Cataract & refractive
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Complicated cases are suitable for laser refractive cataract surgery. The complication rate is not zero but it is low Gerd U Auffarth MD
Catalys OCT image, treatment design and cross-sectional view of Malyugin ring in situ
Catalys image following octant segmentation, and lens softening, with Malyugin ring in situ
Johann Ohly MD, a glaucoma specialist at Mercy, also believes femto-cataract surgery is easier on delicate eyes. In six months he has operated several eyes with Fuchs’ Dystrophy with endothelial cell counts in the 1,400 to 1,500 range, and so far all have been successful with none requiring subsequent transplant. they charged an average of $1,058 more per case for femtosecond laser surgery with conventional IOLs, which would require about five years to break even doing 19 cases per month.
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With cataract surgery already highly successful, justifying the extra cost is a hard sell for the cash-strapped publicly funded systems. Currently, surgeons’ ability to bring it to the masses depends on local
reimbursement rules and their own capacity to work within them. For Dr Dick, public payment restrictions are not an issue because he operates a private clinic. Under Australian rules, Dr Cherny bills patients $300 extra for femtocataract to cover consumables, absorbing the rest of the cost in his professional fee. Under US rules, Mercy breaks even on femto-cataract without charging patients extra. However, as a hospital-owned facility, it has advantages. On average, the US Medicare system paid hospital-based clinics $740 more per case in 2011 than it did free-standing ambulatory surgery centres or ASCs, of which $306 was paid out-of-pocket by patients, according to MedPac, which advises the US Congress. These higher payments are intended to offset higher costs in hospitals for standby emergency services and higher average patient acuity. Still, the list price for femto-cataract was beyond what Mercy could absorb when Dr Tauber first investigated it in late 2011. But working with system managers, he figured with a volume target of 4,000 cases annually, he could negotiate discounts and improve workflow efficiency enough to break even. With its expertise in purchasing, Mercy approached several laser providers with its concept, and OptiMedica responded with a workable offer, Dr Tauber said. Mercy’s five cataract surgeons also standardised anaesthesia, IOLs and OVDs, and obtained volume discounts that further reduced costs, and eliminated now-unneeded items including some disposable knives. Initially, femto-laser added about seven minutes to surgical times that had run nine to 10 minutes – more than anticipated. Over three months, this was trimmed three to four minutes with help from Mercy analysts trained in techniques such as SixSigma. Surgeons who had cut back to 12 cases a day are back to 16. Kevin Rash, Mercy’s vice president of operations for surgery services, is satisfied with the financial progress. “I’m not losing any sleep over it.”
New standard of care? Femtocataract is also a hit with patients. Before he received his laser, Dr Cherny gave patients the option of delaying surgery.
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Just about every complication can be reduced in theory. After 700 cases, my own observation is cases go smoother and there is greater consistency in handling difficult cases. It makes every surgery better Mark Cherny MD
Despite the anticipated extra charge, many did, and he had a two-month waiting list when the machine arrived. Mercy is having no problem increasing its volume, Dr Tauber said. Continuing medical education for optometrists and its extensive primary care network is building referrals, while consumer outreach has created a buzz. Dr Cherny believes femto-cataract will become the standard of care. “Once it’s accepted that the laser adds safety, you will have to counsel patients that it is available as an option. All it will take is one malpractice case where the laser wasn’t used.” Many believe femto-cataract will become more affordable. “The cost will come down, but it will take time,” Dr Dick said. The technology may also have the potential to “de-skill” cataract surgery. Some managers in the UK National Health Service, where ophthalmic nurse practitioners already perform Nd:YAG laser capsulotomy and minor surgery such as chalazia, have already toyed with the idea of nurse-led cataract surgery, according to Oliver Findl MD, Vienna, Austria. But Dr Dick discounts the possibility. “The laser is still surgery. It looks smart like a smart phone but you are still cutting and you are changing the anatomy of the eye. I see no appropriate education in the nurse compared with the medical doctor.” Still, the technology’s complexity is likely to change cataract practice, Dr Cherny said. Surgeons likely will need to band together to share laser system expenses. “As [ASCRS President] Eric Donnenfeld said, we can no longer afford underutilised surgery centres.” Femto-cataract already has affected referral patterns in his community, and not all his colleagues are happy to see it, Dr Cherny added. “This is a very disruptive technology, but it is here to stay because of the precision it gives to surgeons, and the safety it gives to patients.”
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