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Up Front | October 2019

We Are the Frogs

Most of us have heard some version of the story of the frog and the boiling water, wherein a frog placed into boiling water will immediately jump out, but, if the same frog is placed in room temperature water that is subsequently gradually heated, the frog will remain in the water until it is cooked. This story addresses the human tendency to accept highly undesirable circumstances if the onset of said circumstances is sufficiently gradual. It’s a great story, undiminished by the fact that it is scientifically untrue.1-3

The most recent proposed CMS cuts to reimbursement for cataract surgery are just the latest in a long line of cuts to reimbursement for this procedure. Given the general economic forces at work, the aging population, and the rising overall cost of health care, it is unrealistic to assume that these proposed cuts will be the last.

After the proposed cataract cuts were announced, our professional message boards lit up with outrage, despair, and discussions of the feasibility of opting out of Medicare entirely. A fair bit of anger was directed at our professional societies for “agreeing” to these proposed cuts. Rest assured, the proposed reductions were the result of intense negotiations among the AAO, ASCRS, and CMS that likely prevented much deeper cuts. Fairly quickly, the message board discussions quieted down, and most surgeons resigned themselves to this new financial reality.

A 15% cut to Medicare cataract fees will have a dramatic and, frankly, devastating financial effect on many practices across the country, perhaps to a degree many have not yet fully comprehended. Cataract fees represent a large percentage of the typical anterior segment surgeon’s revenue. Many of our practices already operate at high overhead levels because of the ever-increasing need for sophisticated capital equipment and highly trained staff in our technology-driven specialty. While our costs never seem to go down, our revenue is about to take a major, direct hit. Speaking bluntly, these cuts will financially ruin many practices if they attempt to continue in their current paths.

The CMS reimbursement program is not a market-driven economic system. Prices are essentially fixed, and thus, for physicians performing cataract surgery, the only options available are whether to participate in Medicare or not. With the magnitude of these cuts, many physicians have already determined that it will make no economic sense for them to take time out of the clinic to perform cataract surgery. This trend will no doubt accelerate with future cuts. For most physicians, the decision to cease performing cataract surgery is not purely an economic one, but it is difficult to ask someone to take on the stress, liability, and physical toll of performing cataract surgery while his or her clinic time is valued more highly. Other physicians will react to these cuts in the same way that they have dealt with prior cuts: by increasing volume. The net result will be that cataract surgery will likely be performed by a smaller number of higher-volume surgeons.

Will the reduction in fees be enough of a jolt to prompt large numbers of us to jump out of the boiling water? I don’t think so, but the tipping point can’t be too far off. I wonder how much longer lower-volume cataract surgeons can possibly stay in the hot water, given the circumstances. And with the population of seniors growing at an unprecedented rate, a future crisis seems unavoidable. Ultimately, this will become an issue of access to care. Lower-volume surgeons still perform a significant percentage of the cataract surgery in the United States, and, if they were to stop doing so in large numbers, higher-volume surgeons would simply not be equipped to pick up all the slack, no matter how appealing that might sound to them. Ultimately, we will each have to decide our tolerance for what is becoming an intolerable system.

Steven J. Dell, MD | Chief Medical Editor


1. Kruszelnicki KS. Frog fable brought to boil. Conservation Magazine. March 3, 2011. conservationmagazine.org/2011/03/frog-fable-brought-to-boil/. Accessed September 18, 2019.

2. Next time, what say we boil a consultant. Fast Company. October 31, 1995. fastcompany.com/26455/next-time-what-say-we-boil-consultant. Accessed September 18, 2019.

3. Gibbons W. The legend of the boiling frog is just a legend. December 23, 2007. archive-srel.uga.edu/outreach/ecoviews/ecoview071223.htm. Accessed September 18, 2019.

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