• Cataract/Anterior Segment

    This editorial questions the purpose of a recent cost-utility study on cataract surgery in light of cataract surgery’s obvious benefit on quality of life.  

    There are other procedures in which the change in quality-adjusted life years might be marginal or negative, writes author Paul B. Ginsburg, PhD, and other questions that should be asked about the costs and benefits of cataract surgery.

    There are applications of the procedure in which the cost-utility is suspect, says Ginsburg, who is president of the Center for Studying Health System Change in Washington, D.C. Perhaps the most important of these applications is second-eye surgery (after successful surgery for the first eye), he writes. The study that was published examines this and shows that the return on investment is very high although not as high as for the first eye.

    He adds that there are many other areas in which cost-utility analysis might be of substantial value to payers. One is whether the current standard for visual impairment before cataract surgery is the right one. With the cost of the procedure having declined so much over time, perhaps earlier cataract surgery would have a merit that it may not have had in the past. But perhaps it should be paid only partially by the insurer. For younger patients, the question arises about the merits of “clear lens extraction” for refractive correction.

    At the other end of the scale, he asks if cataract surgery is appropriate for very elderly people with severe dementia, those predicted to be near the end of life, or those with severe retinal disease or macular degeneration. These strike him as opportunities to conduct analyses that will lead to wiser policies on the part of payers.

    Ginsburg has studied the declining costs of cataract surgery over time and says the reductions from 1985 to 2000 likely reflect both advances in technology and a radical change in Medicare reimbursement policy, whereas the change from 2000 to 2012 probably reflects slower changes in each area. Many ophthalmologists have been frustrated by the reductions in surgical fees for the procedure, which have meant that adequate compensation from cataract surgery can only be realized when delivery is very efficient. This has led to specialization so that cataract surgery is performed on a high-volume basis at centers that have organized the operating suite around surgeon productivity.

    He concludes that reducing payment to reflect advances in productivity and to prod additional advances in productivity, although challenging for practitioners, makes sense for society.