Stress and Scarcity

For most physicians, the two common themes in 2020 were stress and scarcity – and they have continued into 2021. COVID-19 led to general stress – from both a personal and professional perspective, and scarcity – from PPE in the early days of the pandemic to fees and reimbursement going forward. But stress has always been a part of medicine – life and death in many specialties, eyesight and blindness for ophthalmology. COVID-19 compounded the stress by making ophthalmologists fearful of becoming sick or, worse, becoming another statistic in the death count.

Practice survival was also at stake. Most practices had to slow or shut down, at least temporarily, as the world came to grips with living in a science fiction world of a deadly virus. How could practices remain viable if running on limited capacity? What about patients not returning for injections or emergency eye care? How long would it go on?

Burnout also accelerated last year. Data from Medscape (1) presents a bleak picture: 35 percent of ophthalmologists felt burnt out; women significantly more frequent than men (51 of women as opposed to 36 percent of men). Half of those physicians who felt the burnout said it had a severe impact on their life. And 34 percent of physicians were unhappy with their work life late last year compared with only 19 percent pre pandemic. Burnout had a negative effect on personal relationships in 65–75 percent of physicians, with younger doctors more likely to be affected. Even more startling: 14 percent of physicians felt suicidal during the pandemic.

Aside from the actual virus, gloom and doom, along with fear and blame, were a daily staple of the news. Government public health experts flip flopped on their recommendations, from masks and social distancing, lockdowns and closures, quarantines and off label therapeutics, turning a medical pandemic into a political hot potato on the eve of a presidential election. Battle lines were drawn, not based on science but instead on political preferences. Disagreement and even thoughtful discussion led to ridicule, harassment, and censure. Is it any wonder that physicians on the front lines, in the thick of the pandemic, were burning out at a record pace?

By scarcity, I mainly refer to dollars – not the reason most ophthalmologists chose their careers, but essential to keep the lights on in their workplace. Those employed might have received unpaid time off, making it challenging to keep the lights on at home while their families lived in front of a computer screen for school or entertainment. In private practice, rent, staff salaries, and overheads were omnipresent regardless of the latest case counts.

Ophthalmology was the hardest hit medical specialty, seeing the biggest drop in Medicare physician spending – a 29 percent drop in the first six months of 2020 (2). This is partially because ophthalmologists see a preponderance of older aged Medicare patients but also because it is primarily an outpatient specialty performing elective surgical procedures, all shut down during the early days of the pandemic.

Looking forward is the scarcity of Medicare dollars necessary to keep the US healthcare system afloat. Federal budget deficits are now measured in the trillions, not billions, with a national debt far larger than our GDP. We are in the danger zone. the needle on our collective car dashboard is in the red, warning of catastrophic engine failure. Economist Herb Stein once wrote, “If it can’t go on forever, it will stop (3).” This applies to governments spending money they don’t have; a giant Ponzi scheme. Something must give.

Earlier this year, Medicare reimbursement for ophthalmology faced a 6–10 percent cut for 2021, with no commensurate reduction in rent, wages, utilities, and regulatory compliance costs. At the last minute, Congress blinked and offered a reprieve (4). The death row inmate’s execution was halted, but they are still on death row – a new execution date looming. Instead, the house of medicine received a 3.75 percent one time increase for 2021 to mitigate the financial buzzsaw of 2020. Later this year, the cuts will be back on the table, as Herb Stein would predict.

Sequestration is a result of Congress not agreeing on a past budget a decade ago, specifically a 2 percent across the board cut in Medicare provider payments (5). The sequester was briefly suspended to assist during the COVID-19 pandemic and was set to expire January 1 of this year. The ever-generous US Congress extended the suspension for three months, the 2 percent cut hitting in April. Note that members of Congress and their staffs received their full paychecks without interruption during COVID-19 – more than can be said for their constituents. 

At the time of this writing, the Senate passed legislation extending the sequester moratorium until the end of the year. Now it is up to the House to also kick the sequestration can down the road (6). To pay for the sequester extension, the Senate bill would increase sequester cuts in 2030, a time when many members of Congress will be retired or working at K Street lobbying firms, leaving the mess for others to clean up. As Democrats control the executive and legislative branches of the federal government, this might be their opportunity for “fixing” healthcare once and for all. Medicare is predicted to run out of money to pay hospitals and physicians within the next couple of years (7). 

In typical government fashion, if a program is failing, their solution is to double down and expand it. Enter “Medicare for All”, sitting in a Congressional drawer for years, ready to be voted into law, even if on a party-line partisan basis. Costing over $3 trillion a year, an amount almost equal to the entirety of federal government revenues (8), Medicare-for-All will blow a massive hole in the federal deficit and debt, with costs trickling down to physicians. An analysis by the Mercatus Center at George Mason University predicts that under Medicare-for-All, physicians “will be reimbursed at rates more than 40 percent lower than those currently paid by private health insurance (9).”

Given that such a bill has been the holy grail for the more progressive wing of the Democrat Party, it is likely that they will take advantage of their current control in Washington, DC, to enact such legislation. And that could spell the end for private practice medicine, replaced by something more like the UK National Health Service. Private insurance would go the way of the dodo bird. Medicare-for-All “would prohibit employers and private health insurers from offering coverage that duplicates Medicare-for-All covered benefits (10).” As Medicare covers most healthcare expenses, particularly in ophthalmology, this law would basically eliminate private insurance – a single fixed gear clunker bike replacing a 21-speed racer.

But this is just the tip of the iceberg. There is much happening in ophthalmology, including new surgical techniques and therapeutics. All will be expensive, and so the big question will be: Can we afford them? 

The bottom line remains the same: stress and scarcity are not going away. Though still a wonderful profession and specialty, the COVID-19 pandemic has revealed the new challenges that will face ophthalmologists in the years ahead. I hope we are ready when the time comes.