A Closer Look: The US Model for Cataract Surgery Payment

On average, if a patient in the United States paid for all services and materials him- or herself, the cost of traditional cataract surgery would be $3,279 per eye;¹ this would increase more than $3,000 per eye, to an average of $6,461, if the patient selected a premium lens. Fortunately, although there is not universal government health care insurance in the United States, in most cases patients do not pay all of this amount. Instead, most patients are at least partially covered by US Medicare or by private insurance. The fees paid to surgeons vary among surgical centers and across different geographic regions.

The US Medicare system, a government-administered social insurance program that provides health insurance coverage to residents at least 65 years of age, to residents with a permanent or congenital physical disability, and to residents who meet other specific criteria, currently pays 80% of procedural fees for traditional cataract surgery. This rate covers the cost of the medically necessary portions of the procedure, including the surgery itself (approximately $700), the surgery center fee (approximately $1,000), and the anesthesia fee (approximately $500). If surgery is performed in a hospital, payment for the facility fee is higher because of the higher costs incurred by hospitals. The remaining 20% of procedural costs is either covered by a patient’s private (ie, secondary) insurance or paid out of pocket by the patient.

When discussing the US Medicare system, it is important to consider covered versus noncovered services. Noncovered services include, for example, refraction and corneal topography. Optical coherence tomography is not covered as a general screening examination for cataract surgery; however, it can be covered if the surgeon is identifying and treating a retinal condition, such as an epiretinal membrane. On the other hand, ultrasound A-scans, which are done to calculate the lens power, are covered.

OUT-OF-POCKET COSTS

Traditional cataract surgery involves implantation of a monofocal, nontoric IOL with no astigmatism correction. The US Medicare system allocates $150 for the lens implant. If the patient opts for a premium lens (multifocal, accommodating, or toric), he or she is responsible for the additional cost of the implant and any other costs directly associated with it, including extra diagnostic testing and extra refractions. The selection of a premium lens is considered an elective part of the cataract procedure, and the government does not regulate or pay for these additional fees. For this reason, the cost of premium cataract surgery is extremely variable across the United States.

Another out-of-pocket cost for the patient is any type of incisional surgery—limbal or corneal relaxing incisions— to correct astigmatism, as neither the US Medicare system nor private insurance companies cover astigmatism correction.

THE SPECIAL CASE OF LASER CATARACT SURGERY

At present, laser cataract surgery is still under investigation in the United States, and not many surgeons have access to this technology. The US Medicare system currently does not allow a surgeon to charge more for the same surgery performed by a more expensive instrument (ie, the femtosecond laser rather than a phacoemulsification probe). The only additional charges permitted in laser cataract surgery would be the limbal relaxing incisions created by the laser to correct astigmatism. For this reason, laser cataract surgery is typically offered only to patients with enough astigmatism (approximately 0.50 D or more) to justify placement of one or more limbal relaxing incisions. This may change if these lasers become more common—assuming their approval by the US Food and Drug Administration (FDA)—and as nonastigmatic patients demand access to the latest technology.

THE PROS AND CONS OF THE US SYSTEM

As indicated by the explanation above, payment for cataract surgery in the United States can be complicated. What is good about the US Medicare system is that its rules are clear and its payments are predictable. However, over the decades, the government has continued to cut physician fees—a reality that we are still grappling to accept and deal with.

What US cataract surgeons would like to see is a simple system that pays a fair price for the work done and that covers all patients, regardless of employment or income status. This is a formidable challenge in a world of escalating medical costs and continually improving technologies, but the ideal system would allow patients to see the doctors of their choice and would in turn allow us to respond by providing the services that they need and to receive fees that we feel are appropriate.

John A. Hovanesian, MD, is in private practice at Harvard Eye Associates in Laguna Beach, California, and is a Clinical Instructor at the UCLA Jules Stein Institute. Dr. Hovanesian states that he is a consultant to Allergan, Inc.; Inspire Pharmaceuticals, Inc.; Ista Pharmaceuticals, Inc.; and Sirion Therapeutics. He may be reached at tel: +1 949 951 2020; e-mail: drhovanesian@harvardeye.com.

1. All About Vision Web site.Cataract Surgery Cost.www.allaboutvision.com/conditions/cataract-surgery-cost.htm. Accessed August 4,2011.