Surgeons may be reluctant over simultaneous bilateral cataract

Lisbon, Portugal-Significant financial "disincentives" on the part of governments worldwide may be a major contributing factor to why cataract surgeons are reluctant to perform simultaneous bilateral cataract surgery (SBCS), reported Steve A. Arshinoff, MD, FRCSC, at the annual meeting of the European Society of Cataract and Refractive Surgeons.

To reach this conclusion, Dr. Arshinoff, in collaboration with Sylvia Chen, a joint MBA-MD student, surveyed Canadian provincial health plans and asked well-known international surgeons to submit corresponding information on the financing of SBCS compared with unilateral surgery in their home jurisdictions. The collected data were analyzed for similarities and differences, and related to known patterns of relative popularity of SBCS in the same jurisdictions. They analyzed the health-care financing of SBCS in the four most populous Canadian provinces, the United States, and select Western European countries, and sought to assess whether the financial environments of these areas encouraged or discouraged cataract surgeons from performing SBCS.

"In the real world, everything responds to money, and this is why governments agonize endlessly over how they divide money and how nations, by shifting 1% to 2% of resources every year, change society over a reasonably short time," Dr. Arshinoff said.

Greater surgical efficiency

In presenting the data, Dr. Arshinoff outlined the number of SBCS cases he performs as opposed to his unilateral cases. While he performs his difficult cataract cases with unilateral surgery, he increases his surgical efficiency by 15% to 30% when he performs SBCS.

In comparing physician fee ratios among the large Canadian provinces, he looked at what cataract surgeons get paid if they do SBCS compared with unilateral surgeries.

"In British Columbia, the return is terrible and surgeons do not want to do SBCS," Dr. Arshinoff reported. "In Alberta, surgeons might break even if they are very efficient. In Ontario, where I practice, the surgeons do about the same."

Dr. Arshinoff then looked at how well Canadian surgeons and anesthetists do if they perform SBCS.

"There is nowhere in Canada that it is consistently good for both the surgeon and the anesthetist to perform SBCS. Alberta is okay and efficient surgeons and anesthetists can break even; but everywhere else doctors suffer significantly if they do SBCS," he said.

He concluded that it was not generally beneficial for Canadian doctors to perform SBCS compared with unilateral surgery, despite the cost efficiency that can be gained for the system with SBCS.

He also looked at the situation worldwide and found basically the same results. In Australia, the surgeons fared terribly if they did SBCS, he said. Japan and Israel were the worst of the countries evaluated, according to Dr. Arshinoff. In both countries, the surgeons were not reimbursed for the surgery performed on the second eye, and consequently, few perform bilateral surgeries. In the United Kingdom, one of the places where surgeons are most willing to perform SBCS, surgeons actually may gain 5% or 10% by performing bilateral surgery, if they are efficient, he said.

In the United States, surgeons in private practice uniformly lose a substantial amount of money every time they perform SBCS.