The market for presbyopia correction is growing, in large part due to the aging of the population but also because of the high expectations of today's patients. Specifically, patients presenting for cataract surgery often anticipate a return to the visual acuity they enjoyed in their younger years—without spectacle correction. It is not uncommon for these patients to come to an initial consultation prepared, having researched a variety of presbyopia-correcting (premium) IOLs or eager to get the same premium lens technology as their neighbor.

Given these factors, one might expect an extremely high rate of use of premium lens technologies in Europe. On the contrary, market penetration of premium IOLs has remained relatively low compared with the total number of cataract surgery procedures performed across all countries. According to Market Scope, growth of the premium IOL market in most areas of Europe has been only flat or modest over the past 3 years.

ONE LARGE BARRIER

Although Market Scope anticipates healthy growth in this sector over the next 3 years—a compound annual growth rate of 7.6% for multifocal, accommodating, and extended depth of focus IOLs—there is still one large barrier to widespread use of premium IOL technologies: patient copayments.

According to a survey conducted by the European Union of Medical Specialists (UEMS), only 14 of the 28 EU member states allow copayment for cataract surgery with premium IOLs. In this payment model, social insurance coverage is provided only for the standard procedure, and the patient is responsible for the additional cost of the premium lens. This survey also revealed that surgeons in only one of these countries (Switzerland) are allowed to charge an additional fee for the work and services required for premium IOL implantation, such as extra chair time, comprehensive objective testing with advanced diagnostic equipment, and the use of a femtosecond laser or surgical planning software.

seeking UNIFORM POLICIES

The UEMS survey was sent to delegates in all of the EU member states as part of a UEMS effort to establish uniform health care and copayment policies across Europe. Questions included whether copayment was allowed and, if it was, whether it applied to multifocal IOLs, toric IOLs, and fees for the extra work of the surgeon. Delegates were also asked to share their arguments for or against adopting copayment policies.

Of the 14 EU member states that currently allow copayments, eight have introduced copayment as a general policy, four have introduced it in the private sector only, and two—both federal states—have introduced it in only certain regions. Even this limited availability represents an improvement from 10 years ago, according to UEMS, when premium lens technologies first became available and their use was strictly confined to the private sector.

France is among the member states to introduce copayment across both the private and public sectors. “Copayment is exceptional in our Medicare system,” Béatrice Cochener, MD, PhD, said in an email to CRST Europe. In the near future, however, “an official discussion and meta-analysis will be conducted to conclude [the national health system's] final attitude regarding premium lenses in term of financial support.”

Copayments have also been allowed in Ireland for the past couple of years. In that country, “the insurer pays for a monofocal IOL and the patient pays the difference between the payment received for the monofocal and the cost of the premium IOL,” Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin), told CRST Europe, adding that the surgeon or hospital cannot charge the patient any more than the manufacturer's price for the IOL. “For a toric IOL, the copayment is around €300 to €400, depending on the toricity of the IOL,” he said. “For a multifocal, [copayment] is between €400 to €700, again depending on the IOL choice and whether it is toric or not.”

According to Erik L. Mertens, MD, FEBOphth, Belgium reimburses the patient approximately €80 for a monofocal IOL and €200 for a toric IOL but nothing for a multifocal IOL. “The surgeon, however, can charge an additional fee, but only in a private setting,” he said.

In Greece, “state insurance reimburses €310 per cataract to cover the IOL, facility fee, and surgical fee,” A. John Kanellopoulos, MD, said in an email to CRST Europe. As a result, only a handful of practices even offer premium IOLs because they are typically “used only in private pay patients and in some high-end insured patients.” 

Dr. Kanellopoulos also noted that the public's awareness of premium IOL technologies is extremely low in Greece and that better patient education on this topic is needed. “The sad part is that … most patients are never in the driver's seat to choose objectively,” he said.

The number of practices offering premium IOLs—toric or multifocal—is also relatively small in the Netherlands, Khiun F. Tjia, MD, told CRST Europe, adding that toric IOLs have only an approximate 4.5% share of the monofocal IOL market in that country. “Only a few centers have a reasonable number of toric implants of 10% or more,” he said.

Although the use of multifocal IOLs in cataract surgery is probably less than 1% in the Netherlands, “more multifocal IOLs are implanted in refractive lens surgery, with full payment for the entire procedure,” Dr. Tjia furthered.

In Bavaria, copayments were not permitted prior to 2 years ago, Magda Rau, MD, told CRST Europe. Before then, patients with general insurance who elected a premium IOL had to pay for the entire cost of the procedure, on top of the IOL. “Now if a patient [wants a] premium IOL, the operation is completely covered, [including] the fees for a spheric monofocal IOL,” she said in an email to CRST Europe. “The patient bears only the additional cost of the premium IOL—between €600 and €1,200 for a multifocal IOL and €600 and €800 for a toric—and the additional cost of the examinations including OCT, wavefront, [and] corneal topography, which are necessary before the implantation of premium lenses. This settlement allows insured patients with low copayments to undergo the same operation as private-pay patients.”

CROSS-BORDER CARE

“Our aim as doctors should always be [to provide] the best—not the cheapest—treatment for our patients,” Detlev R.H. Breyer, MD told CRST Europe. “In our eye clinic in Duesseldorf, Germany, copayments are not merely made for premium IOLs but also for various examinations such as Pentacam HD [Oculus Optikgeräte] and aberrometry measurements, as they are the fundamental in premium IOL selection.”

Dr. Breyer also said that 60% of his patients elect premium IOL implantation, “indicating a strong desire for the best treatment available, even in [national health service] patients. One could thus argue that countries in which copayments are not the standard of patient care deprive their patients of this beneficial medical care,” he said.

To Dr. Breyer's point, the current condition of copayment for cataract surgery with premium IOLs across the European Union leaves the door open for patients to seek treatment outside of their home countries. This is because an EU directive mandates “access to safe and high-quality cross-border health care in the [European] Union.”1 Under this provision, patients are free to travel abroad for premium IOL implantation during cataract surgery and, once they return home, can have the basic cost of the procedure reimbursed by their home country.

CONCLUSION

Although the UEMS is advocating that copayment rates should consider the extra work, higher skill levels, and increased responsibilities and risks for surgeons implanting premium IOLs, it may be years before the European Union standardizes copayment policies for cataract surgery with these lenses. In the meantime, surgeons are left to follow the rules that are established in their respective countries. n

1. European Commission website. Directive 2011/24/eu of the european parliament and of the council. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF. Accessed August 11, 2015.

Detlev R.H. Breyer, MD
• Head of Breyer.Kaymak.Klabe Eye Surgery, Düsseldorf, Germany
• Member, CRST Europe Editorial Board
• detlev.breyer@web.de

Béatrice Cochener, MD, PhD
• Professor and Chairman of the Ophthalmology Department, Brest University Hospital, France
• Member, CRST Europe Editorial Board
• beatrice.cochener-lamard@chu-brest.fr

Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin)
• Consultant Ophthalmologist, Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland
• Associate Chief Medical Editor, CRST Europe
• abc@wellingtoneyeclinic.com

A. John Kanellopoulos, MD
• Clinical Professor of Ophthalmology, NYU Medical School, New York
• Laservision.gr Clinical and Research Eye Institute, Athens, Greece
• Associate Chief Medical Editor, CRST Europe
• ajk@brilliantvision.com

Erik L. Mertens, MD, FEBOphth
• Medical Director, Medioplis, Antwerp, Belgium
• Chief Medical Editor, CRST Europe
• e.mertens@medipolis.be

Magda Rau, MD
• Head, Augenklinik Cham and Refractive Privatklinik-Dr.Rau, Cham, Germany
• Head, Eye Centre Prag, Czech Republic
• Member, CRST Europe Editorial Board
• info@augenklinik-cham.de

Khiun F. Tjia, MD
• Anterior Segment Specialist, Isala Clinics, Zwolle, Netherlands
• Editor Emeritus, CRST Europe
• kftjia@planet.nl