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Up Front: Chief Medical Editor's Page | Nov 2010


I read the news brief in the July issue of Cataract & Refractive Surgery Today, “Medicare Patients 5.5 Times More Likely to Get Cataract Surgery Than VA Patients,” with a sneer upon my face. From all appearances, the article seems to indicate that there is either an inappropriately high frequency of cataract surgery performed on Medicare patients or an inappropriately low frequency of cataract surgery performed on VA patients. The implication of the article is that the difference was most likely the result of profit incentives from the surgeons and facilities that provide cataract surgery to the Medicare population. The authors of the study point out that the salaries of the VA physicians are not tied to patient surgical volume. These findings are from a large 8-year study reported in the American Journal of Medical Quality.1

“The researchers concluded that the results of the study raise questions about the possibility of a two-tiered, federally funded health care system that may not be equivalent in terms of quality, leaving ample reason to further investigate the determinants of cataract surgery rates,” according to the news item.

Wow! It sounds like trouble to me. Two tiers. Financial incentives.

I was trained in a residency program that staffed the Truman VA Hospital. I have been an attending surgeon at the John Cochran VA Hospital for the last 19 years. I am proud to teach at this fine institution, and the staff there delivers excellent care.

Based upon over 20 years of service within the VA as an ophthalmologist, I can relate the following observations. The fine men and women who served our country have lots of ocular pathology, and this includes cataracts. The percentage of all veterans who seek care from the VA likely has a higher rate of visually significant cataract than the same-aged cross-section of civilians. The veterans who seek care from the VA often travel very significant distances to seek their benefits, and this commute is a hardship that creates a disincentive for them to come. The attending physicians who are paid anything from the VA, in my experience, do not have any financial incentive to do cataract surgery. I have never seen an attending physician perform cataract surgery for a veteran in the primary surgeon’s position. I have only seen ophthalmology residents performing surgery on veterans. Not that I actually believe that this occurs, but there would technically be a disincentive for the VA staff ophthalmologists to do any cataract surgery at all, since they get paid the same either way. Finally, if you have ever been to the VA, the turnover between cases is typically very long. This means that, when I attend surgery at the VA, we typically plan to complete two cataract operations between 8:15 AM and 12:00 PM. Sometimes, if the resident is really fast, we can get the third one started by noon.

Remember, the residents are learning how to do surgery correctly, so they are slow, too. In the same space of time, I can perform eight to 10 cataract operations on people who I believe actually need the surgery. Because of the training and slow turnover, the throughput at the VA is very low. In fact, they are around five times slower than typical civilian operating facilities, which is pretty close to the 5.5 times greater frequency of surgical activities that were found in this study. Although it may be possible that there is some undertreating or overtreating as these authors conclude, my suspicion is that these different rates are primarily due to differential throughput capacities and not inappropriately greedy physicians and facilities.

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