It's 8:30 a.m. in Operating Room No. 1 and Dr. Alan Aker, peering through a microscope, delicately cuts a quarter-inch incision into the surface of Blanche Klein's right eye.
He carves open the layer of cloudy material that has made Klein feel as if she's been squinting through a dirty milk bottle. Using an instrument that works like a tiny jackhammer, he pulverizes the cataract with hissing sound waves pulsing at 40,000 times a second as a hollow needle vacuums away the particles. Finally, Aker inserts into the eye a new, plastic lens designed to provide 20/20 vision for the 75 year-old Klein.
Aker finishes at 8:50 and strides rapidly from the room, pausing only to strip off his latex gloves and blue surgical gown. He walks into Operating Room No. 3, dons a new gown and gloves and within 90 seconds is working on the right eye of Blanche's husband, George. Twenty minutes later, he delivers his characteristic sign-off line, "thanks for letting us help you," and moves on to another of the 14 patients scheduled for surgery before noon.
For the Kleins and many of their neighbors in the condos and retirement apartments of South Florida, Aker is a hero who can make it possible to continue to drive at night, to go shopping without a chauffeur, to see a golf ball in flight.
Yet for Medicare administrators, government planners and members of Congress, Aker and his patients represent a growing problem, one that is contributing to the relentless escalation of health care costs and threatening the Medicare system with bankruptcy.
U.S. ophthalmologists performed 1.7 million cataract surgeries in 1991 on elderly patients, making it the surgery most commonly reimbursed by Medicare. Total costs associated with the surgery have exploded from $327 million in 1981 to a staggering $3.5 billion in 1991 as medical advances have made the procedure easier, faster and available to more elderly Americans.
The government has fought back by cutting surgeons' Medicare fees five times since 1986. A doctor who got $1,850 to perform the procedure seven years ago will receive about $1,150 this year, and a new payment system approved by Congress will slash the reimbursement to $950 next year and just under $600 in 1996.
Besides cutting fees, the government has issued guidelines suggesting that the surgery is performed too often. While the directives are voluntary, Aker worries about their implications. Of the 14 patients whose cataracts he will remove on this day, he believes that at least two would not be eligible for surgery if the guidelines become mandatory.
"The government," he said he fears, "is trying to ration care because they don't want to pay for it."
Indeed, the debate has implications that extend far beyond eye surgeons and their patients. In many respects, it's a case study of the kind of problems facing the Clinton Administration as it tries to contain costs in a sprawling industry that consumes 13% of everything produced in this country.
"Have we invented a miracle we can't afford?" asked a report by the Society of Geriatric Ophthalmology. "Part of the problem society is facing in providing for cataract care in America is that eye surgeons and lens implant manufacturers have invented a 'cure' that is so reliable and effective that it could virtually become more widespread than false teeth."
President Clinton's emerging plan for health care reform will attempt to accomplish its goals by pushing patients and doctors into cost-conscious networks that will control spending. But it must contend with powerful pressures that push the system in the opposite direction, including virtually unlimited demand for services such as cataract surgery in an aging America. One potential consequence is that some patients will not be allowed to receive certain services, unless they are willing to bear the entire cost themselves.
"We're truly at a crossroads in medicine," said Dr. Dunbar Hoskins, executive vice president of the American Academy of Ophthalmology. "The government wants to cover 37 million uninsured people and reduce costs at the same time. How do you do that? One way to do that is to change the rules for the availability of services."
The focus on controlling soaring medical costs gives new urgency to the debate over cataracts.
Experts who prepared the guidelines for cataract treatment, which urge exploring all other options before resorting to surgery, said that they are simply providing the best scientific advice. They argue that doctors like Aker who attack the guidelines are just trying to protect their pocketbooks.
"You are hearing (complaints) from less than 5% of all the ophthalmologists, the small group of people whose purpose in life is to take out cataracts," said Dr. Alfred Sommer, an ophthalmologist who served on the panel and is dean of the Johns Hopkins School of Public Health.
Cataract surgery is a tempting target because it consumes so much of Medicare's annual outlays. Combine all the money paid to doctors by Medicare for coronary artery bypasses, hip and knee repairs and replacements, hernia operations and breast and prostate surgeries, and the total is less than that spent for cataract removals alone.
Even if some patients could get by without the procedure, the concept of allocating medical services rubs many people the wrong way. In Britain, eligible patients must wait a year or two for a cataract operation, according to Sommer, but few Americans would accept a system that imposed lengthy delays as a means of containing costs.
Things move much faster than that at the Aker-Kasten Clinic, a sprawling 15,000-square-foot building with the Spanish-style roof tiles and pink walls common to this affluent South Florida community. Inside the clinic, more than 30 waiting room chairs are filled with white-haired Medicare recipients drawn by word-of-mouth endorsements.
Their common ailment is the cataract, a clouding of the lens that comes with age, afflicting 400,000 Americans every year. It doesn't kill like cancer or cripple like heart disease. People can live with it but they don't like it.
"Our sense of independence is threatened, we tend to become isolated, fear intrudes in our lives," said Dr. John O'Day, author of the new federal guidelines and head of the ophthalmology department at Vanderbilt University Medical School.
Sonia Garcia Hartman, who had a cataract removed from her left eye three years ago, has an appointment at the Aker-Kasten Clinic to talk about having the right eye fixed so she can keep driving. "I don't mind having glasses but, even with the glasses, I may cause an accident," said the 65-year-old widow. Her car, she said, is her lifeline. It allows her to go shopping, attend Democratic club meetings and get together with friends to play mah-jongg. Even at home, the cataract interferes with her embroidery.
Fifteen or 20 years ago, Hartman would not have been a candidate for surgery. At that time, it was a delicate operation, requiring a week's stay in the hospital, the patient's head held rigid during recovery. Afterward, the patient had to wear special glasses, with lenses thick as the bottom of a soda bottle. The lenses offered a distorted view of the world, with little peripheral vision. So doctors generally waited until a cataract was far advanced and vision greatly deteriorated before scheduling surgery.
The early 1980s brought a revolution. A safe intraocular lens was introduced, a piece of plastic that could be inserted on the surface of the eye to provide 20/20 vision without glasses. New surgical techniques were developed as doctors learned to make smaller incisions, skipping sutures and making entry cuts so small that they sealed themselves with minimal bleeding.
No longer would patients and doctors wait for cataracts to ripen fully. Now they could move quickly. And they did, with the number of operations soaring from 250,000 in 1981 to 2 million last year.
Certainly, some patients who have had the surgery could have functioned adequately without it. Most states will issue a driver's license to a resident wearing glasses that correct vision to at least 20/40. But cataract surgery can completely restore vision and glasses can be tossed in the wastebasket. Little wonder that many elderly Americans are eager to have it done, guidelines or no.
If cataracts reduce the quality of life, those afflicted should be able to have them removed, Aker declared. "We're dealing with an older population, some of whom are heading for nursing homes if they can't take care of themselves at home. If we can help them stay at home, they love it.
"Part of being a good surgeon is being a caring person," he continued. "I look at them as if they are my own mom or dad and ask do they need it?" In fact, Aker's mother had cataract surgery; the operation was performed by Dr. Ann Kasten-Aker, his wife and partner.
George and Blanche Klein are "snowbirds," dividing the year between their home in New York and a condominium in Boca Raton. Years ago, a doctor told them they were both developing cataracts.
"I kept saying, I'll wait and wait, and now my baby cataracts have become fully grown," said George Klein, 78, the day after his surgery. "With older people, their health starts to fail, so it's much easier to have it done when you are in decent health."
Glasses weren't good enough for Klein. "I saw halos and starbursts," he said. "I felt it was dangerous and stopped driving at night."
Aker, who draws a salary of $200,000 a year from his practice, performs about 1,000 cataract surgeries a year, racing from one operating room to another. "There is no down-time here, we have to be efficient," he said.
His fees, set by Medicare, are $1,166.61 for the surgery and $935.72 for the use of his outpatient facility. The total cost includes another $217 for various tests and $200 to $300 for the anesthesiologist. Medicare pays 80%; the patients are responsible for the other 20%. Aker charges non-Medicare patients the same fee.
Medicare limits cut Aker's revenues by $100 per patient last year, and more trimming is under way. A special commission created by Congress seven years ago placed cataract surgery at the top of a list of procedures characterized as overpriced, and the budget knives have been out ever since.
"What was a tricky three- or four-hour procedure handled by just a few top surgeons became a standard 20-minute procedure," said Rep. Pete Stark (D-Oakland), chairman of the House Ways and Means health subcommittee that oversees Medicare.
Further cuts are coming under Medicare's new payment system, which is increasing fees for general practitioners and internists while reducing them for surgeons. The government's goal is to shift the balance of medicine, encouraging more young doctors to enter general practice by paying more for time spent talking to patients and less for operating on them.
Already feeling financially pressured, cataract surgeons exploded in February when the government issued new advisory guidelines for cataracts.
U.S. taxpayers are shelling out more than $3 billion a year through Medicare to pay for cataract surgery, but nobody knows precisely when the operation is needed, the guidelines said bluntly. A panel of experts spent $1 million reviewing thousands of scientific studies but found no accepted standard to say when surgery should be done: "No test adequately describes the effect of cataracts on the patient's visual status or functional ability," reported the Agency for Health Care Policy and Research, which issued the guidelines. (A free copy is available by calling 1-800-358-9295.)
The message from Washington: If in doubt, don't operate. "The use of strong bifocals, magnification, appropriate lighting and other visual aids often satisfies the new vision requirement as the cataract progresses," the guidelines said. "Physicians and patients should not rush into cataract surgery if glasses or visual aids can provide satisfactory functional vision and the patient's lifestyle is not compromised."
Those whose glasses give them corrected vision to 20/40 or better "should not be considered for surgery unless they report quite substantial functional impairment," the guidelines advised. In such cases, "the risk of surgery relative to the expected benefit should be re-emphasized to the patient."
Still, at the Aker-Kasten Clinic and other similar facilities, the decision tends to be a purely subjective collaboration between doctor and patient. In fact, a survey of patients in four states who underwent cataract surgery showed that 24% had no more than slight visual problems before the operation, according to the General Accounting Office.
The surgeons have a vociferous new champion in Sen. Conrad Burns (R-Mont.), a conservative whose normal skepticism about federal spending programs melts into rapt enthusiasm when the subject turns to cataract surgery.
"I had mine done in December," he told a recent workshop, noting that his cataracts clouded his vision even in bright sunlight. "No matter what the folks at the GAO or anywhere else say, it's worth the money."
But a cautionary note was sounded by Eva Skinner, a retired nurse who was the sole consumer representative on the panel that developed the cataract guidelines. With Medicare heading for potential bankruptcy by 1998, "the problem will have to be faced in terms of who will get care and who won't," she said. "The ophthalmologist is going to have to be much more selective in terms of the patients he chooses to operate on. And maybe older people won't be able to go out as much at night."
Skinner said that she would like to see some of the money spent on cataract surgery diverted to prescriptions and false teeth, neither of which is covered by Medicare.
But that's a message that will not play well at the Aker-Kasten clinic or in the retirement communities that surround it.
"It's a question of lifestyle," Aker said. "All these people live in the condos. After they go home tomorrow, their friends will be calling me."
The High Cost of Care
Here are the costs for the top Medicare surgeries and procedures performed in 1991:
No. of operations Physician charges Cataract surgery* 1,736,893 $1,985 million Coronary artery bypass 258,657 $502 million Prostate resection 227,701 $217 million Knee arthroplasty 173,484 $268 million Inguinal hernia repair 167,656 $60 million Coronary angioplasty 152,042 $207 million Hip arthroplasty 106,454 $152 million Pacemaker insertion 86,894 $76 million Modified radical mastectomy 73,743 $51 million Radical prostatectomy 39,824 $53 million
* Total cost of cataract surgery estimated at $3.5 billion, including payments for outpatient facilities where surgeries are performed.
Source: Health Care Financing Administration