In this episode of Evidence Based Retina, Rishi P. Singh, MD, FASRS, is joined by Ryan Sameen Meshkin, MD, to discuss his recent time-driven activity-based costing study of secondary intraocular lens (IOL) surgery.
The study examines whether current reimbursement adequately reflects the operative time, staffing, and resources required to deliver complex, vision-restoring vitreoretinal care.
Dr. Meshkin is a PGY4 Resident at Massachusetts Eye and Ear at Harvard Medical School and will soon move on to continue his training at the Duke Eye Center as a Vitreoretinal Surgery Fellow.
The cost of complex ophthalmologic care
Cataracts are the leading cause of blindness and are mostly considered an age-related disease. An aging population presents increased demand on healthcare systems, along with an increase in more complex cases.
Although most cataract surgeries are routine and successful, a clinically important subset of patients later require secondary IOL placement, exchange, or repositioning because of aphakia, lens dislocation, or prior surgical complications.1
“Secondary IOL surgery is a high-value surgery—it restores vision and independence, increasing the quality of life for patients. There is an increasing demand for this as we have an aging population and more folks are undergoing cataract surgery,” noted Dr. Meshkin. “With that increase, you can anticipate more complications and an additional need for secondary lenses.”
Despite the increase in complexity, reimbursement for procedures has declined over the past few decades.2 This introduces concern for patient cases requiring high-value, time-sensitive procedures that are inadequately reimbursed.
Similar reimbursement challenges have been reported across vitreoretinal surgery, including pars plana vitrectomy (PPV) for retinal detachment repair, scleral buckle surgery, and panretinal photocoagulation.3-5 Dr. Meshkin’s work has contributed to this literature through studies of academic vs. community retinal detachment surgery,6 and cost drivers in scleral buckle surgery.4
Prior work has also shown that secondary IOL surgeries frequently produce net negative margins under Medicare reimbursement.7 His recent analysis of secondary IOL procedures performed with PPV extends this work by defining procedure-specific break-even times and the proportion of cases exceeding those thresholds.8
The cost-analysis retrospective study
Dr. Meshkin and faculty mentor Dr. Nimesh Patel questioned if they could determine the actual time spent on a surgery where the procedures become unprofitable or might break even. Time-driven activity-based costing (TDABC) estimates the cost of care by assigning costs to the time, staffing, materials, and overhead required to delivery a procedure.
They published the results of their retrospective cost-analysis study in the Journal of Vitreoretinal Diseases.7 This data might inform strategies to adjust reimbursement rates or explore other cost-reducing measures.
Comparative cost-analysis study fast facts:
- Cohort: Massachusetts Eye and Ear patient cases with secondary IOLs in conjunction with pars plana vitrectomy in 20237
- Identified by CPT codes for IOL insertion only, IOL exchange, and IOL repositioning (all also billed with PPV)
- Method: Time-driven activity-based costing analysis
- Broken down on a per-minute basis
- Compared with CMS Medicare reimbursement rates
- Results: Break-even time was around 75 minutes, with over 85% performed in excess of that time7
- IOL exchange cases were the most time-intensive and had the worst margins
- Conclusion: Secondary IOLs performed with PPV are unprofitable under current reimbursement rates7
Breaking down the break-even time
“It’s clear from this study that these cases are taking far longer than what the system assumes they should be taking,” outlined Dr. Meshkin. However, depending on the clinical context or the particular practice patterns at different institutions, different variables might affect the associated costs.
For example, Dr. Meshkin says in a large hospital setting, there may actually be two surgeons working on a case. An anterior segment specialist may come in to perform the secondary IOL and they would work with a retina specialist doing the PPV. There are also a variety of secondary IOL types and different surgical techniques developed over the years as options for addressing different challenges presented with complex cases.2,9
Dr. Meshkin shared that subsequent analyses in a paper currently under review may help clarify how specific surgical techniques or IOL fixation strategies influence operative time and cost. Initial findings suggest that anterior chamber IOLs and scleral-fixated IOLs were the most costly, driven by longer operative times.
Future considerations and advocacy efforts
Dr. Meshkin acknowledges that large hospital systems like Massachusetts Eye and Ear often have greater power as an institution to negotiate better contracts with higher reimbursement rates.
Smaller facilities or independent facilities like ambulatory surgery centers may see lower reimbursement and more cases in excess of the breakeven time. The results of this hospital-based study might actually be a best-case scenario compared to those settings.
Additionally, in teaching hospitals associated with academic institutions, longer operative times may partly reflect the educational mission of training residents and fellows, an investment that benefits the future retina workforce but is not fully captured in traditional reimbursement models.
“I just came back from my first Mid-Year Forum as an AAO Advocacy Ambassador and the hope is that putting out data that shows how reimbursement does not adequately address the real cost of performing these important surgeries can have an impact on patient care,” Dr. Meshkin emphasized.
Final thoughts
In conclusion, Dr. Meshkin hopes that this study provides data to guide advocacy efforts and prove useful for specialty societies, policymakers, hospital systems, and payers when evaluating whether existing reimbursement adequately supports complex vitreoretinal procedures.
