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Practitioner: Is it still worth performing cataract surgery?
By operating more efficiently, surgeons can continue to deliver premium eye care and a high level of professionalism and service.
Since I began practicing ophthalmology more than 25 years ago, we have seen a dramatic decline in Medicare reimbursement for cataract surgery. Adjusted for inflation, the current rate of approximately $750 per eye is about 80% less than we were paid in 1985. On the face of it, that sounds like a pretty big pay cut.
Fortunately, the impact of that decline in reimbursement has been somewhat offset by other changes. Better phaco technology allows us to remove cataracts more safely and efficiently than we could in 1985; better IOLs and injectors have reduced incision sizes and made lens implantation easier; and a move away from hospital environments to ambulatory surgery centers (ASCs) has given surgeons far more control over scheduling, staff training and room turnover.
Still, we are reaching a level of Medicare reimbursement that has some ophthalmologists rethinking whether cataract surgery still fits into their business model. Is the remuneration from surgery enough to justify one’s absence from the clinic? Or would the practice bottom line be better served by performing more office-based care?
The answers depend on many factors, including the surgeon’s patient volume and population, speed and efficiency, and ASC ownership stake. For most surgeons, though, the answer is still a resounding yes — cataract surgery is worth performing.
Russell G. Fumuso
Running the numbers
To calculate the profitability of phaco relative to other parts of your practice, you need to multiply the average number of patients you see per hour in clinic by your average per-patient charge, which can vary significantly by region and patient population. Compare this to the average number of cataract procedures per hour times $750.
The number of surgical procedures per hour is highly dependent on the number of operating rooms available. Many surgeons are limited to one OR, and if that is the case, efficiency becomes extremely important.
In my case, I see eight to 10 patients per hour in the office, at $160 to $175 per-patient encounter. That means that my time in the clinic is worth about $1,500 per hour, or about the equivalent of two surgical procedures. So as long as I can do three or more procedures per hour, surgery still makes good financial sense. Richard L. Lindstrom, MD, came to a similar conclusion in an Ocular Surgery News commentary last year on facing the financial realities in ophthalmology.
With the ability to alternate between two operating rooms, most surgeons can perform five or six procedures per hour, putting them financially well ahead of a clinic day. And if the surgeon has an ownership stake in the ASC or facility, surgery is even more profitable.
Premium IOLs further change the equation. Even a relatively small increase in one’s rate of toric and multifocal IOL implantations can make a big difference in the average profit calculation.
Boosting efficiency
At Ophthalmic Consultants of Long Island (OCLI), where I serve on the Executive Management committee, efficiency is a big deal. We have a large ASC that is used by nearly four dozen surgeons, both from within the practice and the larger ophthalmic community. We routinely evaluate surgeons in terms of their efficiency (case time) and complication rates. The most efficient surgeons get the prime morning time slots in the OR. This rewards their efficiency and allows us to predict the overall ASC schedule with greater accuracy.
We recognize that speed is not everything. An exquisite procedure with a perfect technique could be performed in 9 minutes or 16 minutes, with similar outcomes. Surgeons who are efficient could nonetheless have longer average surgical times if they have a patient base with high rates of diabetes, glaucoma or other conditions that might make for more complicated cases. Some of our top surgeons handle a lot of unusual cases referred from others.
However, to stay profitable, we encourage surgeons to constantly look for ways to improve their efficiency. From my perspective, there are four key factors in an efficient surgical practice.
Preparation. Surprises are the enemy of efficiency. Before each surgery day, I review my notes so that I am prepared for any unusual or particularly challenging cases. My goal is to make sure that I have every tool — from viscoelastics to pupil-expanding devices and capsular tension rings — that I might need for the day’s cases, so that I am never waiting for instrumentation. IOL powers are all checked and double-checked against the case roster. In a toric or post-refractive case in which I plan to use intraoperative aberrometry, I might bring several different IOL powers into the room so that I have the right one on hand as soon as I confirm the power and axis intraoperatively. I also alert anesthesia and the circulating nurse of any anticipated challenges, so they are ready when I need them.
Technique. It stands to reason that good surgical technique is essential, but in the “rush” to be efficient, it is easy to forget that one complication in a single case can undo all the minutes gained across many other cases. Not only does a complication slow down the procedure, but it may lead to secondary surgeries or more follow-up visits, further eroding efficiency down the line. My OCLI colleague Marguerite B. McDonald, MD, who brings a refractive surgeon’s sensibilities to cataract surgery, says complications affect performance in other ways, too: “When you have a complication, you are more likely to have to resort to your backup lens or put the IOL in the sulcus, which increases the chance of dioptric inaccuracy.” We both agree that proceeding with surgery in a fashion that is smooth, well-planned, methodical and safe is absolutely essential.
Technology. It is important to choose surgical technologies that boost one’s efficiency. I prefer the speed and power of a Venturi-style pump. I like the ability to tweak my settings as needed for particular cases so that I can move quickly while maintaining a stable chamber. For these reasons, I use the WhiteStar Signature phaco machine (Abbott Medical Optics). Not only does this device give surgeons the opportunity to use transversal phaco to more efficiently debulk the nucleus, but one can also alternate between Venturi and peristaltic pump styles within a single case if desired. “By using the advantages of both pumps, I can be very fast but safe at the same time,” Dr. McDonald says. “Signature has helped me improve the efficiency of my nuclear disassembly and irrigation/aspiration.”
With many exciting new cataract technologies on the market, including advanced diagnostics, intraoperative aberrometry and femtosecond lasers, there is certainly tension between having the “latest and greatest” and controlling overhead costs. Although new technology acquisition often represents a short-term hit in both efficiency and cost, we have always taken the approach that acquiring the best technology is good for our patients and our bottom line over the longer term. Advanced technology attracts patients and draws more surgeons to our ASC, but every practice needs to make its own determination of whether it has or will gain the case volume to support new acquisitions.
Resources. The surgeon is only part of the equation. Even the fastest surgeon is dependent on access to an adequate number of rooms and instrument trays and on having a well-trained staff that can turn rooms over quickly. All of these elements need to work synergistically to keep the schedule on track.
It can be frustrating that in an era of declining reimbursement, ophthalmologists need to see more patients just to break even. We are fortunate that ours is a creative and ever-evolving profession and that there is strong demand for our services. I also am frequently reminded how lucky I am to practice in a specialty in which we get to truly fix problems. Every day, we have the privilege of restoring vision and improving the quality of life for our patients.
I believe that by looking for ways to operate more efficiently, we can continue to deliver premium eye care and a high level of professionalism and service in a way that remains profitable and enjoyable to us as surgeons.