Cataract surgery remains the most common surgery performed worldwide. In the United States alone, an estimated 3.7 million surgeries are completed annually, contributing to the 20 million patients who undergo the procedure globally each year, according to the National Library of Medicine.¹

Despite this prevalence, the surgical output alone does not necessarily result in the most lucrative venture for all ophthalmologists. Presently, Medicare’s national rate for a routine cataract procedure is approximately $550 — a payment that the Centers for Medicare and Medicaid Services and other payers have steadily reduced for surgeons due in large part to the increased volume of cataract surgery each year.

While busy surgeons, and particularly those operating ASCs, do well financially with these procedures, other surgeons struggle, especially those who work in hospital outpatient departments with fewer cases.

When also considering inflation, rising business costs due to supply chain issues, demands for increased employee salaries and pressure on clinics to keep patients’ costs manageable, any added revenue for non-covered services associated with cataract surgery is coveted. With no statutory or regulatory limit on the fees surgeons can charge for non-covered services, the only practical constraint is patients’ ability and willingness to pay. This can cause challenges when attempting to set a price for refractive procedures performed at the time of cataract surgery.

As clinics attempt to provide more services and remain profitable, this challenge is not expected to end anytime soon — regardless of the rate of inflation. In this article, we asked industry experts to describe how they might address this challenge.

APPROACHING THE PRICING PROCESS

John A. Hovanesian, MD, says standardizing pricing protocol for the non-covered costs is a beneficial starting point. “The way you come up with pricing is somewhat formulaic,” says Dr. Hovanesian, owner of Harvard Eye Associates in California and an internationally recognized leader and innovator in cataract, corneal and laser eye surgery. “The out-of-pocket price for the patient is a blend of different non-covered services that you’re providing as part of the premium lens. You want to construct price based on the services that you are going to perform times the likelihood that you’ll need to perform them times the number of times that you will need to perform them. You have to have a methodology so that you’re justified if charges are ever questioned.”

The impact of inflation more directly relates to charges that might need adjusting due to current upticks in expenses that clinics are managing, says Gary N. Wörtz, MD, such as the costs to maintain trained staff members who assist in the surgical process and overall customer service. “Staff costs are the No. 1 cost in most practices,” says Dr. Wörtz, a cataract and refractive surgeon at Commonwealth Eye Surgery, Lexington, Ky.

“We’ve seen a tremendous amount of competition for staff,” Dr. Wörtz says. “We need to be competitive for technicians in the market. When you have staff turnover, you have decreased efficiency while you attempt to hire new employees and train them. I’m glad that employees are making more money, but that’s driving prices up.” Those charges, he notes, can include fees for performing the refractive portion of surgery.

“The bright side is that we have refractive surgery and the premium channel for cataract surgery,” Dr. Wörtz says. “And adding a refractive component to cataract surgery has really allowed us to stem the tide from declining reimbursements.”

Examples of cataract surgery packages can include clearer distance vision with a single-focus lens and correction of astigmatism or a multifocal lens with a full range of vision, says Dr. Wörtz.

PRICING PAIN POINTS

Although inflation leading to economic hardship raises serious concerns for any physician who’s operating a practice, it’s not the most important consideration for pricing of professional services associated with refractive cataract surgery, says Kevin Corcoran, COE, CPC, CPMA, FNAO, president and co-owner of Corcoran Consulting Group.

“Pricing professional services primarily depends on the ingredients of the package and how patients appreciate the benefits of the offering,” he says. “Patients respond well to a clear message rather than a complicated one.” Mr. Corcoran describes three different types of packages: Astigmatism, presbyopia and a package for both astigmatism and presbyopia.

A common part of all three packages is preoperative testing. Mr. Corcoran recommends screening for dry eye disease, macular disease, corneal disease and other conditions that might diminish the desired outcome of cataract surgery. “These tests prove very useful to the surgeon even when patients decline to have a premium IOL and they fall into Medicare’s definition of a non-covered service for which the beneficiary may be financially responsible,” he says.

By improving outcomes, or at least avoiding bad outcomes, a surgeon gains a reputation for excellence with patients and referral sources, Mr. Corcoran suggests. “We may see continued inflation as well as a recession in 2023, yet the practice of medicine and the restoration of sight is much more than just commerce,” he says. In Mr. Corcoran’s view, surgery is a once-in-a-lifetime opportunity to treat cataract and the associated refractive errors. “Patients who can appreciate the benefits of this surgery after you explain it — and have a little bit of money to spend — will be favorably inclined,” he suggests.

Based on industry data, Mr. Corcoran notes that a large percentage, approximately 45-55% of cataract patients, elect to have some additional service that they pay for. “The most popular choice is the treatment of presbyopia with pseudophakic monovision,” Mr. Corcoran says, adding that some new IOLs coming to market will likely make this choice even more popular.

“While we can’t ignore the economic environment in the world, as a rich country the United States has a lot more resources to cope,” he says. “It’s possible to improve the efficiency and the results of cataract surgery. One way is sequential or bilateral cataract surgery. There is increasing interest in ophthalmology to offer it.”

COMMITMENT TO COMMUNICATION

Beyond pricing, comprehensive pre-surgical education can have an impact patients’ decisions as well, Dr. Hovanesian. This should begin before patients enter the office. “Today’s patients get their information from many sources, one of the most influential of which is their friends who have had surgery,” he says. “Whether it’s a positive or negative response, it’s likely to influence their thinking before they arrive in your office.”

As such, Dr. Hovanesian suggests streamlining education through digital tools that are accessible prior to a visit. One example is the MDbackline platform, a cloud-based software that automates physician contact with patients outside of the office setting, provides insight into goals that patients want to achieve and syncs with the practice’s EHR. The system allows patients to submit questions to doctors electronically via a tablet, phone or computer, allows doctors to provide customizable responses, sends patient reminders, lets patients review doctors on social media and can also provide drug and device companies feedback about how patients use their products.

Coupling that presence with interoffice communication that is transparent and orchestrated enhances the experience.

“In the office, we have a very well-worked-out script about price and plan options, just as we do for our cataract consent,” Dr. Hovanesian says. “We introduce the concept that there are extra costs, explain the value and profile patients as to which implants would be best for them based on lifestyles and visual needs. It is worth the physician’s time to have these conversations.”

An important part of the conversation is for the physician to remain neutral and objective.

“We’re not here to push patients in any direction,” Dr. Hovanesian says. “We want them to understand their choices. We want them to get what they want, what they can afford and what is a proper fit for them. And patients appreciate that approach because it’s not a sales pitch. They want to make informed decisions.”

Dr. Wörtz, whose office also utilizes MDbackline, says part of the responsibility behind effective communication hinges on dispelling disinformation.

“There’s no central trusted hub online that everyone can point to as the place to get the truth,” he says. “Patients might end up confused before they get to your office. It’s an evolving problem that we try to solve by asking patients targeted questions about what is important to them and encouraging them to ask us specific questions that will help them understand their options.”

MISSTEPS TO AVOID

As Dr. Hovanesian sees it, the most prominent mistakes that ophthalmologists make when helping patients to choose premium packages is having a lack of confidence in their abilities to provide what the lenses promise in relation to patient costs.

“Doctors might be afraid of bad outcomes but are hesitant to make recommendations [to other clinics],” he says. “You have to overcome that fear, and you can’t conduct premium lens surgery unless you have available options for doing enhancements afterwards, whether that be in your care or someone you refer to.”

Another common mistake, he adds, is when providers form judgments about what their patients need before discussing their needs compared to lens attributes.

“You can’t base that decision on a lack of data,” he concludes. “It’s important to craft what you discuss with the patient and include the information about costs up front. It’s important to explain that insurance covers the largest costs of surgery. This helps them understand the way the system works. Patients will appreciate that.” OM

REFERENCE

1. Rossi T, Romano MR, Iannetta D, et al. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol. 2021;6(1):e000464. Published Jan. 13, 2021.