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Speaker: Advantages of same-day bilateral cataract surgery outweigh disadvantages
Reimbursement penalty rather than medical risk is the main reason for not adopting the practice.
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Immediate sequential bilateral cataract surgery delivers patient satisfaction, is efficient, lowers society costs and reduces risk to the second eye, according to a presentation at OSN New York 2015.
“I do believe at some point in the future if you do not offer same-day surgery to your patients, you will be at a competitive disadvantage,” Richard K. Stiverson, MD, told colleagues while outlining the advantages and disadvantages of the procedure.
The primary reason for not performing the procedure is a financial one, not medical risk, according to Stiverson. Unless surgeons opt out of Medicare or are in a Medicare Advantage setting, as he is at a Colorado Kaiser Permanente facility, insurance companies can impose a “reimbursement penalty” wherein both the surgeon’s fee and facility fee are reduced by 50% for surgery on the second eye on the same day, Stiverson said. Medicare Advantage organizations are paid capitated fees based on diagnosis rather than procedure, he said, so the surgeon and facility are reasonably reimbursed for the same-day surgery.
Another reason why ophthalmic surgeons may not embrace the procedure is the perception of endophthalmitis risk, which he called “the 800-pound gorilla in the room.” However, Stiverson believes there is little risk when intracameral antibiotics are used.
“Since starting intracameral antibiotics in Colorado, we’ve had one endophthalmitis case in 44,000 cases. That extrapolated would be a risk of one in 2 billion for a bilateral endophthalmitis,” Stiverson said.
Since 2012, Stiverson and colleagues have performed approximately 7,000 same-day bilateral cataract surgeries. Patients sign two consent forms, one for each procedure. Prerequisites for success included administering NSAIDs, using intracameral antibiotics and using current generation formulas for calculating IOL power.
“We did over 1,000 same-day bilateral torics with very good success,” Stiverson said, with only one patient needing bilateral toric rotation.
Complications included one case of cystoid macular edema, one case of cystoid macular edema with epiretinal membranes, 12 cases of elevated IOP with aqueous expression, three cases of corneal abrasions requiring bilateral bandage contact lenses and six cases of symptomatic dysphotopsia persisting for more than 6 months.
Same-day cataract surgery “is not medically better, but it’s not medically worse,” Stiverson said. It is, however, more efficient and has been shown in studies to have potential for lowering costs to the patient and the health care system if the reimbursement penalty were eliminated, he said. Furthermore, any difficulties encountered with the first eye can be anticipated or ameliorated for the second eye, thus reducing risk for the second eye. And there is “bilateral precedent,” in that RK, LASIK and PRK procedures are all done bilaterally.
In summary, the advantages of same-day bilateral cataract surgery outweigh the disadvantages, Stiverson said.
“It’s just a choice, and given a choice, a surprising number of patients much prefer this option. With exploding Medicare numbers, we should be incented to be more efficient,” Stiverson said. – by Patricia Nale, ELS, and Kate Sherrer
- Reference:
- Stiverson, RK. Immediately sequential bilateral cataract surgery. Presented at: OSN New York 2015; Oct. 23-25, 2015; New York.
- For more information:
- Richard K. Stiverson, MD, can be reached at Kaiser Permanente, Ophthalmology Department, 10240 Park Meadows Drive, Lone Tree, CO 80124.
Disclosure: Stiverson reports no relevant financial disclosures.
Perspective
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Sumit Garg, MD
Dr. Richard Stiverson presents his favorable experience with same-day bilateral cataract surgery from the Permanente system in Colorado. Bilateral same day refractive surgery is the norm should cataract surgery be any different? Dr. Stiversons experience has been overwhelmingly positive, but he does caution of a few prerequisites: use of intracameral antibiotics, routine use of NSAIDs, preselected healthy eyes and use of current-generation IOL formulas. Additionally, he offers all patients the option of traditional staged surgery and employs a separate consent with a forthright discussion of the unique risks of bilateral same-day surgery. By following these guidelines, he and his colleagues have performed nearly 7,000 bilateral same-day cataract surgeries with increased patient satisfaction and efficiency without sacrificing safety. Dr. Stiverson does state that this approach will not work for many practices because most payers penalize same-day additional procedures by 50%. However, for selected health systems, bilateral same-day cataract surgery is actually more efficient and more profitable. Given the current status of reimbursement and depending on your practice characteristics, it will likely be many years before bilateral same-day cataract surgery becomes the norm, but with increased experience and data, this approach may become the preferred choice of both patients and physicians.
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