Study: HMO's Deprive Some Surgeries

5:21 PM (ET) 6/10

CHICAGO (AP) -- Elderly people with traditional fee-for-service insurance are twice as likely to get cataract surgery as HMO patients, according to a survey of thousands of Medicare recipients in Southern California.

The study does little, if anything, to resolve the question of whether managed care screens out unnecessary medical procedures or prevents patients from getting proper treatment.

Nor does the study resolve the question of whether doctors are performing too many cataract removals, as some researchers have charged.

A cataract is a clouding of the eye's lens that occurs in half of Americans between ages 65 and 75, and 70 percent of those over 75. Removing the cataract and replacing it with a lens implant can restore sight and mobility, including the ability to drive. The 1993 research, reported in this week's Journal of the American Medical Association, studied 43,387 HMO members; 19,050 members of an independent practice association, another form of pre-paid plan; and 47,150 members of a fee-for-service plan. All the patients were 65 and over.

After taking into account age, sex and other variables, the researchers said fee-for-service patients were twice as likely to undergo extraction as those in prepaid plans. "While this study highlights the differences -- and they are large and important -- we can't tell you if there are too many or too few extractions," said the principal researcher, Dr. Caroline Lubick Goldzweig of the Veterans Affairs Medical Center in West Los Angeles.

There are some 1.4 million cataract surgeries each year in this country, accounting for Medicare's single largest expenditure, about $3.4 billion. A 1993 General Accounting Office report claimed that Medicare spent $204 million in 1991 on inappropriate cataract surgery.

In an editorial accompanying the JAMA study, Dr. Stephen A. Obstbaum, an ophthalmologist with Lenox Hill Hospital in New York, wrote that it is clear that the payment system often determines whether surgery is performed. While the survey draws no conclusion on whether too many or too few surgeries are performed, Obstbaum said the results suggest the latter.

"The financial incentives of the physicians in the prepaid settings . . . require greater investigation," he wrote. "Although the researchers indicate that it is beyond the scope of this study, these observations are suggestive of a pattern of underutilization. "