Extra preoperative consultations for Medicare patients about to have cataract surgery have increased rapidly, a University of Washington researcher has found, but the referrals, which incur additional charges, are often for healthy patients who don’t need the evaluations.
Dr. Stephan Thilen, a University of Washington assistant professor in the Department of Anesthesiology & Pain Medicine, focused on extra preoperative consultations for patients about to undergo cataract surgery, the most common elective surgical procedure for patients covered by Medicare.
About 2 million Medicare beneficiaries each year undergo cataract surgery, a low-risk procedure for blurred vision caused by the lens of the eye becoming cloudy. A routine preoperative and preanesthesia evaluation by doctor and anesthesia provider is included in the set fees Medicare pays.
Many patients also get another consultation — a formal preoperative one with a third doctor, which is billed separately, Thilen found after analyzing a random sample of claims from 556,637 patients from 1995 to 2006. In some regions, as many as 69 percent of Medicare cataract-surgery patients get an extra consultation.
Referrals for these consultations, Thilen and his colleagues wrote in the study published recently in JAMA Internal Medicine, “seems driven primarily by nonmedical factors including practice setting, type of anesthesia provider, and geographical region.”
Ideally, such consultations would only be done for high-risk patients who need extra assessment. But that’s not what has been happening, Thilen said.
If a patient who is generally healthy needs such a consultation for a “uniquely low-risk” procedure, he asked, should all patients coming for surgery get them as well?
“We don’t believe that all patients need to have a preoperative consultation,” Thilen said.
Extra consultations were relatively low in the South and West, but the rate was three times higher for patients living in the Northeast.
When he analyzed the data by “hospital referral region,” which designate regional health-care markets for special consultative care and include a major referral center, he found a huge variation. In several regions, no patients were sent for extra consultations, while in others, 69 percent were.
“When you talk about a discretionary service like this, without a clear indication or guideline, there is a practice culture that developed — a culture that has taken hold in a certain geographical region,” Thilen said.
Although he looked to see if patients had any high-risk diagnoses that might arguably qualify them for an extra consultation, he said the scope of this study didn’t show whether doctors or patients initiated the request for a consultation.
“I believe it is very unlikely that patients are driving this process,” he said.
Some doctors argue that higher rates of consultations reflect increasingly better levels of care. Dr. Daniel Albert, a founding director of the University of Wisconsin McPherson Eye Research Institute, told Reuters Health that the idea of doing “a more stringent examination” within 30 days of surgery became widespread overThilen’s study period.
Albert, a professor in the department of Ophthalmology and Visual Sciences at the University of Wisconsin who was not involved in the study, suggested that the data could be outdated, since the procedure has changed significantly since the beginning of the study period.
“It’s much safer, and the complication rate is far lower than it was in 1995,” he told Reuters.
In the last year of the study period, 2006, more than 18 percent of Medicare cataract-surgery patients were referred to such consultations — up from 11 percent in 1995.
At about $180 per consultation that adds up to a figure approaching $65 million — just for cataract surgeries, which are typically done in less than half an hour.
Overall, about 50 million surgical procedures are done in the U.S. annually, Thilen said.
“The question is: How should these patients be managed properly, rationally, cost-effectively?” he said. “We have limited resources and we need to devote them where they make a difference and we don’t waste resources.”
Eliminating unnecessary or wasteful tests and procedures is a focus of a recent campaign by the American Board of Internal Medicine called “Choosing Wisely,” noted Dr. Lee Fleisher in a commentary accompanying the study.
Such efforts to rein in “low-value or no-value care” could potentially save substantial amounts of money, said Fleisher, a professor and chair of anesthesiology and critical care at the Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
Fleisher urged doctors to begin “choosing wisely” on consultations and tests “before external forces do it for us.”
He noted that there has been a shift away from paying for each service separately — the “fee for service” system. Insurers and government payers, such as Medicare, are among those most keenly interested in this change.
Thilen said that in his practice he sees patients who should have had a preoperative consultation but didn’t, and vice-versa. His research group, he said, wants to improve operative care across the board, and is in the first stages of what he hopes will be a long-running research project.
“This is uncoordinated care, which we’re famous for in the United States,” Thilen said. His effort, he added, “isn’t all about finding waste and cutting that out — it’s about establishing rational models of care.”
Material from Reuters Health is used in this report.