Cataract surgery has advanced over the past 2 decades into a procedure that is very successful and minimally invasive, with the ability to give excellent vision to our patients. But it has also become increasingly expensive with the integration of new technology in our operating rooms. In the face of declining reimbursements and increasing regulatory burden, how will the economics play out in our surgery centers?

If we compare the equipment costs for a surgery center now vs 10 years ago, there has been a steep increase. Current surgical microscopes offer excellent visibility, a much-improved red reflex, high-definition video recording, heads-up surgical guidance, aberrometry, and even intraoperative OCT imaging. But it is also far more expensive, with prices exceeding $200 000. In the hands of an experienced surgeon, an older microscope without some of these bells and whistles will suffice at a small fraction of the price. For nucleus division, a half-million-dollar femtosecond laser will provide excellent results, but can’t we achieve something similar using a $200 instrument and the phaco chop technique? Phacoemulsification platforms have also evolved, with newer methods of ultrasound power delivery and forced-infusion fluidics that provide safer surgery. Luckily these machines have remained reasonably priced when adjusted for inflation. Even still, for a state-of-the-art single operating room with all of the newest technology, the equipment costs can exceed $1 million. Add the infrastructure for a surgery center, multiply by the number of operating suites desired, and you will have enough for a king’s ransom.

Even for preoperative testing, our devices again have evolved to give us more information than ever. We have high-resolution OCT imaging, corneal topography and tomography, optical biometry, and the ability to measure higher-order aberrations. With the use of refractive IOLs we can address astigmatism, presbyopia, and achieve excellent vision for our patients. Most of these advances simply did not exist a decade or so ago.

It is important for us to separate refractive surgery from cataract surgery. In the eyes of our third parties who reimburse us for the costs, the goal of our procedure is to address the cataract and not provide a specific refractive outcome. For patients desiring cataract surgery alone, cultivating reasonable expectations are key: they should expect to wear full-time glasses after the procedure. The majority of my patients elect to self pay  to address their preexisting refractive errors and to provide a large degree of freedom from glasses. And for these patients we are happy to do the additional testing, treatments, and postoperative management required.

For a standard cataract surgery, without the desire to achieve a specific refractive outcome, cost efficiency can still be achieved by simplifying the approach. Preoperative testing only requires a keratometer and an ultrasound A-scan. The operating room requires only a simple microscope and phacoemulsification platform, with older models being quite acceptable. All of these devices together can be purchased for about one-tenth the cost of equipment in the state-of-the-art surgery center for the refractive cataract patients.

And perhaps that’s where we are heading: a 2-tiered approach with patients desiring standard cataract surgery in one group and the patients electing to pay for a refractive outcome in the other. This is how it is split in many other countries and I expect the United States may follow to make the economics work.

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