Agree with all your comments. Some thoughts: I Avoid medicaid! The glaucoma surgery situation is indeed terrible! Not a biz I’d like to be in as all
EYE MD

True for UNrelated procedures/visits. But let us take a trabeculectomy patient for example. The follow-up care is usually most of the work.

Let’s start with the unpaid “pre-op” visit after you make the decision for surgery and schedule the patient. This usually involves extensive counseling to educate and manage expectations, and would otherwise likely be a level 4 E&M code visit. Then you do the surgery. Now more uncompensated visits start. These are typically post-op day 1, day 3-5, day 7-14, day 21-28, day 45, day 75. That is for a good, routine trabeculectomy. So you have seven or so uncompensated visits total. In more complicated cases, you may have 10 or more uncompensated visits. There is a story of a surgeon circulating who supposedly did NOT bill for the surgical procedure, but did bill for all the associated otherwise uncompensated office visits. The reason is that the compensation for the office visits was greater in sum than the global surgical fee. Of course this creative approach was disallowed, but it serves as an example to our non-surgical colleagues that the grass is not as green as it may seem in surgical specialties.

What many of our colleagues do not understand too is the large intraspeciality disparity in compensation. Within ophthalmology, pediatrics is one of the lowest compensated subspecialties, with lots of Medicaid. Retina is perhaps the highest compensated subspeciality, by a factor of 5-10 fold over pedi-ophth, even with lots of Medicare. Why is that? One reason is laser procedures, the related testing involved, and the relative absence of 90 day global period visits. Take a focal or grid a laser for diabetic macular edema. This usually requires no postoperative visits within the 90 day global period, yet compensation with the typical FFA/OCT is on par with cataract surgery with 1 preop and 3 postoperative visits in the 90 day global period. If your average office overhead per visit is in the $75 to $80 range, those uncompensated visits really add up versus filling those slots with another paying patient.

an eye md

And then there is a 90 day global fee period in which postoperative care is provided for free! How would you primary care folks like someone to come in for pneumonia and be able to return for any related follow-up visits in the next 90 days for free?

Just why did many in primary care choose NOT to become surgeons, assuming they could “cut it”? Wasn’t it to live simply so that others may simply live? (That was one of my favorite bumper stickers on the Volvo’s of many a future PCP back in medical school days)

One of the reasons is, no doubt, the stress of surgery and the surgical lifestyle. Another is the protracted and competitive residency and fellowship situation, along with multiple more years of subhuman treatment. Add to that the unpleasant surgical “mentality” perceived by many non-surgeons. Would you like to do surgery for peanuts, even if the goobers are larger than those of primary care? You have to dig a lot deeper and harder bloodying yourself to get those slightly larger goobers.