A Blueprint for the Financial Survival of CATARACT SURGERY

Change the rules to improve outcomes and lower costs.

Robert P. Rivera, MD

In 1962, three years before Medicare was signed into law by President Lyndon B. Johnson, my grandmother, who lived in the remotest corner of New Mexico, died sightless for lack of what today would be considered routine cataract surgery.

If my grandmother were alive today, Medicare would take care of the cost of the procedure and a brief but highly effective surgery would take care of her cataracts.

With the vanguard of almost 80 million baby boomers now approaching their late 60s, the primary issue today in the United States is not individuals with untreated cataracts; it's how to deal with the coming increased demand for this procedure. We must do it in a way that does not drain Medicare, cause rationing of care, or see already diminishing reimbursement cut to the point that performing cataract surgery becomes a money-losing endeavor. With about 3 million cataract surgeries performed each year in the United States, the surging boomer cohort may increase that number to 4 million or even 5 million surgeries each year within the next 20 years.

For those who think these concerns are premature or unduly alarmist, the Royal National Institute of Blind People recently confirmed that shrinking national healthcare budgets are already causing severe rationing of cataract surgery in the United Kingdom.

Clearly, we need to think more about meeting the steadily climbing demand for cataract surgery — and doing it in a more efficient, cost-effective manner. I am not particularly concerned with the surgery itself. It is already evolving and progressing in a way that all cataract surgeons can embrace. The advent in recent years of premium IOLs, femto-phaco and instruments that provide more precision intraoperatively are positive indicators of a much improved procedure. However, all of our great technical achievements may well go for naught if Medicare finds that it can't adequately pay for 4 or 5 million cataract surgeries each year.

The multi-point plan I outline below may be too controversial for some, too forward-looking for others. I don't expect that all — or any — of these ideas will be adopted in the next year. However, I do hope that they are thoughtful enough to provoke discussion in the ophthalmology community, at the Centers for Medicare and Medicaid Services (CMS) and in the wider world where controlling medical costs is now a key priority.

Let's Consider SBCS

In our modern era of cost-effective, ultra-efficient ASCs, can we possibly further adapt and evolve into more efficient systems and not sacrifice quality of care in the meantime? If we are to look at international trends, there is one glaring area in which we in the United States lag behind, and that is in performing bilateral cataract surgery. There is no question that in the uncomplicated patient, the opportunity to have a single comprehensive surgical encounter with a single postoperative recovery would reduce many of the negative aspects of having to undergo surgery.

After initial hesitation on the part of surgeons, we now routinely perform bilateral same-day LASIK and implant bilateral same-day phakic IOLs, concepts for which I was an early advocate. Bilateral knee replacements, as another example, are becoming more commonplace in some orthopedic practices for similar reasons.

Yet, while “simultaneous” bilateral cataract surgery remains controversial in our country, there can be no argument with ongoing statistical reports from our international colleagues that show it to be as safe as surgery performed one eye at a time, when strictly obeying the rules and protocol of such procedures. Aside from burying our American heads in the sand, no amount of controversy on our soil will restrain the rising tide of international acceptance of SBCS as the desirable norm of practice (see www.isbcs.org).

SBCS Acceptance is Growing

SBCS has already proved itself a safe and cost-effective procedure. It has been widely studied and adopted in such countries as Sweden, Finland, Canada, Spain and the United Kingdom. It is also becoming increasingly accepted in South Korea, India, South Africa and the rest of Europe.

The factors that have driven acceptance of SBCS are compelling safety studies when SBCS is performed as two totally separate procedures, equitable reimbursement policies, tangible cost savings of 15-20% and widespread reports of surgeon/patient enthusiasm for the convenience and visual benefits associated with same-day bilateral procedures.

When Ophthalmology Management ran a cover article on SBCS in December of 2011, many surgeons expressed interest in performing that procedure and a few were willing to be quoted on the fact that they have been performing SBCS on private-pay patients with no risk factors or for whom refractive information from the first eye would be helpful in operating on the second eye.

Other surgeons quoted in that article said they would like to perform SBCS but either didn't want to be pioneers in doing the procedure, feared lawsuits over less-than-stellar outcomes, or didn't like the fact that Medicare only pays 50% reimbursement for the second eye done on the same day.

Such highly respected cataract surgeons as David F. Chang, MD, the president of ASCRS, have expressed great interest in SBCS, on the condition that a large-scale US safety study is needed before it is adopted widely in this country. Dr. Chang recently told Ophthalmology Management that 75% reimbursement for the second eye done on the same day would be more equitable and might drive greater acceptance of SBCS once a safety study was conducted.

We could broadly implement SBCS in this country within two years, bringing such visual benefits to patients as eliminating the between-surgeries interval characterized by anisometropia. If SBCS can deliver an overall savings of 15% to 20% over current costs, we may find that Medicare reimbursement will not fall off a cliff for these procedures.

Let's Encourage RLE

What's good about our middle-aged patients choosing refractive lens exchange (RLE) as a private-pay procedure rather than waiting for cataracts to develop in later life? What's good about RLE? The answer is: everything.

The highly praised Synchrony IOL is still awaiting FDA approval.

First, a patient who chooses RLE will never develop cataracts and therefore never burden Medicare or other insurer with paying for a cataract surgery. Every patient who chooses RLE is driving cost effectiveness in ophthalmic care. In addition, a patient who never develops cataracts will help avoid the costs to society in falls and auto accidents whose primary cause in many cases is diminished vision attributable to cataracts. Am I being too bold in suggesting that patients who choose RLE and thus relieve insurers and society of significant burdens should perhaps qualify for a tax credit for selecting this option to improve their vision?

Faster IOL Approvals

If one of our goals is to encourage more of our patients to choose RLE, it would be helpful to be able to offer them the best and most-up-to-date choice of IOLs. Many IOLs that have been approved and are in routine use internationally are still considered investigational in the United States. Promising investigational IOLs that could help drive RLE acceptance include the Calhoun Light-Adjustable lens, the Tetraflex from Lenstec, the FluidVision accommodative lens from PowerVision and others in the early stages of development.

One salient example of slow US approval is the dualoptic accommodative Synchrony (Abbott Medical Optics), which has an excellent record in international use and has already completed its US clinical trials.

The Synchrony, which is implanted into a 3.8-mm incision using a pre-loaded injector, has been presented as an IOL designed to allow patients to have a continuous range of focus without the need for spectacles or the drawbacks of monovision or the limitations that have been associated with multifocal lenses. European surgeons have reported that as many as 97% of patients implanted with the Synchrony have no further need for eyeglasses.

The Calhoun LAL is unique in that it can be adjusted by near-ultraviolet light after it is in the eye.

Because the Synchrony requires a well-centered capsulorhexis to achieve best results, the emergence of femtophaco should work to the advantage of its adoption.

John Hovanesian, MD, FACS, of Laguna Hills, Calif., who has implanted numerous Synchrony IOLs, told Ophthalmology Management “the Synchrony design and strict implantation requirements are very complementary with a femto-phaco procedure. The possibilities are very exciting.”

The Calhoun Light-Adjustable Lens (Calhoun Vision) began US clinical trials in 2009 and is currently in final phase 3 studies. First approved commercially in Germany in 2008, the Calhoun lens has been drawing high praise from European cataract surgeons, who are using the lens routinely and successfully. The most compelling feature of the Calhoun lens is that it can be easily adjusted after it is in the eye to meet the specific visual needs of individual patients.

The ‘OUS’ Syndrome

As I reflect upon my career as a cataract and refractive surgeon, my most significant learning experiences have been at the feet of some of the greatest and most innovative minds in ophthalmology, not only in the United States but abroad.

I have spent countless hours both presenting and learning at numerous international conferences, and my opinions have been shaped by what I have seen abroad. In fact, if American surgeons as a group are found to have a fault, it is that most do not travel internationally in search of a broader educational experience. One piece of advice I would offer to a graduating resident would be to make plans to travel to such prestigious meetings as the European Society of Cataract and Refractive Surgeons (ESCRS) and any of a host of other international venues, to see how the proverbial cat is skinned outside the United States (OUS) and how this could affect the future of what we do. I have, in fact, shared with many my opinion that if all American ophthalmologists would jointly attend the ESCRS and see what is happening outside our borders, the resulting furor would cause an end to our currently broken system of device approval, hamstrung as it is by increasingly burdensome red tape.

The former Constitution Eye ASC in Newington, Conn., was purchased by Hartford Hospital in 2011 and converted to an outpatient department of the hospital.

Though OUS remains a fertile ground for groundbreaking advances and innovations in cataract surgery and other medical procedures, it represents a negative commentary on the state of American innovation. If we are to achieve the cost-effectiveness in ophthalmic procedures that will enable reasonable reimbursement, the shackles on US-based innovation must be removed so that we may treat patients with the best technology, procedures and devices available.

End the HOPD Advantage

One greatly concerning trend for cataract surgery cost-effectiveness is the wide Medicare reimbursement differential for hospitals that gain 100% ownership of ASCs and then qualify the facility as a hospital outpatient department (HOPD). In many cases, it is just a question of changing the sign on the front of the building and being able to bill approximately 40% more for routine cataract surgery than a physician- or corporate-owned ASC.

The poster child for this type of conversion in the ophthalmic area is the 2011 purchase of the Constitution Eye ASC in Connecticut for $27 million by Hartford Hospital. The negative implications of this purchase have been cited by the Ambulatory Surgery Center Association (ASCA) in testimony before a Congressional subcommittee in September of 2011.

In that testimony, Michael Guarino of the ASCA warned that hospital purchases of formerly physician- or corporate-owned ASCs would drive procedures to the least efficient, highest-cost provider and create a major drain on Medicare finances allotted to ophthalmology.

The work of the ASCA in this area, buttressed by a cover article in the March issue of Ophthalmology Management, has caused 13 US Senators to request CMS to study the payment differentials according to hospital-owned ASCs to determine whether hospitals are purchasing and converting ASCs to HOPDs for financial reasons.

Standing Pat is Not an Option

As the number of cataract procedures performed in the United States starts to soar and Medicare's finances are increasingly strained, it ill behooves us as cataract surgeons to stand idly by and wait for more axes to fall.

We can become more proactive in pushing for US studies of SBCS. We can do more to inform our middle-aged patients of the many benefits of having an RLE procedure. We can, through the ophthalmic community, demonstrate to the FDA how faster approval of next-generation IOLs can drive cost effectiveness. We can let our elected representatives know that continuing to allow ASC-to-HOPD conversions, with their huge and unwarranted payment differentials, is simply a bad idea for numerous reasons.

If we do not act, it will be us as cataract surgeons who will bear the brunt of future reimbursement cutbacks. If we do make our views on these issues known, we and our patients may be able to enjoy the benefits of efficiencies that will actually improve the quality of the surgery while maintaining a reasonable level of reimbursement.

A Vision Within Reach

As a young resident walking the halls of the Mayo Clinic, I would often think of my grandmother and how her vision suffered. My dreams were that one day we would be capable of operating on patients to restore their vision and simultaneously remove their dependence on eyeglasses. While I never thought this would actually occur in my lifetime, nor that I would come to provide this priceless service that would change the lives of patients, the stunning advances of the last 20 years have brought us all to that point.

Today, my dreams are that, as a profession, we might be allowed to boldly build our continued success on the innovations and technological advances that will inevitably lead to better out comes. Procedures improve, technology evolves and, in the United States, senseless regulatory obstacles to that evolution would do well to cease. There will soon be many millions of new cataract surgery patients who will depend on us to be the best at what we do and the perfect surgical procedure must always remain our goal. Yet, while perfection remains elusive, we can best succeed by lending our passionate support to those ideas and concepts, both surgical and financial, that will enable us continue to serve our patients with real enthusiasm and dedication. OM

Robert P. Rivera, MD, is an intraocular lens and refractive surgeon and director of clinical research, at Hoopes Vision in Sandy, Utah. He has implanted more Visian ICLs than any surgeon in the United States, many as same-day bilateral procedures. He can be reached at rpriveramd@aol.com