EyeWorld India September 2016 Issue

September 2016 24 EWAP FEATURE everyone from the nursing staff to the surgeon to whoever buys materials is involved in the decision about what is being changed and why. He also said nothing used on the patient’s first eye during surgery is used for the second. “By doing that, there hasn’t been a single case of TASS reported in bilateral cataract surgery in the world,” he said. Is reimbursement a barrier? While patient safety is always the physician’s top priority, some cannot ignore the reimbursement factor. In the United States for example, Medicare reduces reimbursement of the surgeon’s and the facility’s fees to 50% for the second eye if operated on the same day. “Obviously, this is not sustainable because the cost of doing the second eye is about the same as the first—we are doing two completely separate procedures,” Dr. Stiverson said. Dr. Mamalis agreed that the financial burden is a factor in a surgeon’s decision-making process regarding ISBCS in the U.S. “I think being convinced of the safety issues and advantages of the efficacy are going to be things that we’re going to think about first, but we do have to think about the financial aspects,” he said. Dr. Arshinoff said that due to recent reimbursement changes in Ontario, Canada, which went from 85% for the second eye to “essentially nothing,” he no longer practices in a hospital setting. In January 2016 he started performing ISBCS in a private center and now has a 6-month wait list. “The patient has to think, ‘How much does it cost me to take a month off work and how much does it cost me to pay for the surgery?’” he said. “It’s a lot cheaper to pay for the surgery.” Even with some of the reimbursement disparity, Dr. Arshinoff said it might still be worth it for physicians to consider performing ISBCS as savings could be realized through fewer visits to the clinic and time saved in the operating room, which could allow for more patients to be seen in the long run, for example. A prospective, controlled, nonrandomized clinical trial involving 42 patients in a private practice by Sloan Rush, MD , Panhandle Eye Group, Amarillo, Texas, et al. published in 2015 in the Journal of Cataract & Refractive Surgery evaluated the visual and economic benefits of ISBCS and found that the overall cost of ISBCS was lower. 5 The economic factors included the total number of patient visits, distance and time traveled for patients, physician reimbursement for bilateral surgery, total reimbursement for the ambulatory surgical center, and cost to the third-party payer. The economic benefit fell on the patient, not the surgeon, the study authors found. “From the physician’s perspective, same-day bilateral cataract surgery had similar clinical outcomes but almost an entirely negative economic impact compared with separate- day bilateral cataract surgery,” the study authors wrote. Based on these conclusions, the study authors made reimbursement recommendations to the Centers for Medicare and Medicaid Services. Based on the number of Medicare patients receiving cataract surgery and the percentage of them having their second eye operated on within 3 months, the study authors wrote that adopting their recommendations could yield a net 2% savings—$72 million annually—on the $3.4 billion annually spent by Medicare on cataract surgery. Since his first ISBCS in the 1980s, Dr. Arshinoff has watched the conversation about same- day cataract surgery change from “totally negative” toward a conversation where he thinks “everyone is going to start doing [same-day] bilateral cataract surgery.” But for now, the centuries-long debate continues. EWAP References 1. del Castillo M. Operación de las cataratas bilaterales en sesión única. Studium Ophthalmologicum . 1986;5:84–8. 2. Lundström M, et al. Benefit to patients of bilateral same-day cataract extraction: Randomized clinical study. J Cataract Refract Surg . 2006;32:826–830. 3. Lansingh VC, et al. Benefits and risks of immediately sequential bilateral cataract surgery: a literature review. Clin Experiment Ophthalmol . 2015;43:666–72. 4. Witkin AJ, et al. Postoperative hemor- rhagic occlusive retinal vasculitis: Expand- ing the clinical spectrum and possible as- sociation with vancomycin. Ophthalmology . 2015;122:1438–1451. 5. Rush SW, et al. Prospective analy- sis of outcomes and economic factors of same-day bilateral cataract surgery in the United States. J Cataract Refract Surg . 2015;41:732–739. Editors’ note: The physicians have no financial interests related to their comments. Contact information Arshinoff: ifix2is@gmail.com Mamalis: nick.mamalis@hsc.utah.edu Stiverson: rkstiverson@live.com Immediately - from page 22