Pay Cuts and Unnecessary Visits: How Medicare Is Compromising Cataract Care

https://www.medpagetoday.com/opinion/second-opinions/119085

It’s time for payment reform and a lasting remote follow-up option

With nearly 1% of Americans undergoing cataract surgery each year, the procedure is the most common operation Medicare covers. For many older adults, it’s a small miracle: a 15-minute procedure and suddenly the world is in focus for the first time in years.

What comes next can be much less miraculous. Patients must arrange rides and caregivers for brief follow-up visits. As an ophthalmologist who cares for these patients, every week I see how, for those who can’t drive, who live alone, or who use walkers or oxygen, these “routine” checkups can be the hardest part of the whole experience.

Meanwhile, Medicare is steadily cutting what it pays for that very surgery — even as Washington can’t decide whether to keep the telehealth flexibilities that would make follow-up easier.

For 2025, the Centers for Medicare & Medicaid Services (CMS) again cut what it pays physicians, marking the fifth straight year of reductions. Since 2018, Medicare’s payment for a routine cataract operation has fallen by about one-fifth, and overall physician pay in Medicare has eroded by roughly one-third since 2001 after adjusting for inflation, making it harder for small community practices to stay open. Now CMS has finalized another double-digit cut for cataract surgery in 2026.

In other words, Medicare is squeezing the margins on a high-volume, sight-restoring surgery that millions of older adults rely on — especially in community and rural settings where cataract surgery is often the only eye care readily available.

During the pandemic, Congress and CMS let Medicare patients use telehealth from home — including audio-only options — with no rural restrictions. Those flexibilities have been extended several times, most recently in a shutdown-ending deal that now runs only through January 30, 2026. After that, unless Congress acts, Medicare’s coverage for non-mental-health telehealth will snap back to the pre-COVID rules that limit services to rural patients in medical facilities — not people recovering from surgery at home.

This is exactly backward for cataract care.

Randomized trials and systematic reviews in recent years have found that virtual or telephone follow-ups for uneventful cataract surgery can match in-person care for safety and patient satisfaction, as long as higher-risk patients are excluded and assuming that concerning symptoms trigger rapid in-person evaluation. Simple web-based vision checks, phone or video visits, and emerging tools like artificial intelligence (AI) phone systems that screen for red-flag symptoms have shown promise for routine cases.

These tools don’t replace in-person exams for people with other eye diseases, complicated surgery, or worrisome symptoms, but they can safely reduce unnecessary travel and free up clinic slots for patients with real red flags. Most surgeons still want at least one early, in-person exam for many patients; the real opportunity is to avoid dragging every low-risk patient back for multiple routine checks when their vision and symptoms are reassuring.

When you combine repeated pay cuts with rigid expectations that every post-op patient trudge back to the clinic, the result is consolidation of facilities, small practice closures, and poorer access, especially in rural and lower-income communities.

For an 82-year-old who no longer drives and lives on a fixed income, automatically requiring every routine follow-up to be in person after an uncomplicated cataract surgery is not “conservative” medicine. It’s avoidable hardship — on top of a system that’s already asking surgeons to do more with less year after year.

It doesn’t have to be this way. If Congress and CMS are serious about keeping cataract care accessible while holding the line on costs, they should pair payment reform with a deliberate shift toward remote follow-up for appropriate patients, rather than letting telehealth die by a thousand temporary extensions.

That would mean making home-based telehealth for postoperative visits a permanent Medicare benefit for procedures like cataract surgery; explicitly allowing early post-op checks to be done virtually under the 90-day global payment that already covers follow-up care — without extra fees — as long as safety standards are met; and funding pilot programs that use telemonitoring to triage which patients truly need to be seen in person.

Telehealth expansions should come with clear guardrails: limiting remote follow-up to low-risk cases, using structured symptom checklists, and maintaining a low threshold to convert virtual visits to in-person exams when something doesn’t look or feel right. At the same time, Congress should replace yearly “yo-yo” cuts with stable, inflation-linked updates to Medicare’s physician payment formula.

Done right, the result would be straightforward. If a surgery was routine and the patient is seeing well, they could complete part of their follow-up at home — on a smartphone, landline, or computer — with clear instructions about when to call or come in. If anything looks concerning, the system connects the patient to an in-person, human doctor quickly. For clinicians, it would mean a payment system that stops penalizing the very surgery that restores sight for millions and a telehealth policy that recognizes reality: much of postoperative cataract care is about screening for rare problems and answering questions, both of which can be supported by remote tools.

At the moment, Washington is sending mixed messages: one set of rules tells surgeons to absorb pay cuts; another tells them to keep seeing every patient in person, even when the evidence says they don’t always need to. Fixing that mismatch — by stabilizing payment and embracing telehealth for routine cataract follow-up — is a concrete way to protect both patients’ vision and the future stability of their care.

Filed under: General Problems