As I See It

Salvation of the ‘Law of Unintended Consequences’

How the Affordable Care Act gave one wary cataract surgeon an out to make life more bearable.

By Paul S. Koch, MD

Paul S. Koch, MD, is editor emeritus of Ophthalmology Management and medical director of Koch Eye Associates in Warwick, RO. His e-mail is paulkoch@kocheye.com.

In this space I have previously discussed the Law of Unintended Consequences. Generally, this describes a well-meaning attempt to establish a policy that has some sort of a public benefit, only to discover that it triggers an unexpected reaction quite contrary to the original purpose.

A loyal reader of this column wrote to me recently about an unintended consequence of the Affordable Care Act that he found to be a big relief. Quite honestly, his predicament was one I had not considered, and so I was intrigued. He does not want me to provide a clue to his identity or to quote him, so here’s the essence of his story, specifics omitted.

He was thrilled to be accepted into an ophthalmology residency and had a pleasant and successful first two years. Held out before him was the opportunity, third year, to learn cataract surgery. This elegant operation would let his patients see better while allowing him to pay his bills and still have a little left over at the end of the week.

Unfortunately, he quickly discovered he did not enjoy cataract surgery. He was afraid to tell his instructors because he did not want them to be disappointed in him. He knew that all new ophthalmologists would be expected to perform competent cataract surgery. It was simply part of the territory.

ANXIETY IN THE OR

He entered private practice and, as predicted, cataract surgery did help his patients and he could pay his bills. But on surgery day, he would wake with “agita,” a gnawing sense of apprehensiveness.

Before each operation, he would take a few deep breaths and plunge in, sweat beading on the back of his neck. He was short with his nurses. When he broke a capsule, his heart would pound. He banged instruments on the table while he demanded vitrectomy tools, speaking faster and louder.

He did not like cataract surgery but he felt he had to do it. It was The Code. He felt his manhood would be shamed if he did not, never mind covering his costs. He felt trapped, and hoped for a way out.

One day, the Affordable Care Act became law and passed Supreme Court review. Then, cataract surgery took a $100 hit from Medicare. Finally, we took another 2% hit from the Sequester.

FINDING A WAY OUT

Suddenly his handful of operations no longer went as far in paying the bills and he actually would do better staying in the office. He could eliminate his anxiety in the OR. If he was asked why he stopped doing surgery, he could say he was a victim of the Law of Unintended Consequences; changes in the medical climate forced him to make adjustments that left his community with one fewer surgeon.

Most of us who perform cataract surgery are comfortable and enjoy the work. I suppose many, like me, assume all surgeons feel the same way. I really hadn’t considered that some colleagues followed a surgical pathway they were not comfortable with, marching on powered by pride, ignoring the anxiety of each case.

It may well be others are in the same boat and will use the ACA, fee cuts and sequestration to cut back in certain areas — or retire. The nascent national plan to improve access to health care could have the unintended consequence of reducing access if more unhappy surgeons leave the OR, but the change may be healthy for their bodies and minds. I wish them good fortune. OM