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FROM THE CHIEF MEDICAL EDITOR

Making Monovision Pay Off

Larry E. Patterson, MD

A few months ago, an article appeared in the Journal of Cataract and Refractive Surgery that showed the outcomes of a multifocal IOL and compared them to monofocal IOLs used as monovision. For some reason, I'm not hearing a lot of talk about it, so I'll start the discussion. It showed that while the multifocal group had slightly better bilateral uncorrected distance and near vision, it wasn't statistically significant. The monovision group did better at intermediate vision, with higher satisfaction scores and fewer complaints. Not surprisingly, monovision was also a lot cheaper.

Jay McDonald, Bill Maloney and others have been telling us for years that monovision actually works quite well. But here's the catch: it works quite well as long as you spend the same amount of time and effort that you spend with multifocal and accommodative IOLs. Which begs the question: can we be reimbursed directly from the patient for that extra effort?

Four years ago, an article stated that you couldn't charge extra for monovision. It said, “For the most part, the pseudophakic monovision procedure is exactly the same as conventional cataract surgery with an IOL, which is fully covered by Medicare.” I respectfully disagree.

When someone is a candidate for pseudophakic monovision, I do the same amount of extra work that I do with a premium implant patient. This includes extra counseling, trial lenses and/or contacts to simulate monovision, ocular dominance testing and corneal topography. Extra care is taken to ensure the corneal surface is as pristine as possible, often necessitating extra visits. Extra sets of Ks and biometry are taken, and OCT is used liberally. All efforts are made to reduce final astigmatism to a minimum through LRIs, wound manipulation and/or toric implants. (If someone is concerned about whether they can tolerate monovision, we offer a Crystalens with a mini-monovision approach.)

As with the premium implant patients, all of my monovision patients are guaranteed to get a certain level of vision and satisfaction, and if we don't achieve that, touchups are performed at no extra charge. No extra fees are charged for any examination related to their refractive surgery in the first year.

Again, this approach requires a lot more time and effort than conventional cataract surgery. I'm not a legal expert, but I have seen a legal opinion stating that this extra time and work to obtain a precise refractive outcome is indeed outside the normal Medicare reimbursement domain, and can be charged for separately to the patient. There was a time when I did all this for free, and then when patients didn't get the result they desired, they wanted me to fix it—again for free!

Further research will be certainly be needed to corroborate this new study. But I'm beginning to wonder if we might not have happier patients by trying this newer approach to an old solution. Who knows? I may have even come up with another reason to use a femtosecond laser!