Harry S. Truman Memorial Veterans’ Hospital
Immediate Sequential Cataract Surgery
During medical school, we rotated through the different clinical specialties in our third year. I still remember clearly the day I finished my surgery rotation. I think I may have exclaimed out loud that I would never go to an operating room again! I was never comfortable in the OR, never had any desire to become a surgeon. Now here I am, the Chief of Staff at Truman VA, leading all clinical care including surgery and I get the “opportunity” to visit the OR frequently. I really enjoy it now though. And my favorite surgery to watch is cataract surgery. These cataracts are so thick and yellow I’m surprised the patients can see anything. Then, in ten minutes, they have a crystal-clear lens in place of the old yellow lens. When we take the bandages off in post-operative care, I love to see the look on their faces when they see their family members clearly. Cataract surgery is a “quick win.” Patients are better immediately. That’s different than open heart surgery. While clearly life-saving, those patients don’t jump off the table and run a marathon.
A few months ago, my chief of ophthalmology approached me with an idea. The idea was to perform cataract surgery on both eyes in the same day for the same patient. I immediately thought, why not? We have many Veterans who need cataract surgery and it seems like a waste to go through the pre-op visit, surgery, post-op visit rigmarole twice. And, with limited Operating Room time, we could improve sight for more Veterans more quickly.
It turns out it’s more complicated than that. Immediate Sequential Cataract Surgery (that’s the term for one patient getting both cataracts fixed in the same day) is not performed in many places yet in the United States. There is debate about infection risk and needing to slightly change the lens implant for the second eye. There are things we do to minimize the risk of infection for these surgeries. We treat each eye like a single, separate surgery with all new instruments, new eye drops, etc. With these precautions in place, the risk of infection is miniscule. Especially for patients who need anesthesia to have the surgery, the risk is greater to have anesthesia twice than the risk of infection with two procedures. For patients with relatively normal eyes, the “learning” needed for the second lens implant is also rare. We have great tools for measuring what is needed for vision correction and rarely need to change the lens for the second eye.
But, there’s even more to it. In the private sector, insurance companies have been slow to pay for two cataract surgeries in one day. In fact, if a physician tried to bill the insurance company for two, they wouldn’t get paid for ANY in some cases and usually only get 50 percent reimbursement for the second eye. So, it is a “losing” proposition to fix both eyes on the same day. Those are the major reasons you cannot get both cataracts fixed on the same day in the United States - insurance companies and profit.
Since we at VA are constantly focused on providing accessible and timely care (without being restrained by cash flow from insurance companies), we formed a work group to look at all the possible issues with Immediate Sequential Cataract Surgery, knowing that being able to provide this service would be beneficial to our patients. The OR team met and reviewed processes. And we started.
This is the heart of the difference between care that is built around patient needs, truly Patient Centered Care, and care that is built around money and insurance companies. I consider myself to be extremely fortunate to work in a system that values Patient Centeredness OVER money. On a daily basis, I get to ask myself and many others “What is best for this Veteran?” or “What would you want for your mother/father in this situation?” I can ask these questions, change practices, make decisions, without regard to what an insurance company is going to approve. You may ask why insurance companies would not pay for Immediate Sequential Surgery, because I ask the same question. It must cost less overall with fewer clinic appointments and fewer prescriptions. We still have the problem in this country that insurance payments and profit are the guiding forces that are structuring the health care that we provide, instead of patient needs. But, I digress.
Immediate Sequential Cataract Surgery is going great at Truman VA. Veterans who have had the surgery so far are thrilled that they can see so quickly out of BOTH eyes. We have been able to increase the number of cataract surgeries that we do per week, so that more Veterans are obtaining improved vision more quickly. Our VA medical center, like most, has fully integrated eye care. Veterans generally first see an optometrist for a routine eye exam. At this exam, if they are found to have a significant cataract, measurements for surgery are taken. Veterans can see an ophthalmologist (eye surgeon) that day, in the same clinic, for a pre-operative visit. So, in the first visit, the cataract is found, the preoperative requirements are completed, the Veteran has met his/her surgeon, and the surgery is scheduled. And now, we can fix both cataracts in one day. This is what Integrated Eye Care looks like. My VA Eye Care providers are very worried about recent language from our administration regarding privatizing eye care. Yes, anyone can get glasses in every mall and many corner shops, but can they get the integrated care that we provide?
Integrated Care is at risk and the threat is privatization. We can see it clearly now.
Lana Zerrer, MD, is the Chief of Staff at the Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri. She is a graduate of the University of Missouri School of Medicine and completed a residency in General Internal Medicine from the same institution. She is also a U.S. Air Force veteran and served in Operation Enduring Freedom.