Disclosures: Beckman and Kontos report no relevant financial disclosures.
November 17, 2020
6 min read

Surgeons weigh value of same-day bilateral cataract surgery

Mark Kontos, MD, and Kenneth A. Beckman, MD, FACS, look at the pros and cons of the controversial practice.

Disclosures: Beckman and Kontos report no relevant financial disclosures.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

Bilateral sequential same-day cataract surgery has been gaining momentum recently. This practice may have numerous advantages but also several disadvantages and added risks. This month, Mark Kontos, MD, and I will discuss the pros and cons of this controversial practice. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS

Same-day surgery is bad business for ophthalmology

There are many compelling reasons to consider bilateral same-day surgery for some patients.

Mark Kontos
Mark Kontos

Patients who have a risk with use of anesthesia, have difficulty with IV sedation or have conditions that may make it difficult to come into an operating space more than once would be good candidates for same-day bilateral cataract surgery.

But when you choose bilateral same-day surgery, it is important to acknowledge you are willingly devaluing your services and sending a troubling message to CMS, or whomever is determining the payment of surgery, that you are willing to work at a discounted rate.

When surgeons choose bilateral same-day surgery, they are paid in full for the first eye, but then the second eye is reimbursed at only 50%. The lost revenue is problematic for a practice, but the fact that surgeons are willingly performing the surgery at a reduced reimbursement is a dangerous precedent. We are choosing to take a 25% pay cut and letting our work be devalued.

Sometimes as surgeons we can get too focused on what is convenient for a patient as opposed to what is best for the practice of ophthalmology. It is true that same-day bilateral cataract surgery can be a more attractive option to a patient. Patients can have both of their eyes taken care of in the same setting, and it saves them time and office visits. Some surgeons promote this in their practice for their premium IOL procedures. Of course, when we do premium IOLs, we can do both on the same day, and we can mitigate the lost revenue by adjusting what patients pay out of pocket for the procedure.

But if you examine same-day bilateral cataract procedures closely, the convenience factor is apparent for the patient but for nobody else. An ASC must still do the same amount of planning, provide the same amount of disposable supplies and, in many cases, solve additional logistics issues. The staff must make sure lot numbers are separate for both surgeries, they must manage a period of time for patients in between surgeries as opposed to letting them leave after a single procedure, and they must solve problems that may arise during the day.

Surgeons also face an increased risk for liability with same-day surgery. If there is a problem, it is going to be a significant issue for the patient and surgeon. They very well may be dealing with elevated pressure spikes or complications in both eyes such as cystoid macular edema or a devastating infection. Patient convenience becomes a poor defense in that scenario.

The merits of same-day bilateral cataract surgery are all about patient convenience. Surgeons have increased liability and risk with the procedure and are paid less. It just does not make sense.

We need to find an alternative to this practice. But what is the solution? My answer to all of this is bilateral sequential separate-day surgery. It makes more sense from a business and health standpoint for everyone involved. Schedule surgeries on 2 days each week, do the first eye on day 1, bring patients back for a postop check on day 2, and if everything looks good, we go right into the OR and do the other eye.

This solves a lot of issues for all parties. It reduces visits and eliminates many logistical and outcome-based problems patients have with wanting to get both eyes done on the same day. You can eliminate most bilateral problems such as refractive surprises, in which the lens calculation may have been off, pressure spikes or other issues by bringing them back the next day for their postoperative exam. The second surgery can be easily modified based on the results of the first eye. You lose this opportunity with same-day surgery.

By performing the second surgery on the subsequent day, surgeons are fully reimbursed for their work. The value of the procedure is protected, we still allow patients to have a reasonable factor of convenience, and we are not allowing agencies that decide on reimbursement to give us less than what our services demand.

Same-day surgery, while convenient for the patient, is not good practice for us as surgeons or businesspeople. It creates the impression we are willing to diminish our services in an era when we are already being bombarded with lower reimbursement rates. Why make it easier for that process to continue?

Bilateral sequential separate-day surgery is a sensible alternative to protect reimbursement, provide patient convenience and send the message that our services will not be devalued.

Same-day surgery may reduce backlog

The concept of same-day bilateral sequential cataract surgery has been discussed among ophthalmologists for years and has long been a source of controversy and disagreement. The obvious counter to this practice is patient safety. The risk for a catastrophic complication such as endophthalmitis, which can affect both eyes from the same-day surgery, would be devastating. In addition, when visual recovery took much longer in the past, the patient might be rendered incapacitated while recovering from bilateral surgery. Now that techniques have improved dramatically, and recovery is close to immediate for so many patients, that risk seems to be much less of a hurdle.

Ken Beckman
Kenneth A. Beckman

Of course, there are many other pitfalls, which Dr. Kontos has discussed already. These are related to not only logistics but also to reimbursement. Unfortunately, during this era of an aging population with greater need for access to surgery, as well as the sudden backlog of cases due to the COVID pandemic shutting down surgery for months, we are having even greater difficulty accommodating patients who need to be treated to continue their activities of daily living.

Some surgeons have elected to move in the direction of same-day bilateral surgery to help decompress the backlog. As Dr. Kontos mentioned, this may create a financial crisis to the surgeon who does this, which may then trickle down to every surgeon. Now that we are in this situation with patients struggling to get treated in a timely fashion, it appears that this topic needs to be addressed again.

During the past several months, the government has tried to allow leniencies in medical practice to accommodate patients. This has included loosening restrictions on telemedicine and other requirements to enable physicians to treat patients in a safe and timely fashion. With the glaring need to move cataract patients in a more timely fashion, perhaps it is time to address bilateral same-day cataract surgery as well.

To the surgery center and hospitals providing these services, they treat each eye as a completely separate case, with new supplies and operative setups. While there is only one admission required, with one IV and one course of anesthesia, most of the costs are duplicated, but reimbursement is only 50% for the second eye. Perhaps the payers could consider treating each eye as a separate event and reimburse as such. The same goes for the surgeon, whose role in the surgery is identical for each eye. If the payers were to reimburse the surgeons and the surgery centers in full for both eyes, then this practice may increase dramatically. The advantage is providing access to surgery for many more patients, requiring fewer postoperative office visits as well. This would open the office for more patients to be seen and would allow surgeons to accommodate many more patients requiring cataract surgery. There would be no increase in cost to the payers, as those patients would have otherwise been treated on separate days in which full reimbursement would have been standard. The surgery centers and hospitals would actually save money, despite duplicating supplies, and be able to move more patients through in the same amount of time.

I do not know the best option in this situation. Obviously, patients are struggling to be seen and to be treated in a timely fashion. With the current reimbursement system, the option of same-day bilateral surgery is not likely to gain much traction, and a viable method to decrease the backlog may never come to fruition. As we all have adapted during the COVID crisis to come up with ways to be more efficient, safe and accommodating, this practice may be what we need to solve this backlog.