ADD ON Treating astigmatism and presbyopia are non-covered services, so facilities can charge patients additional fees for improved vision outcomes.

The reimbursement reality of cataract surgery is all too familiar to James Dawes, MHA, CMPE, COE, chief administrative officer at the Center for Sight in Sarasota, Fla. This year, his physicians received a 13% cut in professional fees for simple cataracts and a 21% slashing of payments for complex cataracts. On the facility side, his payments have stayed relatively flat, which means they're essentially decreasing. "From the surgery center perspective, we're not making any headway," he says. "In fact, we're going backward. On the professional side, we're going backward fast."

Rather than sit back and accept the declining reimbursements, the Center for Sight decided to get innovative, offering patients "cataract upgrade packages." In exchange for improved vision outcomes — defined as reducing their dependence on glasses by treating astigmatism or presbyopia — the center upcharges patients and bills them directly for the improved outcomes. Two examples:

HYPE MACHINE Femtosecond laser surgery offers the promise of safer, repeatable outcomes. It also has a "wow" factor that patients love.

• Advanced Vision ($3,295 per eye). Involves laser cataract surgery, implantation of presbyopia-correcting IOLs, treatment of astigmatism and post-op LASIK enhancement if patients aren't satisfied with the vision outcomes. This package offers patients the best chance to get out of glasses, although it's not guaranteed. Mr. Dawes says 95% of patients don't wear glasses after surgery.
• Custom Vision ($1,695 per eye). Involves laser cataract surgery, implantation of standard IOLs, treatment of astigmatism and post-op LASIK enhancement. Because a non-presbyopia-correcting IOL is used, patients will deal with presbyopia following surgery. Surgeons set focal points so patients will be out of glasses for distance vision, but they'll still need glasses for reading.

Yes, cataract surgeons are being successful in raising per-case revenue by adding non-covered services, delivering better refractive outcomes to satisfy a savvy patient population willing to pay thousands of dollars in order to see without glasses. "How much you charge depends on whatever your local market will absorb and your value proposition to patients," says Mr. Dawes, who has seen some centers charge as much as $5,000 to $6,000 per eye. "How much value do they place on being out of glasses after surgery?"

He suggests you conduct focus groups to find out. "I met with 45 local residents who weren't current patients and asked them what it would be worth to do away with glasses," he says.

The Center for Sight offers a "basic vision" package to patients who don't mind wearing glasses and who don't want to pay out-of-pocket above what Medicare reimburses.

"It's about giving patients a choice," says Mr. Dawes. "Patients who want to pay a little extra to have better outcomes and better lifestyles are able to do so. This is the way the free market should work."

Technology upgrades
Technology continues to improve, says Mr. Dawes, allowing for those improved visual outcomes. "And patients are becoming aware of the advances and the possibility of doing away with glasses, and asking, 'How do I get this?'" They're increasingly drawn to facilities that invest in such game-changing devices as femtosecond lasers and intraoperative aberrometry.

• Femtosecond laser surgery. Laser platforms let surgeons make accurate and repeatable capsulorhexis — the large circular incision in the anterior lens capsule — without taking a blade to the patient's eye.

Karl G. Stonecipher, MD, director of the Laser Center in Greensboro, N.C., is a big proponent of the technology. "In my experience, it provides safer, predictable outcomes because of more effective lens positioning."

When the FDA approved presbyopia-correcting IOLs 7 years ago, Mr. Dawes's surgeons were among the first in the country to offer the vision upgrades to their patients. "We were simply excited to offer improved outcomes, regardless of the financial benefits we realized," he says.

So when femtosecond laser cataract surgery hit the market, he evaluated the technology with his physicians and decided it would help them deliver improved refractive outcomes. When deciding to allocate significant investment dollars in the laser platform, he looked at how much the technology would cost and how many patients would opt for the procedure upgrades.

The Center for Sight has been performing laser cataract surgery for about a year now, with nearly 70% of patients opting for upgraded refractive packages that include the laser, which has exceeded Mr. Dawes's expectations.

You can't charge patients out of pocket for using the laser platform during cataract surgery, unless it's used in conjunction with presbyopia-correcting IOLs or the treatment of astigmatism. But patients know femtosecond lasers are the top-of-the-line technology, so they seek it out.

"It has a 'wow' factor that really helps our marketing efforts," says Mr. Dawes. The laser component of surgery is set up in an area of his facility where patients' escorts can observe the action. "We're very much into allowing friends and families to share the surgical experience. It goes a long way in selling our services to potential patients."

Mr. Dawes points out that laser cataract surgery hasn't yet been proven to be safer than conventional manual surgery — cataract surgery is already the safest procedure performed in the United States, he says. "But we believe lasers help produce better visual outcomes for patients who want to reduce their dependency on glasses. Patients who don't mind wearing glasses do just fine with conventional manual techniques."

• Intraoperative aberrometry. Surgeons are also using intraoperative aberrometry to image the eye, better select the power of the lens implant and achieve improved refractive outcomes, says Mr. Dawes. He explains that the real-time imaging is not a covered service, so it's another technology cost, though far less expensive than lasers, that can be passed on to the patient.

An intraoperative aberrometer is an essential piece of equipment in the ORs of P. Dee G. Stephenson, MD, FACS, ABES, FSEE, of Stephenson Eye Associates in Venice, Fla. The small device — about 3 inches deep and a foot long — attaches to the surgical microscope. It takes aphakic readings, reads the amount and axis of astigmatism, and measures the posterior corneal surface.

Before using intraoperative aberrometry, Dr. Stephenson says she overcorrected the lens placement in some of her patients because they didn't have as much astigmatism as she thought they had.

The imaging upgrade is used on patients willing to pay for her premium Toric IOL packages, which she says most do. "It has really raised the bar for me, because I'm getting LASIK-like results," she says, noting that 97% of outcomes are within a half-diopter of her targets and 75% are within a quarter diopter, a rate she calls "pretty damn good."

Dr. Stephenson also emphasizes that the latest surgical microscopes provide incredible views that improve surgeons' abilities to perform capsule polishing and watch how incisions are made to ensure they're well sealed and the architecture is appropriate for whatever implant they're using.

Dr. Stonecipher says cataract surgery volumes are increasing because of the growing numbers of diabetics and post-refractive patients who come back for vision tune-ups so they can see as well as they did after the first surgery.

His patients accept the added expense of vision upgrades because he's charging them reasonable fees, and still making money. "I'm not trying to break the bank, and I'm not trying to be the lowest guy on the block," he says. "I'd much rather do 100 patients well at $2,000 than 200 patients hurriedly at $1,000, and make the same amount of money."

EYES HAVE IT Satisfy demanding patients to dramatically increase revenues and make eye surgery's bread-and-butter procedure financially viable.

Demanding more
The days of pumping cataracts through your ORs and counting the reimbursement checks are over. Facility fees have flatlined, case costs continue to climb and patients are more educated than ever about their care options. You should focus less on surgical efficiencies and more on giving your docs the tools they need to improve outcomes. How can you help make average surgeons great? What can you do to make great surgeons even better? How can you take cataract surgery to the next level?

Dr. Stonecipher doesn't want his patients to see with cataract-like results. He wants them to see with LASIK-like results. "This isn't the '90s, when 20/40 post-op vision was acceptable," he says. "Today, 20/15 post-op vision is the goal."

He believes surgeons have gotten complacent in their outcomes, even as patients have become more demanding. "They're paying us extra money," he points out, "so they expect better outcomes. Even the patients that aren't paying extra are demanding more."

As Dr. Stephenson says, today's patients want nothing less than crisp, sharp vision. Are you ready to deliver?