Why Did My Cataract Surgery Cost Me $5,000?

   A cataract is the eye’s own natural lens that becomes cloudy over time. Cataract surgery is offered when the cloudy lens interferes with your daily activities. Once the cataract is removed, it needs to be replaced with an artificial lens to see well. This is the point where a decision on your part becomes very important.

   When I began practice in 1987, we only had one type of intraocular lens implant (also known as an IOL) a monofocal IOL. This was and still is the mainstay of all IOLs. It has a set focal point for either near or distance and does not correct astigmatism. If you have a small amount of astigmatism and opt for distance vision, you will need reading glasses. If you have a small amount of astigmatism and opt for near vision, you will need distance glasses. You cannot have both with a monofocal IOL. The trick was to calculate the exact power for the implant leaving as little nearsightedness or farsightedness as possible. Every cataract surgeon got paid the same amount from Medicare. This included the surgery along with all pre and post-op care for a period of 90 days. I remember my very first check for cataract surgery was $1750.00 and that was in 1987 dollars. Because cataract surgery was one of the most commonly performed procedures on seniors, the Center of Medicare and Medicaid decided to target cataract surgery and reduce reimbursement to surgeons. The idea was to save money to help sustain Medicare. Each year, the reimbursement was cut until this year when surgeons are getting paid around $500.00 for a much more advanced procedure. Cataract surgery has made leaps and bounds since 1987. While the surgery has become much more challenging for the surgeon, the patient has a much better experience with much better results. Decreasing reimbursement was based on financial concerns. Less money for a much safer, reliable, and technically demanding surgery. It did not take long for cataract surgeons to cry foul. The government came up with a compromise. Hence was born the premium IOL.

   Medicare’s thinking went something like this: I’ll use a luxury car as an analogy. We will pay for everyone’s car (standard IOL) as long as it’s your standard midsize sedan but are not paying for a luxury $80,000.00 SUV. So, Medicare will pay for the “standard” IOL but not the premium IOL. Before this change, surgeons were not allowed to balance bill for IOLs. In other words, whatever Medicare paid the surgeon, that was all they got. You couldn’t charge anymore. When Medicare changed the rules, surgeons could bill anything they wanted for a premium IOL as long as the patient qualified for a premium IOL and agreed to pay for it. The important thing to know is that NO ONE IS OBLIGATED TO GET A PREMIUM IOL. This is strictly a choice between the surgeon and the patient. Medicare’s attempt at free-market economics.

   Why would anyone want a premium IOL? Listed below are the options for lens replacement. Not everyone is eligible for all options. To qualify for a multifocal or EDOF IOL your eye has to be fairly healthy with little other than the cataract causing problems. Patients with macular degeneration or other eye diseases may not qualify. Your ophthalmologist will discuss which options are available to you.