In last month’s e-newsletter I briefly commented about the shaky financial premise of cataract surgery, noting that, without income streams from such things as premium lenses or in-office services we lose money on every case. 

This has been true for some of us for some time, and for others it’s not far off. Why has payment for cataract surgery continued to decline? Is it cheaper to perform? No—and the associated costs of running a practice continue to increase. With balance-billing requirements we’re the only service that can’t pass on our costs to our “customers,” so we’ve had to figure out how to compensate. And, yes, we can take home fewer dollars, but who wants to? Don’t we deserve a raise or at least a cost-of-living adjustment? I suppose that depends on how well you think ophthalmologists have been paid—or perhaps overpaid—over the years. It’s hard to generalize since there are so many local variances of practice type, different levels of overhead, etc. However, the general trend has been sobering and getting worse. We are running out of ways to pull rabbits out of our hats.

It’s an established fact that we’re victims of our own success, and maybe our hubris. We made cataract surgery so much faster, more predictable and more successful that it was easy for non-ophthalmologists to trivialize it. With the outcomes being this good and the procedure this safe, we drove the surgery’s indications down to where almost anyone with lens changes could benefit. No one wanted their vision to be even a little bit blurry.

Over time—and, again, this isn’t new—cataract surgery became the most frequently performed procedure in Medicare, by a lot. Of course, this made it the largest dollar outlay of the program. Or, as one might say, “Our butts were the highest and the driest.” Cataract surgery was the perfect target when someone wanted to control costs.

So, what’s changed? Nothing, except that we’re running out of ways to lower our costs, improve our efficiency, and develop patient-pay add-ons—and the reimbursements will only continue to go lower. The next shoes to drop are more physician retirements and a further move to selling practices to private equity or academic centers. In other words: the death of private practice. Neither private equity nor academic institutions have a magic formula for making more money from cataract surgery. There’s only so much more inefficiency to be wrung out of clinical care, and we’re reaching the end of that. Academic centers have other lines of work and other sources of income, such as research monies, that can paper over the losses in clinical care—but, again, only to a point.

What I’m saying above applies not only to cataract surgery but to most of ophthalmology. Try making a living as a pediatric or neuro-ophthalmologist. Other subspecialties aren’t far behind. 

This brings us to the proverbial cliff: While we’re suffering from declining reimbursements, the entities that pay us are completely unsustainable. The coming demographic changes ensure health-care Armageddon: an aging population; fewer people working; and for-profit insurance companies that answer to their shareholders, not their patients. Medicare part B, which pays for physician services, is supported directly from the federal budget, with only 15 percent coming from Medicare premiums. This means Congress needs to approve these monies every year, which is an almost impossible task given the increasing percentage of our GDP devoted to health care.

There are further reimbursement cuts on the way, and a push to totally revamp the physician pay program. You know that will mean even less money. And despite all this, we just keep rearranging the deck chairs … .

While few want to ration care, the current system of patient-driven utilization can’t continue. Some new form of health-care delivery is inevitable, either by design or from the ashes of our pending cataclysm. I’d like to think we can do this rationally but given how messed up the public space is currently, that’s not going to happen. Time to find a life raft.

Dr. Blecher is an attending surgeon at Wills Eye Hospital.