In fiscal year 2009, Miami’s Jackson Memorial Hospital incurred $619 million for all charity service costs, of which $268.2 million were unfunded, largely for the care of undocumented immigrants. In fiscal year 2010, the Anne Bates Leach Eye Hospital provided $22.9 million of unreimbursed eye care to Jackson patients through more than 29 000 encounters (personal communication, Michael Gittelman, September 1, 2010).

The PPACA mandates eligible individuals to enroll for health insurance and creates penalties for those who do not purchase insurance. If the penalties for not purchasing insurance are less expensive than the cost of buying coverage, then currently uninsured patients may elect to remain without health insurance. The largest group that will receive health care coverage are an estimated 16 to 20 million Medicaid recipients with incomes up to 133% of the federal poverty level. Where these newly covered Medicaid patients decide to receive eye care could affect the financial support of safety net and teaching hospitals for funding resident training. If patients elect to go elsewhere, then a potential new revenue stream for currently uncompensated care would be diverted to outside providers. If newly funded patients choose to receive care at teaching hospitals, then revenues could increase. Entering newly eligible young adult patients into a stable eye care environment could lead to an increased detection and treatment of potentially blinding conditions, such as diabetic retinopathy and primary open-angle glaucoma, especially in high-risk groups. Currently many older patients with cataracts, macular degeneration, or glaucoma are Medicaid or Medicare beneficiaries and children with strabismus and amblyopia are recipients of Medicaid. It seems unlikely that either group would migrate to other providers; however, this remains an unknown.