Special-interest groups representing ophthalmologists are calling for the repeal of 4-year-old government clinical guidelines that urge physicians to perform fewer cataract surgeries on Medicare beneficiaries.
The guidelines recommend less invasive methods to improve beneficiaries' vision.
The groups, one of which initially endorsed the guidelines, now say the clinical rules are outdated.
In a letter to John Eisenberg, M.D., administrator of the Agency for Health Care Policy and Research, the American Academy of Ophthalmology and six other eye-care groups are asking for the cancellation of the fourth of 19 clinical guidelines the agency has published.
Any guideline governing cataract lens replacement has great implications for the Medicare program because it is one of the most frequently performed procedures on Medicare beneficiaries.
Cataract surgery accounted for 2.9%, or nearly $900 million, of the $30.5 billion Medicare paid to physicians in fiscal 1996, according to the Physician Payment Review Commission. Only office and ambulatory visits and diagnostic radiology cost the Medicare program more, according to the PPRC.
The AHCPR guideline was controversial when published in February 1993 because it said patients and doctors should consider stronger glasses or visual aids to improve vision before turning to cataract surgery.
At the time, many ophthalmologists objected, saying the guideline would lead to a reduction in medically necessary cataract surgeries.
It came at a time when cataract surgery rates had begun shrinking because the market had been saturated. In fact, cataract surgery has declined as a share of Medicare physician spending to 2.9% in 1996 from 3.7% in 1993.
The ophthalmologists' letter-sent to the AHCPR earlier this month-said the guideline is based on out-of-date studies and that more current guidelines exist. Among them is one published by the American Academy of Ophthalmology, which gave a two-year endorsement to the AHCPR guideline when it was published.
The AHCPR, meanwhile, has withdrawn from all guideline development activity and reshaped that function into a research and technical assistance center for private-sector guideline development.
"The current guideline that is available for cataract surgery is now 4 years old since its date of publication, and the latest date that studies in the literature were included was in 1992 and early 1993," the letter said.
"Because a more current document is available and more accurately reflects the most up-to-date scientific literature and expert knowledge in a rapidly evolving field, we believe that the most appropriate action at this time is to withdraw the AHCPR guideline," it said.
In addition to the ophthalmology academy, the letter to the AHCPR was signed by the American College of Eye Surgeons, the American Society of Cataract and Refractive Surgery, the Ophthalmic Anesthesia Society, the Outpatient Ophthalmic Surgery Society, the Society for Excellence in Eyecare and the Society for Geriatric Ophthalmology.
AHCPR spokesman Howard Holland said the letter "raised some important issues," although he couldn't say whether the agency would withdraw the guideline.
He said the agency had been reviewing the cataract guideline but wanted further clarification from the ophthalmic groups about what they believe is outdated.
"We're working with them to address the issues they've raised," Holland said.
The ophthalmologists' letter came only two days before the publication of a study that indicates Medicare beneficiaries receiving care on a fee-for-service basis were twice as likely to undergo cataract surgery as those enrolled in managed-care plans.
Published in the Journal of the American Medical Association, the study concluded, however, that it was unclear whether that was the result of overutilization in the fee-for-service sector or underutilization in managed-care settings.
Although the rate of cataract surgeries on Medicare beneficiaries has generally been on the decline in recent years, they spiked up in 1996. Medicare paid for more than 3.1 million outpatient cataract surgeries in 1996, up 31.9% from the 2.4 million outpatient cataract surgeries in 1995, according to statistics compiled by Sachs Group, a healthcare information company.