SLT: It can do more than reduce IOP

This glaucoma procedure can benefit both patient and practice in terms of efficacy and financial costs.

By Nathan Radcliffe, MD and Meredith Remmer Klifto, MD

In last month’s issue of OM, Dr. Cynthia Mattox described how the Centers for Medicare and Medicaid Services (CMS) had reduced the 2016 physician payment for laser trabeculoplasty (CPT code 65855) by 19% as of January 1, 2016, with additional reimbursement cuts planned. Because laser trabeculoplasty, most commonly performed as selective laser trabeculoplasty (SLT) is a trusted modality of care for the glaucoma patient, it is time to review how a reduced SLT reimbursement could impact the glaucoma patient’s overall healthcare and the healthcare costs of the practice.

More than 250 articles in the peer-reviewed literature demonstrate the utility, efficacy and safety of SLT for the treatment of primary open-angle glaucoma (POAG). These articles show SLT to be efficacious as a first-line agent; as an adjunctive therapy; and as a replacement for drop therapy.^1,2 SLT, furthermore, delivers IOP-lowering efficacy comparable to incisional glaucoma techniques, yet is far less invasive and destructive to the ocular surface with less potential to induce complications.³

Compare and contrast

Although SLT is comparable to eyedrops in terms of pressure lowering, the similarities end there. Laser trabeculoplasty is a physician-delivered therapy, whereas patients or caregivers instill eyedrops. Laser trabeculoplasty can remain effective for many years, whereas the effects of most eyedrops last for 24 hours or fewer before they require re-administration. On the surface of the eye, laser trabeculoplasty has no effect, whereas a growing body of literature demonstrates that drops induce dry eye, hyperemia, eyelash and orbital changes, and allergy — and, in most cases, ocular discomfort.⁴

Given these obvious differences, it is fair, let alone prudent, to ask why more patients are not receiving SLT. One possible reason is that it takes more time for the physician to discuss the therapy with patients (particularly in comparison to prescribing an eyedrop). However, the benefits of SLT to the patient, the physician and the healthcare system are worthy of the time investment.

From the practice’s vantage point, the benefits of SLT — including the financial ones — are equally important.

A question of efficiency

Modern ophthalmic practices, as we all know, are under tremendous pressure to be cost effective and efficient in function. The ideal glaucoma treatment, therefore, would be delivered once and would possess a durable and lasting efficacy. In glaucoma, we know that up to 50% of patients have difficulties with compliance, and so a chronic, self-administered medical therapy would seem a less-than-optimal approach.⁵

But eyedrops as therapy also affect practice administration, and often adversely. Where practices strive for efficiency, planning for and administering these drops belies that goal. For one, prescription-plan payers are constantly shifting their formularies, so the practitioner often doesn’t know which therapies (including generics) are covered and which are off the formulary. As a result, there is a high likelihood when any therapy is prescribed that it will not be given to the patient, and instead a series of phone calls between patient, pharmacist, insurance plan and physician’s office will ensue. While these phone calls are going on, the patient may remain untreated, and extensive additional resources are required to deal with the fallout. All because a doctor wrote down on a piece of paper the name of a drug she believed to be best suited for the patient’s needs, (See related story http://tinyurl.com/jv5z3ur.)

SLT or medication: cost comparisons

This chart shows the amount of time that elapses (time threshold) in which SLT becomes the more cost-effective choice for the glaucoma patient. This chart, adapted from a 2012 Archives of Ophthalmology article, was published before Travatan Z (travoprost, Alcon) retired its patent. Lumigan (Allergan) still has its patent.

*Source: 2011 Red Book
Manufacturers of these products: Xalatan: (Pfizer), Alphagan P: (Allergan), Combigan: (Allergan)
Seider, MI, Keenan JD, Han Y. Cost of selective laser trabeculoplasty vs topical medications for glaucoma. Arch Ophthalmol. 2012;130:529-530.

Formulary battles also have practical fallout. Many busy ophthalmic practices will hire staff to cover these phone calls to sort out patients’ difficulties in getting medications, thus translating to a significant practice expense, one that drains physician and staff resources away from other patient care duties.

To be fair, laser trabeculoplasty also can require use of a practice’s resources. The patient must be scheduled for the laser and appropriate prior authorization may be obtained; but, given that the therapy is typically delivered only once every few years, the resources required to support laser trabeculoplasty are less onerous. Furthermore, the physician is reimbursed to perform laser trabeculoplasty, unlike eyedrop therapy, so a portion of the reimbursement for the laser supports those resources used. Medical therapy in glaucoma, on the other hand, is at best cost-neutral from the practice standpoint; it is often a primary source of lost revenue; and, at worst, it ends up costing the practice money and time.⁶

Patients and Payers

How do patients and insurance companies benefit from increased utilization of SLT?

Let’s start with the patient perspective.

When the patient is prescribed a medication, she must take the time to go to the pharmacy to pick it up. While some patients will need to do this four times annually, many patients receive prescriptions on a monthly basis, so their visits to the pharmacy are much more frequent. Problems with under-filling are well known, as are issues with patients missing the eye with the instillation: It is common for patients to run out of medication much sooner than 30 days. Aside from the stress this induces, it also leaves patients with inadequate coverage for their intraocular pressure elevation.

After the patient has spent time picking up the prescription, she must find time every evening or morning (or both) to apply the drop. Many specialists recommend that patients close the eyelid for one to five minutes after the application of the drop or perform punctal occlusion at the same time. Because patients cannot easily apply a drop to the fellow eye while closing the first eye, it is often necessary to dedicate up to 10 minutes once or twice a day to drop therapy.

Keeping in mind that compliance is more than remembering to take eyedrops, and that it also includes instilling them, it becomes apparent we may not be setting patients up for the best chance at a successful outcome. Alan Robin, MD and colleagues have shown that few people — 36 out of 117 — can instill one drop into the eye without the bottle touching the eye.⁷

And then there is the cost. Many of my patients tell me about $100 co-pays (or higher on multiple medications) and their difficulty in trying to understand the nuances of coverage variables. Although it is reasonable to expect patients to be partners in their own care, I also believe we should advocate for therapy choices that are easy to understand and comply with, that are the least burdensome to quality of life, and that do not unduly add out-of-pocket expense.

Insurance plans and third-party payers

Ironically, insurance payers may be the biggest winners in a choice to use trabeculoplasty — and the biggest losers if the reduced SLT reimbursement results in fewer SLT procedures being performed. While a large variability exists in eyedrop therapy costs, is an overall upward trend in cost to payers, inclusive of higher prices on generic medications. Generally speaking, between 2010 and 2014, spending on generic drugs has risen 17.3%, from 12.5%, according to IMS Health.⁸

However, one cost that health insurance providers do not seem to tune into is the cost of disrupting glaucoma therapy. When the annual formulary comes out and medications have been changed or if one needs to be added, the plan may recognize a small savings from having negotiated a better prescription price with one pharmaceutical company versus another.

But what they may not realize is that most ophthalmic practitioners will want to re-examine their patients multiple times on the new therapy, and changing a therapy can create medical intolerances and allergies which would generate additional office visits. For example, 20% of patients who take Alphagan (brimonidine 0.2%, Allergan) will develop allergy, resulting in an unscheduled visit to the physician with a new, alternative prescription given.⁹

Because prescription plans are constantly changing formularies, medical therapy for glaucoma is, by definition, an unstable environment. For example, five years ago we had brand-name Xalatan (latanoprost, Pfizer), Travatan (travoprost, Alcon), and Lumigan 0.03 (bimatoprost, Allergan) on the market, and today these medications are essentially unavailable, having been replaced with latanoprost, Travatan Z, and Lumigan 0.01. Seider and colleagues provided a careful and thoughtful cost analysis on laser trabeculoplasty compared with medical therapy. Assuming the laser would replace a single eyedrop, they found that compared with brand-name medications, laser usually became cheaper after about six months, well within the period of efficacy for laser trabeculoplasty. Even with generic medications, within a year or slightly longer, most medications were more expensive than laser. Generic timolol did particularly well in the analysis: the authors noted that it would be just over three years before the laser became less expensive than timolol monotherapy—however, in the real world, timolol is rarely used as a front-line agent.¹⁰

Conclusion

The net effect: While eyedrop therapy takes resources of all types out of an ophthalmic practice, laser trabeculoplasty puts adequate financial resources back into the practice, although thanks to the CMS’s recent action, “adequate” does become an arguable point. The practice benefits from SLT adoption, and those benefits are paid forward into reduced costs for both patients and payers. While SLT is well tolerated,¹ up to 20% of patients prescribed an eyedrop may experience hyperemia, allergy, stinging, or some other side effect (including serious systemic side effects) which result in emergency visits and unscheduled return examinations — all of which create extra work and disorder for the ophthalmic practice.⁴

Despite CMS’s recent action, SLT is still likely a cost-saving measure for glaucoma patients and their payers. SLT is proven safe and effective in most patients. If reduced reimbursement for SLT results in fewer performed SLT procedures, based on the data presented above, it is possible that physician practices would be adversely affected; patients would suffer greater adverse events; and overall healthcare costs would be increased. OM

REFERENCES

About the Author
	Nathan Radcliffe, MD, is director of the Glaucoma Service and clinical assistant professor at New York University Langone Ophthalmology Associates.
	Meredith Remmer Klifto, MD, is a second year resident at New York University Langone Medical Center.