The disproportionate fees for cataract surgery

TheGlobeandMail.com – news/commentary/editorials
Published Friday, Jul. 15, 2011.

Cataract surgery and implanting a new lens used to take one hour to perform, almost a decade ago when British Columbia ophthalmologists were paid $533. Technological improvements mean the surgery can now be done in a fraction of that time – 15 minutes – yet the fee is unchanged.

When a surgery becomes quicker, less intense and safer, it’s fair to consider a fee reduction, especially in a publicly funded health-care system where value for money and sustainability are inextricably linked.

Should B.C. ophthalmologists be paid $28.17 a minute for cataract surgery, when orthopedic surgeons receive $4.89 for a hip replacement and a surgeon bills $5.49 per minute to remove an appendix?

This disparity is a familiar story across Canada. A Freedom of Information request revealed that eight of the 20 Ontario doctors who billed medicare more than $2-million each in the fiscal 2009-10 were ophthalmologists. In B.C., 13 ophthalmologists billed more than $1.5-million that year. (These numbers are not take-home pay, but billings to provincial health plans.)

The high billings are a side effect of the federal government’s $41-billion health accord, which expires in 2014 – the supposed fix for a generation. It sought to whittle down wait times in five areas, including cataract surgery.

B.C. and Ontario say they will seek fee reductions during negotiations with their medical associations. Ontario has obtained one fee decrease; a second (the ophthalmologists suggested it themselves) is to take effect in September. Though still too high – $491.05 for a cataract removal and lens implantation – the change is at least in the right direction.

Overpriced cataract surgery highlights why the fee-for-service system, where doctors are paid for each procedure they do, should be replaced with a mixed payment system. Since 1999, such a system has been in effect for some surgical groups in Quebec and has resulted in reductions in billable services, more time spent with patients and increased time for doctors to do administrative work and teaching.

At a time when Ontario’s Excellent Care for All Act is tying hospital chief executive salaries to quality of care, all provinces need to be rethinking how they pay for their medical services and how much is too much. They need to negotiate hard with their medical associations.

Though some fees will go up, others down and procedures may be dropped or added, what’s really needed is a new way to compensate doctors that is fair and equitable, and helps sustain the public health-care system for decades to come.

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