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At issue: One eye or two?


Immediately sequential bilateral cataract surgery may be in peril as a procedure because it is penalized to varying degrees by government-imposed reimbursement cuts.


Immediately sequential bilateral cataract surgery may be in peril as a procedure because it is penalized to varying degrees by government-imposed reimbursement cuts.

Dr. Arshinoff

By Lynda Charters; Reviewed by Steve A. Arshinoff, MD, FRCSC

Toronto-Immediately sequential bilateral cataract surgery (ISBCS) is being performed in numerous countries worldwide. In many countries, however, surgery performed in the second eye is seriously penalized financially.

Steve A. Arshinoff, MD, FRCSC, co-president of the International Society of Bilateral Cataract Surgeons, offered arguments for equal payment for the second surgery.

“A large number of countries simply do not know what they are doing with regard to the finances of cataract surgery,” said Dr. Arshinoff, of the Departments of Ophthalmology and Visual Sciences, University of Toronto and McMaster University and Ben Gurion University of the Negev, Beer Sheva, Israel.

Extensive experience with ISBCS

Dr. Arshinoff reviewed his routinely performed ISBCS cases from January 1996 to December 2012, for a total of 8,046 eyes of a total of 10,406 cataracts (i.e., ISBCS represents 77.3% of all cataracts).

“Numerous articles and presentations have shown that ISBCS is as safe as delayed sequential bilateral cataract surgeries [DSBCS],” he said. “The incidence of complications is not higher with ISBCS and patients prefer ISBCS.”

Dr. Arshinoff recounted the case of a 28-year-old man with Duchenne x-linked muscular dystrophy who traveled 200 miles to undergo ISBCS. The patient is unable to lift his arms and has 10% bone density.

The convenience of both surgeries was implicit since the patient spends his life in a wheelchair, with watching television and reading his only activities. He underwent ISBCS with monovision on Jan. 2, 2013, after which his visual acuity was 20/20 at near and far on postoperative day 1.

Considering this patient and others who also are aged and/or infirm, the convenience of bilateral cataract surgeons performed in one session cannot be overstated.

“The choice of a medical procedure should be based on the weight of the medical evidence, or, if a new procedure, the expectation of improvement of the current practice by careful study and discussion among the profession, and not by politicians or administrators dictating practice based on poor understanding of the issues,” Dr. Arshinoff said.

He argued that there is no logic to reimbursing the surgery on the second eye by less than the amount reimbursed for the surgery on the first eye.

In the United States, the physician is reimbursed only 50% for the surgery on the second eye.

In Japan and Israel there is no reimbursement for the second eye.

In Ontario, Canada, historically, reimbursement for the second eye has been 15% less than that of the first eye.

It is becoming very difficult to perform bilateral cataract surgery in Ontario, Canada, with different jurisdictions imposing varying restrictive funding models that make no sense in eye care or any branch of health care, Dr. Arshinoff noted.

“In June 2012, the government of Ontario significantly changed surgical funding models such that hospitals were no longer funded to perform bilateral cataract surgery in a socialized health care system, thus financially eliminating the procedure,” he said.

Ontario retroactively reduced the facility fees for surgery and issued a “patient-centered philosophy,” meaning that a facility only gets paid for the first procedure performed. The logic behind this is that the patients, not procedures, are counted, and no money is reimbursed for any second procedure.

In October 2012, the government reversed the payment policy for the second eyes, but the amount paid to the facility was less than that for the first eye, specifically, $497 for the first eye and $326 (66%) for the second eye.

This rate scale was guaranteed for only 5 months. Surgeons’ cataract fees were reduced (inflation adjusted); in 2012 the rate was $397, with 15% less for the second eye ($337) compared with $966 (inflation adjusted dollars) per eye in 1987.

In Canada, ISBCS generally has been an on-again, off-again proposition, with the surgery prohibited in my own jurisdiction from Aug. 1 to Oct. 31, 2012. We were then told that we must perform 400 more ISBCS cases (800 eyes) from Nov. 1, 2012, to March 31, 2013.

On Jan. 25, 2013, ISBCS was again halted. On March 1, we were told that we must perform 11 more ISBCS eyes by March 31.

We were subsequently give exact allocations form April 1, 2013 to March 31, 2014, with an exact number of ISBCS and DSBCS  ± 0, with the second eyes of ISBCS again heavily discounted. In other words, we were told that we must perform an exact number of bilateral and an exact number of unilateral cataract surgeries, irrespective of what problems the patients presented with.

Savings in money and time

Previous studies have supported the savings in money and time that ISBCS affords. A study by Leivo et al. (J Cataract Refract Surg. 2011;37:1003-8) estimated that the savings was 1,600 Euros per patient.

O’Brien et al. (Can J Ophthalmol. 2010;45:596-601) enumerated the decreased social costs (to patients, families, and employers), institutional costs, and extra medical care costs  due to fewer visits for ISBCS, yielding similar savings with ISBCS to the study of Leivo et al. If the estimated frequency of simultaneous bilateral endophthalmitis (SBE) is in the range of 1:100 million cases, as suggested in the literature, the potential cost savings of bilateral cataract surgery, if reimbursed fully, to the payer is about $100 billion U.S. dollars per anticipated SBE.

A logical approach to ISBCS would be for governments and other payers to pay the same fee for the second ISBCS surgery as for the first surgery, because the ISBCS surgeon is already saving the system over $1,000 U.S. dollars per patient, Dr. Arshinoff noted.

“Sharing a small part of the financial gain from ISBCS with the surgeon would remove disincentives for ISBCS and save health-care systems huge amounts of money,” he said.

“Delivery of health care should be based upon scientific evidence of what is best for the patient,” Dr. Arshinoff concluded. “Ophthalmologists, globally, should politically resist imposed ill-conceived restrictive health-care schemes.”

Steve A. Arshinoff, MD, FRCSC

E: ifix2is@sympatico.ca

Dr. Arshinoff has no financial interest in the subject matter.


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