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Across the Pond | Sep 2011

Chief Medical Editors Sound Off

CRST Europe editors comment on the US cataract surgery payment system.

SHERAZ M. DAYA, MD, FACP, FACS, FRCS(ED), FRCOPHTH

Dr. Hovanesian’s article demonstrates how complex payment systems become as they evolve and as loopholes are found to maximize financial gain. This is almost an art in itself and clearly a considerable resource, as significant administration time is typically required to ensure maximal gain and to keep up with the system. Ultimately, this cost becomes an overhead that is passed on to the patient or the third-party payer.

In the United Kingdom, private sector, third-party reimbursement through insurance companies is much simpler. However, this system still requires significant resources. As a provider, I must confess that self-pay is even simpler yet. With this arrangement, the patient pays a global fee out of pocket for cataract surgery, which is excellent for cash flow and inexpensive to administer. In our practice, we make the self-pay option straightforward by offering three global charges, including 60 days of follow-up care, without any hidden extras: (1) cataract surgery with a monofocal lens, (2) cataract surgery with a multifocal or toric lens, and (3) cataract surgery with a multifocal toric lens. Regardless of what lens the patient chooses, we perform incisional surgery at no additional cost.

Having a complex, menu-driven service complicates matters, with lengthier chair time and possible mistrust and doubt. Our goals are to provide each patient with a good refractive outcome, to ensure we have happy patients, and to generate word-of-mouth recommendations. In addition to the three global charges described above, I expect we shall probably have a fourth global fee to accommodate laser cataract surgery—although I wonder if, in these very recessionary times, patients can afford to pay the extra fee.

Insurance payment for cataract surgery in the United Kingdom is not too dissimilar from payment in the United States, with contracted coverage for facility fees (very low in the United Kingdom), surgeon fees, and anesthesia fees. Patients pay the remaining balance to the surgeon and anesthesiologist only. To become a facility provider, a contract with an agreed facility fee must be signed along with an undertaking not to balance bill.

I agree with the principle of Dr. Hovanasian’s ending comment: “The ideal system would allow patients to see the doctors of their choice and would in turn allow us to respond by providing the services that they need and to receive fees that we feel are appropriate.” However, I must confess my worries regarding a few realities. First, we are in recessionary times, and it looks like we shall be for a while to come. This will affect what third-party payers and patients will be able to afford. Second, fees are undoubtedly volume-dependent. After fixed costs are covered, whether it be for a practice or an ambulatory surgery center, profitability increases considerably. Last, based on demographics, there will be a huge volume of patients requiring care in the future with less overall funding available.

My proposed solution (which I expect will ruffle a few feathers) is to cover regular cataract surgery fixed costs by providing a minimum volume of patients to a practice or institution. As volume increases, a certain level of profit per case would be maintained (eg, $800 per case). This might mean a decrease in charge per case if this is to a third-party provider like Medicare in the United States or a government-commissioning body as in the United Kingdom, but all parties win, including, ultimately, the tax-payer (you and I). For premium and added-value procedures, patients would pay an appropriate additional fee determined by the treating surgeon.

I have no doubt that cataract payment systems will continue to evolve, with the fittest surviving, and either the above model will be voluntarily adopted or it will be thrust upon us.

Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth, is Director and Consultant of Centre for Sight and the Corneoplastic Unit and Eyebank, Queen Victoria Hospital, East Grinstead, United Kingdom. Dr. Daya is a Co- Chief Medical Editor of CRST Europe. He states that he is a consultant to Bausch + Lomb. He may be reached at e-mail: sdaya@centreforsight.com.

ERIK L. MERTENS, MD, FEBO

The European cataract payment model, and the Belgian model in particular, is completely different from that which is used across the Atlantic Ocean. A Belgian patient can undergo surgery in a hospital setting or in an ambulatory surgery center that is recognized by the national health care system.

Let us first take a closer look at cataract surgery performed in a general hospital. The total cost per eye for cataract surgery with a monofocal IOL is approximately €1,690. This covers the surgical, anesthesia, and hospital facility fees, as well as a fixed fee for radiology and microbiology, the disposables, ophthalmic viscosurgical devices (OVDs), and a monofocal IOL. Of the €1,690, the total out-of-pocket cost per eye for a patient is approximately €300, and the rest is covered by the universal government health care system regardless of the patient’s age or social status. The facility fee payment from the government health care system is approximately €500 per case; additionally, the OVDs, disposables, and a monofocal IOL are partially covered. If a patient opts for a premium IOL, he or she is responsible for an extra charge of about €750.

In comparison with the United States, the total cost of cataract surgery in this setting is significantly less. The surgical fee is comparable, but the surgery center fee and the cost for anesthesia are higher in the United States.

If the patient chooses to have his or her cataract surgery done in an ambulatory surgery center, the prices are fixed. In this setting, the total cost to be paid by the patient for surgery with a monofocal IOL is €1,350 per eye. Unfortunately, the health care system covers only €550 of this cost. There is no reimbursement for the facility fee, for the OVDs, or for the disposables. This makes cataract surgery more expensive for the patient, unless he or she has private insurance. If that is the case, private insurance will pay exactly €800 toward the procedure, and the patient is fully reimbursed for his or her surgery.

The cost for the government is significantly lower when surgery is performed in the hospital setting compared with an ambulatory surgery center (€1,390 vs €550, or a difference of €840). However, there is no difference in payment for pre- and postoperative visits. Covered services include refraction, visual field examination, specular microscopy, and axial length measurement. If the patient elects a premium IOL, the out-of-pocket cost is €2,500 per eye in the ambulatory surgery center or €2,000 out of pocket in a hospital setting, with no difference in reimbursement for the patient in either setting.

In Europe, we would like to have a uniform system of payment for cataract surgery no matter the setting. We do not have any experience with laser cataract surgery at the moment, but when the time comes, the patient is likely to pay the extra cost out-of-pocket. What this extra cost will be still remains to be established.

I agree with Dr. Hovanesian that, as in the United States, we in Europe like to get paid a fair price for our services.

Erik L. Mertens, MD, FEBOphth, is Medical Director of Medipolis, Antwerp, Belgium, and Medical Director of FYEO Medical, Eersel, Netherlands. Dr. Mertens is a Co-Chief Medical Editor of CRST Europe. He states that he has no financial interest in the material presented in this article. Dr. Mertens may be reached at tel: +32 3 828 29 49; e-mail: e.mertens@medipolis.be.

KHIUN F. TJIA, MD

The Dutch medical reimbursement model is a general social health care system available to all citizens. Regular medical procedures are completely covered, and the monthly premium is approximately €1,200 to €1,300 per adult. Under this system, cataract surgery with monofocal IOL implantation is fully reimbursed.

The total payment for a cataract procedure is between €800 and €1,200 and includes the facility and surgeon fees. Recently, the Dutch government cut the surgeon fee to an incredibly low payment of €114 per cataract for both diagnosis and treatment, a combination that includes all pre- and postoperative consultations as well as biometry, other exams, and the surgery itself. As a result, cataract surgery has become an unprofitable activity for Dutch ophthalmologists. The facility fee for an ambulatory surgery center is generally 15% less than a hospital would receive, but the surgeon fee is fixed at €114 for all services described.

The Dutch health care system does not cover the extra expense of toric and multifocal IOLs. Although there is not yet any legal basis for copayment of these premium IOLs, out-ofpocket payments to cover additional costs are tolerated by the authorities. The copayment price varies from center to center. In general, the additional charge ranges from €500 to €800 for a toric IOL and €900 to €1,250 for a multifocal or multifocal toric IOL. This includes the additional cost of the lens and all special diagnostic exams. This copayment system is quite unusual for Dutch people, who are used to a fully reimbursed social health care system where only cosmetic surgery is privately funded.

The highly socialized Dutch health care system has the advantage of total accessibility to high-quality care for all cataract patients. The recent and dramatic cuts in surgeon fees, however, threaten the motivation of cataract surgeons. I foresee a significant decline in initiatives to innovate and improve the quality of care in my country. For instance, laser cataract surgery has not yet been introduced in the Netherlands. Our financial model makes it practically impossible to reimburse the extra cost of the laser. All additional expense must therefore be covered by the copayment sum for the refractive part of the procedure and the special IOL. It will be difficult to convince a Dutch patient to pay a significant extra sum of money for the laser procedure. Perhaps with time and lowering of cost there may be a higher acceptance of the technology.

The present situation of tolerated copayment for the refractive component of cataract surgery (ie, upgrading a monofocal IOL to a toric or a multifocal toric IOL) is beneficial for everybody. It remains unclear what authorities will do in the future. A change in the political direction of this country has led to repeated and drastic changes in the payment system for cataract surgery. Currently, the main focus is limiting health care costs, no matter the consequences.

Khiun F. Tjia, MD, is an Anterior Segment Specialist at the Isala Clinics, Zwolle, Netherlands. Dr. Tjia states that he is a consultant to Alcon Laboratories, Inc., and Hoya Corp. He is a Co-Chief Medical Editor of CRST Europe. Dr. Tjia may be reached at e-mail: kftjia@planet.nl.

Sep 2011