Financially Efficient Cataract Surgery in Today's Healthcare Environment

Mark S. Hansen; David R. Hardten


Curr Opin Ophthalmol. 2015;26(1):61-65. 

In This Article

Abstract and Introduction


Purpose of review To review the literature and create a concise evaluation and comment on the ways to provide financially efficient cataract surgery in a healthcare environment that produces significant challenges to providing care, while maintaining quality outcomes, safety, patient satisfaction, and employee satisfaction.

Recent findings The recent reductions in reimbursement for cataract surgery have fueled an increased need to drive innovation in ways to be more financially efficient. At the same time, new technology in the field, especially as it relates to use of the femtosecond laser for portions of lens surgery, has increased the challenges in creating an efficient and cost-effective structure for providing care.

Summary Cataract surgery is one of the most beneficial procedures for a patient's quality of life, and is one of the most common surgical procedures performed. At the same time, the current cost–effectiveness is quite high, and yet there are still ways to become more financially efficient in many centers providing cataract care.


Cataracts are the most common cause of preventable visual impairment, and it is estimated that 22 million Americans over the age of 40 have a cataract.[1] By age 80, half of all Americans have a cataract. Estimates suggest that by 2020 the prevalence of cataracts in the USA will increase to 30.1 million.[2] With the exception of intravitreal injections for macular degeneration, cataract surgery is the most frequently performed surgery in the US Medicare population.[3] Ophthalmology is a specialty that relies heavily on patients with cataract-related diseases, and it is estimated that direct medical costs for cataract treatment are $6.8 billion per year; however, the reimbursements have been cut in half over the last several years.[4] Reports also indicate future cuts in reimbursement are on the horizon, with a suggested 13.6% Medicare payment for cataract surgery. With continually declining reimbursement, the growing need for cataract management, and these proposed cuts, it is critical to be financially efficient within the evolving healthcare environment.

Despite the enormous amount of money spent annually on cataract care, the quality-of-life gain is tremendous. In an evaluation of the cost utility of cataract surgery, it was calculated that monocular cataract surgery conferred a gain of 1.62 quality-adjusted life years (QALYs), whereas bilateral cataract surgery conferred over 2.8 QALYs of benefit.[5] The QALY metric is increasingly used to help understand how many years of expected life a patient would trade for a specific healthcare benefit. The fact that patients would trade almost 3 years of life for bilateral vision improvement after cataract surgery is telling for the importance of this procedure. Therefore, the growing desire for cataract surgery among this population will need to be managed with increasing attention to not only quality and safety, but financial efficiency.

There is a growing trend to move cataract surgery to ambulatory surgery centers (ASC) where efficiency may be maximized. Recent data have suggested that more than 50% of cataract surgeries are performed in an ASC rather than a hospital outpatient setting,[6] and the numbers are anticipated to increase. ASCs are able to concentrate on a smaller subset of surgical procedures to gain efficiency in equipment and also the efficiency obtained by performing the surgeries over and over again. In a hospital setting wherein a wide variety of cases may be performed on any given day, there is less efficiency from the difficulty in training the staff, coordinating equipment needs, and the care of the patients in the preoperative and postoperative areas. One of the best ways to increase the financial efficiency of cataract surgery over the next decade will be to increasingly consolidate these cases into surgical centers that are primarily delivering eye surgical services.

Although traditionally ASCs are more efficient than a hospital setting, or even a hospital outpatient surgical center, there is still a need to evaluate new ways to improve efficiency. In 2003, a study involving 62 centers found that those with the shortest procedure times had the most staff. In 2001, the median procedure time was 19 min with a turnover time of 24 min. Two years later in 2003, the median procedure time was 14 min and the turnover time was 13 min.[5] Although increasing the personnel helped with procedure time and turnover time, the cost of more employees reduced the profit margin with salaries being the major expense for multispecialty ASCs.[4] The key to a financially efficient system for providing cataract care is trying to reduce both turnover and procedure time without significantly increasing staffing costs or reducing the quality and safety of care for the patients.

Many articles have been published suggesting ways to increase efficiency and profits utilizing ASCs.[4,6–17] Some of these suggestions include:

  1. Surgeons should focus on surgery. Try to limit the amount of time the surgeon spends doing nonsurgical tasks. With a well trained assistant, this could even include speaking with family after surgery. Much of the preoperative and postoperative counseling can be done in the clinic before the surgery or on the phone at a convenient time for the staff and the patient.

  2. Have brochures and videos to assist in lens choice discussions. Some clinics have reported success using computer programs such as intraocular lens counselor. The patient should be certain of their lens choice before the day of the surgery to minimize disruption on the day of the surgery in flow of the operating room.

  3. Maintain a high volume to maximally utilize the operating room time. This may require marketing and maintaining relationships with referral sources. Understanding the typical seasonality of the surgical demand can also help to plan the needs for staffing. Staff may be able to do nonpatient-related activities such as training, equipment upgrades, or facility improvements when the demand for services may be less, such as winter in the northern regions or summer in the southern regions.

  4. Minimize the amount of preoperative paperwork. This can be accomplished by using standardized templates. Working to standardize as many of the processes as possible for various case types and also for various surgeons can have significant time savings for staff training and also for supplies.

  5. Surgeons who use the ASC should agree on a standardized tray of instruments. Unusual items or seldom-used items can be peel packed. The fewer instruments that are in a tray for the standard cataract surgery, the less cleaning and repackaging needs to be done, as well as less confusion when setting up and passing instruments on the table.

  6. Operating from the head of the bed will eliminate moving the scope and equipment around the room and decrease turnover time. If surgeons move from one side of the bed to the other for left and right eyes, then the surgical setup may need to be different for a left or a right eye, reducing efficiency. Some centers have tried to bunch together right and left eyes to allow these to be done sequentially, although this also increases the scheduling problems. For a right-handed surgeon, it is not too difficult to train yourself to operate temporal on the right eyes and nasal on the left eyes, so that you can remain at the head of the bed during the surgical procedure for a cataract surgery.

  7. If you do operate temporally, then organize cases by laterality. For example, the right eyes could be done in the morning, and the left eyes in the afternoon. If the surgeon does not feel comfortable sitting at the head of the bed for the cases, then organizing the cases by laterality can improve room setup efficiency.

  8. Keeping patients in street clothes improves the preparation time. The patients can wear shoe covers to reduce time in the preoperative and postoperative area with shoe removal and keeping track of clothes items.

  9. Having enough carts to eliminate moving patients from bed to bed. Moving a patient to a different bed in the operating room than in the preoperative and postoperative areas is particularly difficult and time consuming in the older patient population.

  10. Efficiency for the surgical procedure starts before the first case. Complete as much paperwork as possible ahead of time, and make certain the day before that everything is ready for the next day.

  11. Some clinics prefer to use a retrobulbar block on all cases. The blocks can be preformed in the preoperative area by an anesthesiologist or anesthetist to save surgeon's time. This may reduce the surgical time for the surgeon, but it also increases some costs for anesthetics and block supplies as well as anesthetist or anesthesiologist costs.

  12. Some surgical centers prefer sublingual or oral anesthesia that eliminates the time and supplies needed to obtain intravenous access.

  13. Using minimal sedation speeds the recovery process after surgery. Most patients are easily coached through the typical surgical procedure with a calm reassuring manner of describing what they will experience during the surgery, especially if they are warned about the sting of topical anesthesia, the pressure on the eyelids which are not numb, and the pressure sensation when the pressure goes up or down as the irrigation pressure is changed.

  14. Using Goniosol (Novartix, New York, NY, USA) or Goniovisc (HUB Pharmaceuticals, Rancho Cuamonga, CA, USA) or Cornea Coat (Insight Instrument Inc, Stuart, FL, USA) on the cornea maintains a clear view through the cornea and reduces the need of staff to irrigate the cornea.

  15. Compounded combined eye drops allow fewer doses of drops that need to be administered. An example of this is the 'slurry' method utilized by Dr Chang, which includes a lidocaine jelly, dilating drops, an antibiotic, and nonsteroidal anti-inflammatory. This is administered once before surgery and the eye is taped closed until surgery.

  16. Review postoperative drop schedule with the surgery scheduler prior to surgery. Have the clinic call the patient at home to answer any remaining questions. The drops can be started a few days before the surgery to make sure that any issues with insurance coverage, medication allergies, and physically obtaining the medications are taken care of and resolved before the day of the surgery.

  17. Keep the family within close proximity to the recovery room so that you can find them quickly after the case is over.

Constantly evaluating your process of efficiency before the surgical procedure, during the surgical procedure, during the turnover time in the operating room, and in the postoperative area can consistently drive efficiencies. The goal is to improve the efficiency while at the same time constantly improving quality of care and patient satisfaction. Like any other business, time is money, and a penny saved is a penny earned, so even a few minutes on each case may allow you to add a few extra cases throughout the day.