As I See It

A New Cataract Complication: Walletopathy

By Paul S. Koch, MD, Editor Emeritus

Last week, the school committee in my town was sharing the news about the economic realities of budget cuts, such as their need to increase class size by one or two, when a young mother stood up and asked, "Putting money issues aside, can you explain how this will help our children?" The chairman replied, "I'm sorry, we cannot put money issues aside. It is all about the money. We don't have enough of it."

Neither does our reimbursement model for cataract surgery, judging by the myriad fees we tack onto the bill.

My patients have average out-ofpocket co-pays for cataract surgery (including facility) of $350. They each take a topical antibiotic, an NSAID and a steroid. If they use the newest (and greatest!) of each, they could easily spend another $350. Perhaps they want one of the presbyopia-correcting lens implants ($2,000), or maybe a toric ($1,000) or perhaps just an LRI ($500). Maybe they can't afford the premium lens and go with custom monovision ($500). Quite possibly you'll want to check the accuracy of your lens or the response to your LRI with the ORange analyzer ($150).

So, grandma came to your office waving her BankAmedicare card thinking she was covered for her cata - ract surgery, only to discover that one eye could have a very excellent operation once she shelled out an ad ditional three to six hundred dollars, or a very sophisticated one for an additional three grand.

Fortunately, we do elective surgery, so there's time for us to explain the range of services we offer, and give the patients time to contemplate and select the opportunity that they want.

And now we have for our consideration three companies developing a femtosecond laser for cataract surgery. No prices have been announced, but I doubt they'll be cheap.

Cover/Uncover Test

Every decade or so something comes along that equalizes things among surgeons, improving outcomes across the board. Cryoextraction of the lens was one great equalizer. It reduced the com plications of capsule forceps extraction dramatically and opened the opportunities for performing excellent surgery to a wider number of surgeons.

Another was viscoelastics. Before that, implanting an intraocular lens under the protection of air was a tough job, best left to a handful of surgeons. Healon came out and suddenly excellent IOL surgery could be found everywhere.

Let's also throw in the excimer laser. The challenges of RK disappeared overnight, replaced by PRK.

And now we see a future in which all incisions will be identical; all capsulotomies the same; LRIs without breaking the epithelium; and the lens softened so it can be sucked out of the eye. On the one hand, it will be another great equalizer, improving the results of surgery everywhere. On the other hand, it will let existing cataract surgeons extend their careers long after the wobblies begin.

On the third hand, it's completely different from the other revolutions. Cryosurgery was still "covered" cataract surgery. Viscoelastics were just a tool for improving "covered" cataract surgery. Refractive surgery was never "covered" to begin with.

Femtosecond cataract surgery will be… what? A new tool bundled into a standard cataract fee? A value-added "premium" cataract operation? A procedure linked to some other self-pay procedure, such as premium lens implantation? A completely new operation with its own new procedure code that pays much more than our standard operation?

This very excellent technology is being developed for us even as our economy is in the tank. Will the winning economic model for this product be a high-cost system for a handful of patients, or a lower cost system for many more? We don't know yet, and even when the lasers are introduced the initial financial model might not be the final one.

There are a lot of unanswered questions. Will these lasers change our world as we know it? Or will our patients finally tell us, "I'm sorry, we cannot put money issues aside. It is all about the money. We don't have enough of it." OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His e-mail is: paulkoch@kocheye.com.