Lindstrom's Perspective

Incremental but transformational changes expected for cataract surgery

According to the most recent Market Scope data, we are approaching 4 million cataract surgeries per year in the U.S. The number of cataract surgeries is growing at about 3.5% per year. The average age of the cataract surgery patient in the U.S. today is just under 70 years, so the majority continue to be covered by Medicare.

When I started out in ophthalmology 40 years ago, almost all procedures were performed in a hospital. All had anesthesia standby, an IV was started, and most were done with a retrobulbar and facial nerve block or under general anesthesia. The typical procedure time approached 1 hour. Most were admitted to the hospital for 4 to 7 days.

Today, 20% of cataract surgeons do 10% of our nation’s cataract surgery in a hospital, but they are discharged the same day. The other 80% of surgeons do 90% of cases in an ASC. The ownership of the ASC varies, but the majority are surgeon owned. As we all know, topical anesthesia predominates, and anesthesia standby and an IV are still commonplace, but many cases are now done with oral sedation and a nurse with no anesthetist. Most are topical anesthesia, and procedure times are usually less than 20 minutes. If we evaluate cataract surgery using the goals proposed in the “triple aim” of the Affordable Care Act — good outcomes, happy patients and reduced cost — the cataract surgeon of today is the top poster child in all of surgery.

Through the combined efforts of surgeons and the industry that supports us, along with a heavy dose of innovation, cataract surgery is far better today in regards to outcomes as well as patient satisfaction and is an economic bargain per eye to boot. In inflation-adjusted dollars, the cost of cataract surgery is 10% of what it was 40 years ago. It would be impossible for we surgeons to meet the needs of our growing senior population today without the extraordinary innovations in surgical technique, technology and delivery models. Can you imagine trying to do 4 million intracapsular cataract extraction procedures per year in a hospital with 4 days of inpatient care and then 5 to 6 postoperative visits, including the fitting of a contact lens or aphakic spectacle? While we can and should pat ourselves on the back, the unfortunate fact is that we cannot rest on our laurels and must continue to innovate and make cataract surgery even safer, more effective and less expensive.

With a 3.5% growth rate, we will be doing 8 million cataract surgeries annually in 20 years, and it is unlikely the growth in demand will stop there. The approximately 9,000 surgeons who do cataract surgery, about 50% of U.S. ophthalmologists, is not expected to grow and may well decline slowly as retirement dominates over new trainees. So, I can imagine 8,000 U.S. cataract surgeons doing 8 million cataract surgeries per year by mid-career of the resident completing training today.

As we develop a procedure that can generate an emmetropic outcome in 99% of patients with high-quality dysphotopsia and spectacle-free vision from far to near, I can imagine patients demanding replacement of their “dysfunctional lens” soon after the onset of presbyopia. The median age of the patient who undergoes removal and replacement of his natural lens with an artificial lens will migrate down into the early 60s or perhaps even the 50s. As I try to look ahead to this future, I see several almost inevitable trends. Whether it is called an ambulatory surgery center (ASC) or an office surgery center (OSC), most surgery will be done in or adjacent to the doctor’s practice. The quality standards will remain high, as no surgeon or patient in the U.S. will accept any lowering of the safety. As patients become healthier and younger, there will be no need for an IV or an anesthetist in the vast majority of cases.

The psychological and physical trauma inflicted on a patient while having dental caries repaired, a tooth removed and replaced with an implant, or even simply having teeth cleaned at the dental office is, by objective analysis, arguably higher than a routine topical anesthesia clear corneal cataract operation. It is rare to have an IV and anesthesia standby when one visits the dentist. It is also rare to have the procedure outside the dentist’s office.

In the future, almost all patients will undergo same-day bilateral sequential cataract surgery, and there will be no drops to take after the surgery. Infection prophylaxis and inflammation/pain management will be by one or another approach performed by the surgeon during or just after the surgery before the patient leaves the ASC or OSC. Postoperative visits will decline, with some being done in a virtual fashion with the patient at home. Visual acuity, refraction, external and fundus photos, and maybe even an OCT will all be available on a smartphone app.

Economically, insurance will continue to play a role in reimbursement, but today’s so-called “fee for service” will be a historical footnote for the primary procedure. The primary procedure will be prepaid or capitated in one fashion or another, and the surgeon will be caring for a population of patients’ total eye care health, including the management of their cataracts. If a wound leaks or there is a retained lens fragment that requires a return to the OR, there will be no additional reimbursement and the surgeon/facility will bear the cost. If the patient requires a YAG laser capsulotomy, even 5 years later, there will be no additional fee to the surgeon. There will, however, be an ever increasing patient-shared responsibility for the cost of the care, and this is where reimbursement akin to today’s fee for service will persist.

We will transition from today’s “defined benefit plan” approach for insurance reimbursement to a “defined contribution plan” approach. A certain fee toward cataract surgery will be prepaid one way or another. On a positive note, so-called “premium options” of every sort will be allowed, and surgeons will be allowed to charge for anything and everything patients might perceive as beneficial, from chauffeured transportation to and from the facility to an enhanced surgery technique or IOL technology that provides patients benefits they are willing to pay for themselves. Most patients will have the option of having a preoperative, intraoperative and postoperative surgical procedure and experience customized to their individual needs. If they chose a “custom” approach, they will pay an additional fee negotiated with the surgeon/facility above the defined contribution.

We ophthalmologists will continue to meet and exceed the triple aim, improving outcomes and patient satisfaction, all at a reduced cost per eye to the third-party payer. The costs of cataract surgery to the federal and state government will decline progressively as the Medicare age is increased, Medicaid eligibility is tightened, high deductible plans proliferate and patients choose to have surgery in their early 60s before Medicare eligibility.

The dental analogy is, to me, an interesting one, and I see much in its model to emulate. It is the rare dentist who does procedures outside his office or repairs a single tooth at a time, scheduling them sequentially weeks apart rather than sequentially on the same day. Dentists also do not utilize an IV and anesthesia standby routinely. Finally, they delegate much routine care to employed associates and assistants and generate profit doing so. It is also the rare dentist who is being driven from practice or is suffering from burnout caused by dealing with the complexities of our current medical reimbursement and regulatory environment.

Time will tell, and these changes will occur incrementally and not all at once, just as they did over my career. But the changes that occur over the next 40 years are, if anything, likely to be even more remarkable, and I must add disruptive to those who lag in adoption, than these projections.

According to the most recent Market Scope data, we are approaching 4 million cataract surgeries per year in the U.S. The number of cataract surgeries is growing at about 3.5% per year. The average age of the cataract surgery patient in the U.S. today is just under 70 years, so the majority continue to be covered by Medicare.

When I started out in ophthalmology 40 years ago, almost all procedures were performed in a hospital. All had anesthesia standby, an IV was started, and most were done with a retrobulbar and facial nerve block or under general anesthesia. The typical procedure time approached 1 hour. Most were admitted to the hospital for 4 to 7 days.

Today, 20% of cataract surgeons do 10% of our nation’s cataract surgery in a hospital, but they are discharged the same day. The other 80% of surgeons do 90% of cases in an ASC. The ownership of the ASC varies, but the majority are surgeon owned. As we all know, topical anesthesia predominates, and anesthesia standby and an IV are still commonplace, but many cases are now done with oral sedation and a nurse with no anesthetist. Most are topical anesthesia, and procedure times are usually less than 20 minutes. If we evaluate cataract surgery using the goals proposed in the “triple aim” of the Affordable Care Act — good outcomes, happy patients and reduced cost — the cataract surgeon of today is the top poster child in all of surgery.

Through the combined efforts of surgeons and the industry that supports us, along with a heavy dose of innovation, cataract surgery is far better today in regards to outcomes as well as patient satisfaction and is an economic bargain per eye to boot. In inflation-adjusted dollars, the cost of cataract surgery is 10% of what it was 40 years ago. It would be impossible for we surgeons to meet the needs of our growing senior population today without the extraordinary innovations in surgical technique, technology and delivery models. Can you imagine trying to do 4 million intracapsular cataract extraction procedures per year in a hospital with 4 days of inpatient care and then 5 to 6 postoperative visits, including the fitting of a contact lens or aphakic spectacle? While we can and should pat ourselves on the back, the unfortunate fact is that we cannot rest on our laurels and must continue to innovate and make cataract surgery even safer, more effective and less expensive.

With a 3.5% growth rate, we will be doing 8 million cataract surgeries annually in 20 years, and it is unlikely the growth in demand will stop there. The approximately 9,000 surgeons who do cataract surgery, about 50% of U.S. ophthalmologists, is not expected to grow and may well decline slowly as retirement dominates over new trainees. So, I can imagine 8,000 U.S. cataract surgeons doing 8 million cataract surgeries per year by mid-career of the resident completing training today.

As we develop a procedure that can generate an emmetropic outcome in 99% of patients with high-quality dysphotopsia and spectacle-free vision from far to near, I can imagine patients demanding replacement of their “dysfunctional lens” soon after the onset of presbyopia. The median age of the patient who undergoes removal and replacement of his natural lens with an artificial lens will migrate down into the early 60s or perhaps even the 50s. As I try to look ahead to this future, I see several almost inevitable trends. Whether it is called an ambulatory surgery center (ASC) or an office surgery center (OSC), most surgery will be done in or adjacent to the doctor’s practice. The quality standards will remain high, as no surgeon or patient in the U.S. will accept any lowering of the safety. As patients become healthier and younger, there will be no need for an IV or an anesthetist in the vast majority of cases.

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The psychological and physical trauma inflicted on a patient while having dental caries repaired, a tooth removed and replaced with an implant, or even simply having teeth cleaned at the dental office is, by objective analysis, arguably higher than a routine topical anesthesia clear corneal cataract operation. It is rare to have an IV and anesthesia standby when one visits the dentist. It is also rare to have the procedure outside the dentist’s office.

In the future, almost all patients will undergo same-day bilateral sequential cataract surgery, and there will be no drops to take after the surgery. Infection prophylaxis and inflammation/pain management will be by one or another approach performed by the surgeon during or just after the surgery before the patient leaves the ASC or OSC. Postoperative visits will decline, with some being done in a virtual fashion with the patient at home. Visual acuity, refraction, external and fundus photos, and maybe even an OCT will all be available on a smartphone app.

Economically, insurance will continue to play a role in reimbursement, but today’s so-called “fee for service” will be a historical footnote for the primary procedure. The primary procedure will be prepaid or capitated in one fashion or another, and the surgeon will be caring for a population of patients’ total eye care health, including the management of their cataracts. If a wound leaks or there is a retained lens fragment that requires a return to the OR, there will be no additional reimbursement and the surgeon/facility will bear the cost. If the patient requires a YAG laser capsulotomy, even 5 years later, there will be no additional fee to the surgeon. There will, however, be an ever increasing patient-shared responsibility for the cost of the care, and this is where reimbursement akin to today’s fee for service will persist.

We will transition from today’s “defined benefit plan” approach for insurance reimbursement to a “defined contribution plan” approach. A certain fee toward cataract surgery will be prepaid one way or another. On a positive note, so-called “premium options” of every sort will be allowed, and surgeons will be allowed to charge for anything and everything patients might perceive as beneficial, from chauffeured transportation to and from the facility to an enhanced surgery technique or IOL technology that provides patients benefits they are willing to pay for themselves. Most patients will have the option of having a preoperative, intraoperative and postoperative surgical procedure and experience customized to their individual needs. If they chose a “custom” approach, they will pay an additional fee negotiated with the surgeon/facility above the defined contribution.

We ophthalmologists will continue to meet and exceed the triple aim, improving outcomes and patient satisfaction, all at a reduced cost per eye to the third-party payer. The costs of cataract surgery to the federal and state government will decline progressively as the Medicare age is increased, Medicaid eligibility is tightened, high deductible plans proliferate and patients choose to have surgery in their early 60s before Medicare eligibility.

The dental analogy is, to me, an interesting one, and I see much in its model to emulate. It is the rare dentist who does procedures outside his office or repairs a single tooth at a time, scheduling them sequentially weeks apart rather than sequentially on the same day. Dentists also do not utilize an IV and anesthesia standby routinely. Finally, they delegate much routine care to employed associates and assistants and generate profit doing so. It is also the rare dentist who is being driven from practice or is suffering from burnout caused by dealing with the complexities of our current medical reimbursement and regulatory environment.

Time will tell, and these changes will occur incrementally and not all at once, just as they did over my career. But the changes that occur over the next 40 years are, if anything, likely to be even more remarkable, and I must add disruptive to those who lag in adoption, than these projections.