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Why Cataract Surgery Is More Complicated Than It Should Be

Discussion in 'Ophthalmology' started by Hadeel Abdelkariem, Apr 16, 2018.

  1. Hadeel Abdelkariem

    Hadeel Abdelkariem Bronze Member

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    Eye surgery is a delicate business. It involves operating within an orb the size of a large marble to remove a cataract or repair a retinal detachment.

    Not only is superb eye-hand coordination a must, but also an awareness of the myriad other medical issues in the elderly population most in need of eye surgery.

    Traditionally, patients undergoing cataract surgery had a preoperative medical evaluation, including blood work, chest X-ray, and EKG, to determine their suitability for surgery. This is a remnant from the days when cataract surgery was a long operation with a week of hospitalization and bed rest.

    Today, it’s a much quicker procedure, performed with minimal anesthesia. Patients return home an hour after surgery. It’s no surprise that researchers from the University of California, San Francisco found that routine preoperative testing before cataract surgery is neither necessary nor cost-effective.

    Case closed, right? Not so fast. Enter the bureaucrats. The Joint Commission and Centers for Medicare and Medicaid Services require all patients undergo “A comprehensive history and physical assessment” prior to their surgery — including for post-cataract YAG laser procedures that take only minutes to perform. This usually means a referral to another doctor. But even worse, the bureaucracy mandates that the preoperative physical be performed “No more than 30 calendar days prior to date the patient is scheduled for surgery in the [ambulatory surgery center].” Also, it must be done then “Regardless of the type of surgical procedure.” This means that a healthy 68 year old, who had her annual physical six weeks ago, needs to repeat the process in order to have a two-minute laser procedure.

    Note that if the same patient were undergoing a molar extraction or a root canal — both longer and far more invasive surgeries — needs none of this.

    Why all this bureaucratic red-tape? It’s called “defensive medicine.” If an elderly patient happens, by timing and bad luck, to have a critical medical event during the few hours they are at the surgery center, the surgeon will be blamed for not knowing this would happen and not taking appropriate measures to prevent it. The tort lawyers will feast on his practice. Hence the excessive evaluation and testing, just in case.

    Still another group of bureaucrats, insurance companies, have also nosed into eye surgery. Anthem’s new policy decrees, “It’s not medically necessary to have an anesthesiologist or nurse anesthetist on hand to administer and monitor sedation in most cases.”

    Says who? The suits in the corner office at Anthem think they know better than surgeons. Meaning that when the surgeon is intently focused on the delicate task at hand, and the patient’s blood pressure drops or their heart rhythm starts dancing, the surgeon is expected to notice this and manage it appropriately while at the same time performing intricate microsurgery on the eye. How might that work out?

    I wonder how many Anthem executives would let their mother with high blood pressure have eye surgery without an anesthesiologist monitoring Mom’s vital signs?

    Bureaucrats and surgery just don’t mix. On the one hand, they mandate costly and unnecessary preoperative testing. On the other, they cut corners by refusing to pay for appropriate patient monitoring during actual surgery. They strain out the fly and swallow the camel.

    And we wonder why medical care in the United States is so costly without outcomes that reflect this high cost. Because the bureaucracy thinks it knows better. It requires low-value preoperative testing, while at the same time casting patient safety aside in a misguided attempt to save a few dollars.

    Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor. This article originally appeared in the Washington Examiner.

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