Post-refractive Enhancements: Who Pays?

An "upfront" approach to addressing additional costs.

BY JOHN A. VUKICH, M.D.

With today's progressive healthcare market, patients have come to expect that vision-improving procedures, such as cataract surgery or LASIK, are standard, one-time treatments with emmetropic results. As surgeons, we are prepared for the occasional refractive surprise or the need for a postoperative enhancement, but our patients are not. When additional adjustments, which bring accompanying expense, are necessary to achieve the desired visual goal, patients tend to become disappointed or disenchanted.

In my practice, we have developed a philosophy to handle the inevitable necessity that some patients will require an enhancement procedure. With the options available today in premium IOL choices, cataract patients selecting them have now become refractive patients, and this development needs to be reflected in preoperative consultations in order to achieve patient satisfaction. This article will discuss our approach in explaining to patients the issues surrounding possible enhancements.

A "No-Surprises" Approach

Our approach to patients is the anticipation that some procedures will require more than one step. We lay out our treatment plan so that patients are prepared for what steps to expect in the acquisition of the desired refractive endpoint. We counsel the patient on what to expect the day of surgery and postoperatively, set up an appointment for a secondary procedure in advance and outline what the charges are for their treatment plan.

This treatment plan helps in the management of patient expectations in the postoperative period. We explain to the patient that there may be residual astigmatism, or that some other contributing factor may impede full, immediate return of vision. The patient understands that there is another step in the process that won't be completed until we can fully assess the outcome following the initial surgery.

For example, if a patient has 2 D of cylinder preoperatively and we plan to implant a multifocal IOL, the anticipation is that the patient won't be satisfied with their vision until the astigmatism is corrected. Therefore, we have an astigmatic treatment plan in place preoperatively. We usually plan to perform PRK 4 to 6 weeks postoperatively. That gives us the ability to adjust anything that might be off spherically in our IOL calculation, as well as treat the astigmatism. The patient knows that in this case, it is a two-step process and there will be an additional charge for it, not covered by insurance, of course. We significantly discount what would be charged for those patients whose primary procedure is laser vision correction, yet this enhancement fee is part of the upfront expectation.

This philosophy works to the advantage of both patient and surgeon because there are usually no surprises. The patient participates in the value-of-care decisions each step of the way. The second procedure is planned in advance, and the patient will play a major role in deciding whether it is needed or desired, knowing there is a cost associated with that second procedure. Otherwise, the patient may feel entitled if he or she perceives that the procedure has been paid for already. The decision then becomes based on that feeling of entitlement rather than whether is it really necessary.

Avoiding Patient/Surgeon Tension

When the charge for a secondary procedure is built into the initial treatment, the thinking can easily become, "I paid for it, and therefore I deserve it." We have found that it is not uncommon for a patient whose postoperative vision is 20/25 to say, "I'm actually fine where I am." Should a patient decide he or she would like an enhancement, it's known ahead of time there is an additional cost associated with it.

We find this policy is better than an all-inclusive concept because some will feel that they are buying the proverbial "extended warranty" or paying in advance for something that they may or may not need. In an all-inclusive fee structure, the costs must be built in upfront, so the patient may be paying for something that is not necessary.

No matter how tiny an improvement in the visual outcome may be, patients may feel that they paid for it, so they may as well get it. This can then become an issue of an enhancement not being the clinically best decision from the standpoint of the surgeon. A contrary opinion from the surgeon could leave the patient feeling that there is denial of a service to which he is entitled, and a belief the doctor is not living up to the contractual agreement. This type of tension can create some ambiguity with the patient.

We have found that most patients appreciate an honest, transparent approach to providing care that is necessary and that they view as valuable; they know the treatment plan and the timeline for what to expect in terms of where they hope to be visually following cataract surgery. Our approach has provided a good way for people to understand the emmetropic endpoint of premium corrections with premium IOLs.

Keeping the Patient Informed

Patients understand that cataracts are a pathologic condition, but many of today's patients are quite savvy. They search the Internet and talk with friends. They understand there are treatment options and they want to know more about the entire process. Part of our patient counseling is to impart an understanding of why premium choices cost more, why Medicare doesn't cover the additional cost and why this premium correction is not insurance coverable. There is just more involved in the premium process and it is our job to help patients understand that this is an elective option to improve quality of life. It is a lifestyle improvement that many patients find important and valuable, and therefore they are asked to contribute to defray the costs of additional services that the practice needs to provide.

As mentioned earlier, we generally perform PRK for this enhancement procedure, and sometimes IntraLase (Advanced Medical Optics [AMO], Santa Ana, Calif.) LASIK. PRK is often the choice because the correction is usually quite small and typically of the mixed astigmatic type involving 15 μm to 20 μm of tissue. As a relatively minor treatment, PRK eliminates the necessity of creating the LASIK cap as well as the additional expense of IntraLase. It also eliminates one more incisional component, as well as any concerns about the pressure on the eye for the integrity of the corneal wound. We believe PRK is well-suited to these very minor touch-ups that have refractive value.

Our planned enhancement rate after multifocal IOL implantation is approximately 15% to 20%. This is primarily due to pre-existing corneal astigmatism. We come very close in our IOL calculations, although occasionally there is a greater residual spherical component than we expected and this error may lead to an unanticipated enhancement.

The Post-LASIK IOL Patient

That being said, our post-LASIK patients undergoing multifocal IOL procedures are an entirely different story in terms of enhancement rate. Typically, these patients are the first to ask about multifocal lenses. They understand the value of a refractive procedure and have enjoyed freedom from glasses following LASIK surgery, often for a decade or more. These patients believe that spectacle independence is something that they would very much like to maintain. They understand that the premium IOL can provide near, far and intermediate vision — and they absolutely want that.

Previous LASIK surgery adds a great deal of additional uncertainty to the amount of IOL power that is needed. In spite of all our efforts to come up with algorithms and different formulas to predict effective corneal power, we're still not as good as we are with corneas that have not undergone refractive surgery. Enhancement rates are just higher, probably coming close to 50% in patients who have had LASIK surgery and wish to have to have a premium IOL.

We tell these patients that we'll do our best, but there is additional ambiguity in the refractive endpoint, no matter what we do. We tell patients that we could be off as much as a full diopter. We try to not be, but it happens. We explain to this patient population that if uncorrected distance vision is the goal, then it is very likely that a touch-up procedure will be necessary. We schedule it at the same time we schedule the initial procedure. This is also the case for those patients whose refractive endpoint is monovision.

No Preoperative Test Charges

Additional testing is often necessary prior to multifocal IOL implantation, such as a more in-depth evaluation of the cornea and sometimes the eye's posterior segment. This may include Pentacam (Oculus, Lynnwood, Wash.), additional A-scan or optical coherence tomography of the macula; this testing can become an important component of the patient assessment. Whether to charge for this additional testing or not can be a gray area. We do not charge for it in our practice. The patient does not like to feel "nickled and dimed." Instead, we build some of this additional expense into the surgeon fee rather than having an "a la carte" approach to these more sophisticated assessments of eye.

Limbal relaxation incisions (LRIs) are commonly performed on the monofocal patient whose endpoint isn't as tight. An LRI is an add-on at the time of surgery that gets very close to the desired result. It's generally acceptable to leave a small amount of cylinder, around 0.5 D or so. When plano or emmetropic endpoint is much more critical and 0.5 D to 0.75 D really can't be left behind, then an LRI is not the solution. I believe that a premium IOL should be paired with a premium enhancement, and in our practice that is the standard.

Enhancements After Laser Correction

Our enhancement policies are different for laser vision correction when LASIK or PRK is the primary procedure. For 1 year, any necessary retreatment is free of charge. Following the 1-year postop mark, there is a graduated system of additional cost to the patient. From 1 to 2 years following the initial surgery, the fee is 25% of the current cost of the procedure; from 2 to 3 years postop, it is 50%, then 75% for 3 to 4 years postop, and at 5 years and beyond, the cost to the patient is 100% of the current fee. With today's advancements in technology, the rate of enhancement following laser vision correction is so low that this becomes almost a non-issue.

The rate of enhancement following laser vision correction in my practice is 2% or less. I perform LASIK using IntraLase most of the time, and custom treatment with the Visx Star 4 excimer laser (AMO) whenever possible. Each generation of the custom laser platform has led to improved visual outcomes. From capture of the wavefront to centration and iris registration, each step contributes to the excellent results that we achieve. Custom surgery is the whole process, involving capture, algorithm, raw data interpretation and delivery to the cornea. The cumulative effort of the process is what allows us to achieve remarkable results. Enhancement policy for multifocal IOLs and laser vision correction patients is a management issue involving the cost of delivery and the patient's perception of good value.

Transparency is Key

There are many advocates of bundling fees, and it works well in many practices. Our philosophy reflects our belief that patients want to understand the value of the care they are receiving and not feel that they are being taken advantage of by being charged for something they may not need. That can create a certain amount of skepticism. It has worked well for us to adopt the policies we have in place. Again, we find that patients appreciate the transparency of our philosophy.

Counseling patients and managing expectations are key to having happy patients. How the doctor and the staff treat the patient is invaluable in the whole experience. Patients want to feel comfortable from the moment they pick up the phone to schedule an appointment, to the moment they walk in the door for their preoperative evaluation, all the way through to their final postop visit. So many factors influence patient satisfaction. Those who may need retreatment should be able to understand the value of their care and believe that "the doctor didn't give up on me, they got it right." And if it was all properly explained to them from the beginning, the result will be satisfied patients. OM

John A. Vukich, M.D., is a principal in the Davis Duehr Dean Center, Madison, Wisc., and assistant clinical professor of ophthalmology at the University of Wisconsin, Madison. He can be reached via e-mail at javukich@facstaff.wisc.edu.