How Much Does Cataract Surgery Cost? An RVU Analysis

So how much does cataract surgery cost you ask?  Mrs Happy's Grandma stayed at our humble cottage last night.  She underwent cataract surgery and couldn't drive the 30 minutes home yesterday.  Today Mrs Happy took grandma back for her follow up visit.  Everything was great.  The room was filled with people much older than grandma.  All of them looked decrepit.  Probably used a walker or a wheelchair.  Perhaps a cane.   None of them looked like they could break a sweat.

But a magazine on the rack caught Mrs Happy's eye.   Runner's World magazine.  You see, I have recently been excited at the prospects of Mrs Happy's new devotion to running.   This magazine had some excellent articles in it for the beginner.  She wanted to take the magazine home.  More on that in a little bit.

Mind you, this is an ophthalmologist office.  An office lined from door to exam room with old 100% insured Medicare patients draining the full service Medicare National Bank of all its bankrupt glory.   Perhaps a few minutes more or less checking off the mini H&P or reading the primary doc's H&P.   A few minutes to gown and glove and the race begins.  An army of nurses prepare the patient, dilate the eyes, fill out the paper work, the discharge work as the doctor roams from surgery to surgery at the speed of light.

It's a highly lucrative business, that cataract mill.   Not to mention the facility fees you get from owning your own specialty hospital. CPT® codes 66982-66984, depending on which code is billed pays between 10-15 work RVUs.  These are cataract extraction/lens implant codes.  Here is how cataract surgery cost is determined as explained through RVUs.  The current government rate is about $35 per RVU.  I'm sure there are other codes that can be added on as well.    This is a global 90 surgical period.  It doesn't really matter however.    The surgeon probably spent about 15 minutes operating perhaps another 5-10 dictating or talking with family.  Perhaps a good 10 minutes answering and looking at the eye post op day #1.  I would guess the total time spent was maximum, 45 minutes.  For which they were paid 10-15 work RVUs.  Not to mention practice expenses and malpractice.  That's $350-$500 for physician work effort (work RVU) only.  For 45 minutes of work.  And no phone calls.  No paper work.  No busy work.  No preauthorizations.  No family medical leave forms.  No disability forms.  No complicated drug evaluations.  No multiorgan failure.

Just to cut out a cataract.  And move on.  It doesn't get any better than that.  Remember volume rules in the current payment environment.  Pay for volume, get volume.  It doesn't matter what you do with any reform, as long as volume rules.  By the way, the cataract surgery cost  used to be much higher.  Now,  let me put that in perspective for you.  It's all relative.  For me to generate 10 RVU's of critical care time (in work RVUs) , I am paid 4.5 RVUs for the first 30-74 minutes of a dying critically ill patient (CPT® 99291).  The next 30 minutes could get me another 2.25 RVUs (99292).  The next 30 minutes could get me 2.25 RVUs (99292).

In other words, to generate just under 10 RVUs, I would have to take care of a critically ill patient with multi organ failure for two hours and fifteen minutes.  And I still wouldn't generate enough RVUs to equate to a 45 minute cataract surgery cost.

How about hospital follow up visits?  The highest level hospital follow up visit pays 2.0 work VUs.  I would have to see five of them to generate 10 work RVUs.  This is the highest level of complexity for a hospital follow up visit.  Here is how you meet the requirements.  The AMA expects a CPT® 99233 to take 35 minutes.  On a good day, I can maybe get five 99233 done in 30 minutes each.  That's 2 1/2 hours of work to generate 10 RVUs.

Now, let me ask you, as a medical student, if you have the opportunity to slave away with complicated medical disease or do 10 or more cataract surgeries a day generating 3-5x the income, which would you rather do.

Now back to the original story at hand.  Mrs Happy found this running magazine in the office full of old blind Medicare patients who couldn't walk without a walker, let alone take up running.  So Mrs Happy asked the front desk if she could take the magazine home with her, thinking it may as well get some good use out of it.

Thinking the asking was only a formality, she was shocked to learn that not only is the waiting area "low on magazines" (which no one can read anyway), but they asked she bring it back next week.  Almost offended that someone would even ask.  How about that.  I find good humor in it all.  An office raking in the dough like a blind puppy mill filled with senior citizens who can't see, let alone run.  And yet they can't seem to find enough cash to stock their front office with magazines.  And when they do, they pick a magazine that will find no use amongst the blind and disabled and find annoyance that someone would ask to take it home.  Most people would have just taken it.  That's what makes Mrs Happy special.

Good Facebook humor:

--> Major complication of cataract surgery from Grandma Happy: "I never realized how many wrinkles I have" Good humor... 

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

Print Friendly and PDF

37 Outbursts:

  1. I've seen cataract surgery and it is just that fast. That little implant unfolds in place like a charm. Patients also love their docs because their fears end up being for naught, and the improvement in their vision is usually amazing. The Docs I've met are happy and relaxed people. Sounds like a decent gig if you like cutting into eyeballs... day after day...
    -Second career nursing student

    ReplyDelete
  2. You're just jealous you didn't go into Ophtho.

    Ha.

    Seriously, I do not understand how *thinking* became so undervalued in medicine. It seems like the more thought is involved in a specialty, the less it reimburses.

    NeuroOphtho is a prime example of this. No cataracts, no dough. Ah the irony.

    ReplyDelete
  3. "None of them looked like they could break a sweat. "

    Unless they have gall stones.

    ReplyDelete
  4. Congrats I guess for not choosing to steal?

    Are you sure you ever break a sweat? Based on your paces to the right I'm not sure you do either.

    ReplyDelete
  5. Borrowing/stealing magazines from the waiting area - LAME

    Acting like you're entitled to those magazines - EVEN LAMER

    ReplyDelete
  6. O physician who complains about an entitlement mentality, heal thyself; the doctor's office is not a lending library.

    ReplyDelete
  7. Ok, now it is official, you're a tool.

    ReplyDelete
  8. i was once waiting in an e m p y t waiting room for my husband and i saw an article i thought he might really like...i asked one of the two ladies at the desk (who, as far as i could tell, were doing nothing) if she would be willing to copy it for me and i would p a y her to do it...she replied "I don't think we can do that." Bitch. This is at what a know to be a very lucrative practice that just happened to be qiuet at that time of day.

    ReplyDelete
  9. ROFLMAO... years ago I worked for a private practice during the days, so I could go to school at nite with no take home work responsibilities... we know you steal the magazines, we don't care, we get 'em for free (unless you are a clueless office). But WTF? Why should staff copy articles for you? Get a life. If you want the magazine, go buy it or just take it like a normal human being. Geesh!
    -Second career nursing student

    ReplyDelete
  10. If it was Runner's World, you might want to direct Mrs. Happy to their website, which is chock-full of info for beginners (and everyone else who runs). The articles she was interested in were probably posted on the website long ago.

    ReplyDelete
  11. When I had mine done,the bill was $5,000-per eye.Which my insurance co
    happily payed the entire cost of.I can see why people go to third world countries
    for non emergent procedures though,$ wise it's just not worth all that but
    emotionally,you cannot put a price on one of life's richest gifts.But in their defense,they did have excellent,up to date reading material so they obviously invested that money wisely.(haha)

    ReplyDelete
  12. I've worked in Drs offices for years,too. Very few people swipe them. I think that little white square thingie with the Drs. name on it dissuades them. And fergoodnesssake nurses who donate to their ER waiting rooms, you are marking out your address,right??? My PSA for today.

    ReplyDelete
  13. Nursing Student.
    i have a life thanks..and why should the staff copy an article for me when i will pay them to do it? Is just plain doing something nice for someone very concerned for a loved one in your new Nursing vocabulary? Is compassion? Hope you like nursing. And, oh yes, it was an o l d issuse of National Geographic and of course i wasn't going to steal it.

    ReplyDelete
  14. Some big time articles in these magazines, huh. Compassion = Magazines...hehe, I am so passive- agressive lately!
    -Second career nursing student

    ReplyDelete
  15. OK.Next time this happens,slip the receptionist a $20.Trust me, she'll take it.Ask her if she'll watch Grandma for a half hour while you make a quick run to Kinko's to get nice new color copies of the articles.No snot!! No ads!!No vexing moral dilemmas!! thanks for some really good entertainment,guys

    ReplyDelete
  16. So since the offices are given something for free, taking it from them wouldn't be stealing? Talk about morally bankrupt...

    ReplyDelete
  17. Aside from the ridiculousness of bizarre magazine kleptomania issues, you are being (unless you're just dumb) willfully disingenuous in comparing reimbursements. The payment to the ophtho is meant to cover all those people working in his office, the office, the lights, those magazines you love so dearly and any follow up appointments or further procedures she needs in the next ninety days. Your payment is meant to cover... you. Perhaps for your next comparison you can do apples and oranges.

    ReplyDelete
  18. As a first year ophtho resident who has seen hundreds of cataract surgeries that look easy - now that I'm trying to learn cataract surgery - I can tell you it's not that easy. It's among the most stressful undertaking I've ever attempted. The experienced attendings experience a great deal of stress as well, which may not translate well while watching a surgical video, for example. Many even very experienced surgeons do not get their cases down below 15 minutes of surgery time. Each case is nuanced, which is difficult to understand for the causal observer. The only possible way to spend only 45 minutes total with a pt between initial workup, preoperative appt, surgery itself, and multiple postops (minimum of 3, which includes typically a more extensive dilated exam as well as refraction and dispensing of glasses - which by the way the surgeon must provide, as it's bundled into the reimbursement) is to have a literal army of staff to do paperwork, field patient questions, and perhaps an optometrist or two to see postops, etc. This, as you can imagine, results in exceedingly high overhead paying multiple salaries. This is why mean ophtho salaries are on par with other surgical subspecialties. And unlike other surgical subspecialties, such salaries in optho typically take longer (more years in practice) to achieve due to the high overhead and the challenges of building a practice. I will probably make $120,000 - $150,000 starting out and may have to borrow another million or two to start a practice one day. My friend in internal medicine took a job at a hospital in CA on staff for $200,000, paid hourly for extra time, plus full benefits for he and his family, plus malpractice insurance. On another note, the cataract surgery complication rate is on the order of 1%, which means that complications are relatively common considering the volume. Many such patients must be seen daily or near daily for weeks to months to manage the complications. This is not meant as an exhaustive response, just I guess sort of a shotgun response to make the point that life is not all trips to the bank and ski vacations for the ophthalmologist. By the way I will instruct my future office staff to just give away the freaking magazines if someone asks.

    ReplyDelete
  19. Anon 10:17
    Didn't mean to imply that every cataract was an easy one. I did observe tableside (lucky me) the entire of many varied surgeries from that to CABG/valve etc., to trauma, to major hip redo etc. These all by excellent surgeons as well (lucky me :o) One thing I came away with is that each surgical specialty creates a different animal in its surgeon. Totally different people in every respect.

    Oh yea, and did you all know that nurses now buy malpractice insurance on top of any facility insurance? Not to your extent, but these days we really can't be without.

    -Second career nursing student

    ReplyDelete
  20. You're correct - I did learn of your blog through SDN. I otherwise would not have been aware of it.

    "Certainly neither is easy but to say that cutting out a cataract is 2-5 X more difficult, on a time based axis, is ludicrous."

    As a former medicine resident who has been responsible for managing multiple ICU patients, and as a new optho resident, I don't think that statement would fall into the ludicrous category. 8 hours rounding in the ICU with my attendings, while stressful and "intense", involves a lot of thinking, standing around, reviewing labs, talking to nurses, calling consults, looking at films, writing orders, talking to family, putting in a line, running an occasional code (sure which gets the adrenaline going), but none of which quite equates to the sort of driving on ice in the dark or walking on a tight rope kind of intensity that one feels when working with an instrument intraocularly.

    But this is a relatively fruitless point for extensive discussion, as I will likely never know what it's like to be an ICU attending, and you likely will never perform any intraocular surgery.

    You're correct that I lack an education on the way RVU's are figured. It sounds like you would feel better about things if the reimbursement structure was altered so that ophthalmologists had their practice expense component of RVU's increased and their work component decreased? That would be fine with me - I was just making the point that the medicare reimbursement for the procedure functions to fund many perioperative components and salaries, and does not simply just ensure that ophthalmologists make an easy $2000 an hour during their surgery days.

    "As for your starting salary, I wasn't born yesterday. I know how salary, profit sharing, partnerships etc work.

    As far as the 1% complication rate, and bundling the payments, again, I wasn't born yesterday. The time spent caring for the complications in a bundled system is peanuts compared to the amount of money paid in the 99 other cases, which seems to assume every patient will have a complication."

    This reimbursement schedule does not assume that every patient will have a complication. That scenario even with the present reimbursement system would likely make ophtho salaries the lowest in medicine, namely because we would rarely perform new cases - we'd just be in clinic managing complications. I know that you weren't born yesterday, which is why it's difficult for me to understand why you have so much energy around the way our specialty is reimbursed when you seem to acknowledge that we don't make particularly more than other surgical subspecialists, and in the case of my newly graduated friend I referenced above, even other hospitalists.

    ReplyDelete
  21. The thing about docs... (BTW, this doesn't happen in my old corporate world, so I do like to observe it sort of from a sociological micro point of view...) is, that you all do a lot of "You suck, and let me write a dissertation as to how much and why you suck." stuff to each other. I have also learned that nurses can be just plain tricky/bitchy to each other. This will take some adjustment for me. What an odd little sub culture I am entering into.
    -Second career nursing student

    ReplyDelete
  22. You have no clue. Ordering a BMP and replacing potassium, or prescribing a beta blocker takes about zero brain cells. Ophthalmologic surgery is the most delicate surgery on earth and the slightest mistake can mean blindness. Also, starting salaries for ophthalmologists is only around $150,000, which is the same as a hospitalist.

    ReplyDelete
  23. You really are a Dork...
    If you're gonna Steal somethin, don't ask
    permission...
    Can I come over to your house and "Borrow" that Running Magazine??? Perhaps a DVD or 2 cause I can't imagine a magazine about Running is very interesting...
    Some people are born to be Internists...

    Thanks for the idea... coming up with another differences between Surgeons and Internists post...

    Frank, M.D.

    ReplyDelete
  24. Intensivists are the absolute worst for sucking the Medicare dollars. As an internal medicine resident we spend millions on worthless procecures, tests, labs and care on people who come into the ICU with a life expectancy of basically zero. We save these people for a week until the doctor convinces the family to change a code status. If intensivists, ER docs, and yes admitting internists did their job we would stop the madness before the 80 year old with heart failure, metastatic cancer, emphysema, in septic shock sucked off thousands of dollars in a hopeless prolongation of the unevitable. Do not blame a surgery that seriously improves quality of life. My brother had cataracts and he says the surgery was the best thing ever for his life.

    ReplyDelete
  25. 7:41
    You are an internal medicine resident?! If you are looking for a way out there is a door with an exit sign at the end of the hall. If not you need to do some of your own soul searching. Why do you want to be a doctor? What is it you want to do? When you answer that, you can finish the crap that is your education, and focus your energy on what really is important to you in medicine. That is what I plan to do.
    -Second career nursing student

    ReplyDelete
  26. He's an Internal Medicine Resident for the same reason %90 of em' are...its required to do a Cards,GI,umm I think those are the only ones worth doin...Fellowship...

    ReplyDelete
  27. Uh oh, just wait till he perfs a colonoscopy and has to send the guy to ICU...
    -Second career nursing student

    ReplyDelete
  28. He/she and you are right, but what are ya gonna do.
    -Second career nursing student

    ReplyDelete
  29. I just spent 20 minutes or so reading through all these comments. I really need to get a life...

    ReplyDelete
  30. I am an Ophthalmologist who has been in practice for 10+ years in a sucessful, busy practice in an urban area. My take home pay is about 170K per year. Hardly getting rich.

    ReplyDelete
  31. What a sad commentary and a great example of how even someone on the inside could not be more wrong about his peers, while at the same time being correct about how things need to change.

    I am a young Ophthalmologist in a large city in solo practice. I make a rasonalble salary, nothing offensive. It cost me over 1m to start my practice, I have everything on the line, I will be in my late forties when I become debt free. I am good at what I do.

    Your descriptions in this blog are offensive and show how little you know about how your peers in other fields must perform to survive when not under the umbrella of the hospital industrial complex. You also imply poor quality which could not be farther from the truth.

    Cataract surgery reimbursment and its decline is well documented and has fallen BELOW the profitablity of staying in clinic. I have many older colleagues capable of operating, who send their cataracts to me because I still enjoy it and am proficient at it. They lose topline reveune but rarely take a salary hit, and simplify their lives and their liablilty tremendously.

    Defending the work RVU component of cataract surgery realtive to the intellectual value of 2.5 hrs of your time on the ICU floor is pointless, they are both very valuable and both undervalued. I can tell you I have been in both environments and nothing I saw in all of my training appeared more wasteful to me of our resources than watching the meter run in the ICU. 1/3 of our spending goes to hospitals and 1/3 of that is end of life care that other mature societies handle much more gracefully than we do. We handle it with a child-like stricken panick self inflicted by a largely ignorant population our hospital centric model.

    Your snapshot description reminds me of my lasik patients who on surgery days count the peole in the waiting room, multiply that times the cost of the procedure, and then imagine me depositing a check at the end of the day for that amount. But I'm not surprised you think that way, you are not used to thinking in a cost of business fashion, your a hospital employee.

    The only thing you could not be more right about is the need to abolish the current system and have not only a serious national debate about value, but beginning to empower the people to determine value. Nothing would give me greater joy. If you think I am overpaid now, imagine a system where hospitals did not have the legal favoritism they currently hold (which would put your job in jeapordy right off the bat), where patients had to actually think about where they wanted these limited resources to go and at what stage in their life they wanted the money to be spent. Where do you think those resources would go? I would be willing to wager they go to prevention, management of preventable and curable disease, and procedures that have a measurable impact on quality of life while quality is still good.

    This is not your realm my friend. You a pawn in a hospital centric model whose time needs to end. I would guess a third of your weekly work RVU is dealing with life threatening complications acquired in your own backyard. What patient unless it were forced upon them, would be willing to pay for that? I knwo what they think my cataract surgery is worth, I once asked 200 in a row in an internal survey and I can tell you its a whole lot more than 17 RVU's.

    ReplyDelete
  32. you are really wrong about the "no phone calls, no disability forms" etc.

    the preop counceling can last an hour.

    many cataracts are complex and take 45min to an hour.

    cataract surgeons are geriatric specialists, just like you. and when vision is on the line, you can bet there are lots of phone calls, disability etc.

    you forget the stress of cataract surgery. one mishap, and the patient is blind. how many rvu does the cataract surgeon get for telling the patient something untoward happened during surgery?

    'just to cut out a cataract' shows your ignorance.
    the grass is always greener.

    vision is 'critical' too, ask your patients.

    i don't perform cataract surgery, but i am very familiar with the LOW reimbursements.

    take a look at comp surveys. average comprehensive ophthalmologists comps arent much higher than critical care.

    you are jealous. maybe if you were in the top 5% of your medical school class at an elite institution, had perfectly steady hands, and a more even handed approach to looking at problems, you could be a cataract surgeon too!

    ReplyDelete
  33. Here is a nice summary from 2007. Pan down to the chart on compensation per work RVU and compare a Hospitalist to an Ophthalmologist.

    http://www.rsmmcgladrey.com/images/stories/amga_compsurvey.pdf

    ReplyDelete
  34. dear happy hospitalist. i am not a resident, i have practiced ophthalmology for over 10 years. as i said before, i don't perform cataract surgery, but i do perform facial plastic surgery. contrary to your writings, i do think cataract surgery is worth 2-5x more. only a hospitalist or non-surgeon would compare scratching ones beard by the bedside to determine a medication dose or frequency to surgery. surgery requires all of your problem solving skills, plus specialized dexterity and fine motor training/skills, plus additional skills to deal with the surgical patient, plus the risk of potentially blinding a patient at any moment during a complex surgery occuring at video game speed. the 'mill' you talk about is a tribute to ophthalmologists' innovative skills and has helped millions of people see throughout the world while decreasing reimursements for ophthalmologists. ophthalmologists are just better than hospitalists at staying one step ahead of the payors by innovating to help more patients in faster and safer ways. risk is a factor in e/m coding, and the same applies to rvu. further, owning a successful asc requires skills and risks hospitalists just don't have or want, its not free or easy money. hospitalists do not perform nanosecond type decsions hundreds of times a day. unless that includes avoiding a confectionary sugar spill from a doughnut on their white coat. while i am literally running from one 'puppy mill' to the next in our hospital to perform my craft and help patients, i trip over 'rounding' hospitalists every day. unfortunately, the rounding is often of the waistline variety rather than the bedside type.

    ReplyDelete
  35. Dear Happy Hospitalist: Always enjoy your blog especially since I as an ophthalmologist who works in a "blind puppy mill" don;t get to work in a hospital much anymore. Before 1987 we did most of our work in the OPD of hospitals. However we were 'thrown out' by many because the hospital could not figure out how to do it efficiently mixing very sick people with outpatieiint surgery. The history of ASC development has been one of adaptation to internal conflict and external pressure.. As reimbursement decreased efficiency became very important. When I started prior to IOLs and phacoemulsification a typical case took from 40 minutes to an hour, required retrobulbar injections with all the attendant risks of heart block, punctured eyeballs, as well as a two or three day stay in hospital. The informed, inclding some physicians see a cataract surgery and probably align it with starting an IV or PIC line. Today we do clear cornea incisons (bloodless) with topical lidocaine anesthesia, no blocks, and few post op problems. And yes, the vision on day one for most means they can read all those issues of "runners" and hiking and scuba diving. We even do multifocal IOLs. Today people live much longer and remain very active in no small part to the "puppy mills". Demand produces results and we have adapted. Currently we do a case in about 10 minutes for most surgeons, add the turnover time, run two rooms at a time, do 14 to 20 cases a day and back to the 'puppy mill'
    Next year with health care reform I expect a 30% increase in demand and our time for surgery will have to decrease to maybe five minutes for uncomplicated surgery. Believe me this surgery looks easy but is not. It's akin to sucking fluid through a piece of toilet paper without destroying the paper. I do understand your point of view, you deal with really 'sick patients". Hospitals don't provide magazines (although I seem to remember volunteers running around providng reading materials (probably don' offer that anymore since there is no CPT code or ICD to bill for it.
    Many of my colleagues have seen your post and were quite 'amused' by it, some were infurated. I see it as an interesting observation. Keep up the great work!!! Give Matt and Cooper a pat on the head and a bone from me.

    ReplyDelete
  36. You're wrong on multiple points most of which have already been pointed out. The one thing you did get mostly right was "if you have the opportunity to slave away with complicated medical disease or do 10 or more cataract surgeries a day generating 3-5x the income, which would you rather do."

    I LOVE what I do (cataract/cornea) and couldnt imagine life as anything but an ophthalmologist. I WISH I made the 3-5x of the average pcp.

    ReplyDelete
  37. Um? Entitlement mania? Im sure you make pretty good money too, pal. You dont really need that TV of yours, or that lawn mower do ya? Im sure you wouldnt mind if I just helped myself to em... What a weirdo you turned out to be.

    ReplyDelete

By Posting Here I Promise To Do Something Nice For Someone Today