In March 2010, President Barack Obama signed into law The Patient Protection and Affordable Care Act. With efforts to control expenditures, expand access to care, and increase the quality of care delivered, the act features numerous provisions that will take effect over several years. As these reforms will affect the future of medical services in the United States, it is vital that we, as physicians, are aware of this evolving environment and are prepared to adapt.

WORKFORCE CHALLENGES

The most significant factor affecting retinal services is the dramatic changes in workforce that will be initiated by the Patient Protection and Affordable Care Act. Despite the stability of the retina workforce, there will be 33 million new people who will be covered, 22 million under Medicaid. Additionally, many of these newly insured individuals are minorities with higher incidences of ophthalmic disease. In order to handle this influx of patients, a few changes must be made to the way in which retina is traditionally practiced. We must shift to a more team-based approach, and the use of remote imaging will increase. Further, we will be teaming up with community health centers, which have been very soundly funded under the law.

POPULATION HEALTH

In the past 30 years, we have focused on what is best for the individual patient seated in front of us. Now, however, the law strongly emphasizes the coordination of care among different providers to improve the overall health of the general population, and we will be graded on how we affect the total health of a community. Therefore, we must learn to address the issues of disparities of care. There are huge problems with health literacy, as 63 million people cannot read or understand the directions that are given to them by their doctors or pharmacists. Great mistakes are also made in adverse outcomes in some populations at risk. It is therefore necessary that we learn new ways to communicate and achieve the desired outcomes for patient populations. Copious research is currently being performed on this subject.

PATIENT-CENTEREDNESS

In the past, patients were less interested in the cost of care because they were not paying for it. Currently, however, patients are paying out-of-pocket more frequently, and they want to know what they are buying. In the future, the decision-making will be shared because independent sources are going to educate patients. It may be slightly uncomfortable, as this shift infringes on our doctor- patient relationship; however, this emphasis on patientcenteredness enables and empowers patients and their families to make decisions based on evidence.

PUBLIC REPORTING

One of the most significant changes in the future of US physician services lies in public reporting. What you do—your competency, outcomes, efficiency, and patient satisfaction—will be publicly reported. It is a new world. In last month's Consumer Reports, 53% of cardiovascular surgeons in the United States reported their outcomes. Although we in the ophthalmic community have not reached this point, it is where we are headed.

A greater emphasis will also be placed on quality of care. Early quality measures were generally simple process metrics: Did you document the degree of diabetic macular edema? Did you contact the patient's primary care physician? In the future, there will be robust outcomes measures: What was the level of vision in a patient with a new subretinal vascular membrane in age-related macular degeneration at 1 year? Not only will you be graded on these outcomes, you will report them publicly, and the amount of resources that you use to reach that quality goal will also be measured.

PAYMENT REFORMS

In terms of value-based purchasing, we will be measured on the quality and costs of our care. Currently, there is an emphasis on the Physician Quality Reporting System, e-prescribing, and electronic health records; these are all beta movements to encourage the adoption of health information technology. This a carrot-and-stick approach. The carrot leads to a 4% increase in payment, which for ophthalmology translates to a bonus of $200 million. However, more important than the bonuses are the cumulative penalties (the stick), which will total around $400 million. Therefore, expect to adopt these technologies in the near future.

Under the Patient Protection and Affordable Care Act, Medicare reimbursement will emphasize the value of your services, and fee-for-service will be less important as a revenue source. There will be a move from pure feeper- service to bundled payments, where the physician assumes some risk for the care of a population of patients. What are your 1-year costs and outcomes to provide care to a patient with diabetic retinopathy? The Centers for Medicare & Medicaid Services (CMS) is flooded with people who are interested in providing good quality care at cheaper prices. Bundling will be a major revenue source in the future.

The Affordable Care Act directs CMS to provide information to physicians and medical practice groups about their resource use and the quality of care they provide to their patients. By 2015, CMS will begin applying a valuebased payment modifier, and both cost and quality data will be included in calculating payments for physicians. Physicians will also be rewarded for taking risks. Dramatic changes will therefore occur in the way we receive our income.

CONCLUSION

In the future of US physician services, we will be both providers and managers of care. We will be required to function in teams. There is no way to meet the increased demand for services with a fixed number of providers without using remote-imaging technology and physician extenders. We will be judged on our ability to deliver care on a patient and population basis, and our results will be publicly reported. Finally, we will be paid for taking risks, but only while providing care of high quality in an efficient manner. It is a new environment, but retina has always been adaptive. We have thrived through changes before, and we will continue to do so in the future.

William L. Rich III, MD is currently the Medical Director of Health Policy for the American Academy Ophthalmology. He is the Senior Partner at Northern Virginia Ophthalmology Associates in Falls Church, VA. He can be reached via email at hyasxa@gmail.com.