Before femtosecond cataract lasers were available commercially, ophthalmologists’ enthusiasm for the technology was tempered by concern for overcoming the large initial capital expenditure. Many still question the potential for financial gain with laser-assisted cataract surgery (LACS) in an era of ever-declining cataract reimbursements.
As an academic medical practice, Wake Forest University Eye Center is motivated to adopt the latest technologies, and the recent decision to jump into LACS in conjunction with the building of a new operating facility has been professionally and financially rewarding. Answering three seemingly simple questions has helped us to set a pricing strategy for this new mode of cataract surgery.
HOW SHOULD YOU DETERMINE PRICING?
In academic practice, there is a strong push to stay on the cutting edge of technology, be a leader in the community, and expose residents to the latest technologies. To achieve these goals, we have special budgets that enable us to acquire new technologies sooner than many private practices can. My colleagues and I purchased the Catalys Precision Laser System (Abbott Medical Optics), and, with four surgeons operating with the laser (Figure 1; eyetube. net/?v=enogg), we felt confident that we could meet the monthly minimum (12 surgeries) necessary to stay profitable. eyetube.net/?v=enogg
Like many recently introduced cataract surgery technologies, LACS is not covered by US Medicare or other insurance companies, giving us the freedom (and responsibility) to determine the out-of-pocket cost to the consumer. Together with our administrators, we calculated the price per case with the interface, maintenance, and amortization of the machine. Considering that a primary marketable benefit of LACS is astigmatism management, we priced the procedure slightly less than the cost of a toric IOL to encourage patients with lower levels of astigmatism to choose the laser over a toric lens.
We offer out-of-pocket options, both à la carte and bundled, for our patients. In addition to the prices previously set for toric and multifocal IOLs, pricing has been set for three packages:
- Astigmatism Management Package: LACS with a standard monofocal IOL;
- Astigmatism Correction Package: LACS with a toric IOL; and
- Full Correction Package: LACS with a multifocal IOL.
The bundled price of LACS and a premium IOL (toric or multifocal) is less than the individual costs for both of those options separately. Enhancement following LACS is rarely needed, and, for the less than 1% of patients who could benefit from PRK, we do not charge for this enhancement beyond what they have already paid for cataract surgery.
DO PATIENTS WANT TO PAY?
Even if all premium cataract surgery offerings were covered by insurance, the fact that there are choices requires a significant investment in patient education. We have tackled this by sending out a packet of information to patients scheduled for a cataract consultation before their appointment. The packet includes a cover letter from the surgeon thanking them for choosing our practice and letting them know that, because of the availability of new technology, they now have choices in regard to their eyes. The letter helps to inform patients of the two decisions they must make before surgery: (1) how the cataract is to be removed and (2) what it will be replaced with. The letter also briefly explains the availability of LACS and the different lens options. Within the packet is also a brochure on the laser platform we use and a fairly extensive pamphlet on the different lens platforms.
When patients come in for consultation, they watch a video about manual cataract surgery versus LACS while their pupils are dilating. By the time I meet with them, patients are fairly well informed about their condition and their options, and many have made notes in the brochures they were sent and also prepared questions. Invariably they are attracted to LACS, and the responses are split between those concerned about the cost and those feeling that their quality of sight merits any cost.
I inform my patients that there is an upcharge for LACS because, in addition to increasing safety, it will correct their astigmatism and provide them with optimized distance vision if they choose a monofocal lens or near and distance vision if they choose a multifocal lens. Most patients present with some astigmatism, but even for the few who do not the incision produces some. Therefore, it is rare that a patient cannot benefit from astigmatism management.
I explain that a patient who chooses standard cataract surgery will likely need bifocals for distance and near, whereas a patient who has LACS has a good chance of achieving excellent distance vision with a standard lens.
I guide my patients to first make the decision about removal of the cataract via standard cataract surgery or LACS, because the lens options hinge on that decision.
If a patient selects LACS, he or she then has to decide between a monofocal and multifocal IOL. If the patient asks for my opinion, I explain that I prefer to implant a multifocal IOL in conjunction with LACS because I can manage astigmatism and he or she will get better results. For patients with more than 2.00 D of astigmatism, I note that they can benefit from a toric IOL. Some of these patients request a toric IOL without LACS, and that is fine.
HOW DO PATIENTS RESPOND?
My recommendation for patients is to have LACS if they can afford it. Most who can afford out-of-pocket options are appreciative of the technology and willingly pay the additional cost to have optimized vision. In my practice, between 60% and 70% of patients end up electing LACS.
Our initial goal was to have a combined total of 12 LACS cases per month to pay for the interfaces and amortize the laser over 5 years, but we are currently performing at least 30 cases per month. On postoperative day 1, patients are happy with their outcomes, and as a result we have seen an increase in referrals. Because we are correcting astigmatism and getting perfectly centered lenses, more patients are achieving 20/20 or 20/25 UCVA on day 1 than ever before.
Many surgeons, especially those in smaller practices, are concerned about capital investment for a LACS platform. But when you experience the enthusiasm patients have for the new technology and do the math, you realize that LACS can be affordable in any setting. Key to our success has been trust in our laser platform and, thus, our results. A dependable laser creates a confident surgeon, and that confidence is conveyed to the patient.
Keith A. Walter, MD is a board certified ophthalmologist specializing in cornea and refractive surgery and is a Professor of Surgical Sciences at Wake Forest University Eye Center in North Carolina. Dr. Walter states that he is a consultant to and speaker for Abbott Medical Optics. He may be reached at e-mail: email@example.com.