PAYING FOR UPGRADES In the typical facility, from 11% to 20% of all patients purchase at least one service out of pocket.

For close to a decade, patients have been allowed to pay out of pocket for such cataract surgery upgrades as toric and presbyopic IOLs, astigmatism-correcting arcuate incisions, intraoperative wavefront aberrometry and now laser cataract surgery. To find out just how popular and prevalent these out-of-pocket upgrades are, last month we surveyed 212 managers at facilities that host cataract cases.

We found that premium services are becoming a bigger and bigger part of cataract surgery. In the typical facility, from 11% to 20% of all patients purchase at least one service out of pocket. Overall it’s been a positive trend: The outcomes are generally good, patients are generally pleased and the upgrades are providing surgeons (although not facilities) some extra profit.

The main problem: Many elderly cataract patients don’t have the money to pay for upgrades. As a result, facility managers expect only moderate growth in these services — don’t expect them to take cataract surgery by storm anytime soon.

Gaining traction
Our survey respondents say premium cataract services have definitely gained traction over the decade they’ve been available. The one that’s grown the most is correction of astigmatism, the decline in vision that happens when the cornea is oblong rather than spherical.

The most popular way to attack astigmatism is via toric intraocular lenses, designed to compensate for corneal astigmatism as well as refractive error. In a typical facility doing cataract surgery, 11% to 20% of all patients receive these lenses. “Our toric patients are routinely ecstatic,” says a facility manager.

A solid number of patients also receive arcuate corneal incisions, incisions in the cornea itself aimed at altering the curvature to make it more spherical. In the typical facility, 1% to 10% of patients receive these incisions. “We seem to perform many astigmatism procedures — limbal-relaxing incisions with or without toric lenses,” says anesthesiologist Tod Tolan, MD, of Westside Surgery Center in Portland, Ore.

Presbyopic IOLs — designed to let patients see both near and far, like bifocals — are the second most popular premium service. Up to one of every 10 cataract patients ends up opting for these lenses.

Somewhat less popular, for the moment anyway, are intraoperative aberrometry and laser cataract surgery. The former is a technology that helps surgeons perfect the IOL power and astigmatism correction during the procedure. Just 31% of facilities offer intraoperative aberrometry, and only 29% of facilities currently offer laser cataract surgery, which has only been on the market a couple of years.

LASER SURGERY
Thinking About Laser Cataract Surgery?

CROWDED MARKET Market-leader Alcon may soon face challengers.

Although fewer than 30% percent of centers that host cataract surgery currently offer laser cataract surgery, more will soon. Half of our survey respondents say they expect laser cataract surgery to “grow somewhat” or “grow significantly,” and several leaders of hospitals and ASCs said they’d be adding laser surgery this year.

If the newbies follow the current trends, 60% will buy the lasers outright or lease on a “per click” basis from the original equipment manufacturer, and 40% will outsource them from a mobile cataract surgery service.

Which laser do facilities use? Right now the overwhelming market leader is the Alcon LenSx. Two-thirds of facilities that own a laser own this brand, and that actually understates the market dominance, because virtually all outsourced lasers are Alcon. However, Alcon may face more market challenges soon; medical giant Abbott Medical Optics recently acquired and is now marketing the Catalys laser, and Bausch & Lomb is about to enter the market with its Technolas Victus laser. Also on the market is the LensAR laser, accounting for about one-fifth of all facility-owned lasers.

— Outpatient Surgery Editors

A solid B+
By and large, patients who buy upgrades do get superior visual results, report 55% of our readers who have an opinion on the subject. Eight percent of our readers say they get “very superior” results.

Readers are most convinced about the results they see with toric IOLs, presbyopic IOLs and arcuate incisions. “Any time you can correct astigmatism and presbyopia in an IOL and you hit your keratometry readings, the patient, doctor and facility win!” says a Midwestern surgery center nurse manager. “Patients appreciate the vision correction and the decrease in need for glasses,” says a Kentucky physician.

With regard to laser cataract surgery, the newest technology, the results are a little more mixed. “Those who have their cataracts done with femtosecond lasers heal faster,” says the nursing director of an East Coast ASC. But many more say the jury is still out. “Some patients have been highly pleased while others have been disappointed with the outcome,” says a Tennessee surgery center manager.

The administrator of a very busy East Coast eye center reports that about half of the surgeons in her center use femtosecond laser, and “all have good outcomes.” But the other half “express that the femto is a gimmick and there’s no need for it.”

READER SURVEY
Paying for Premium Products

About what percentage of your patients currently pay an additional out-of-pocket fee for some premium product or service related to cataract surgery?

None	2.9%
Less than 10%	35.4%
11% to 20%	26.8%
21% to 30%	14.4%
31% to 40%	9.1%
More than 40%	6.7%
Don’t know	4.8%

Source: Outpatient Surgery Magazine Reader Survey, July 2014, n=212

Limiting factors
Even though premium services do typically result in better outcomes, patients have been somewhat slow to embrace them. Predictably, the biggest barrier is money. Premium services can cost thousands of dollars extra, and more than three-fourths of our survey respondents say at least some of their patients simply can’t afford them. Says Venice, Fla., ophthalmologist Dee Stephenson, MD, “It’s too expensive on a fixed income.”

Another reason is that some patients are not great candidates for premium services. Two-thirds of all patients don’t have significant astigmatism and aren’t candidates for toric lenses or arcuate incisions. Although virtually all cataract patient could benefit from a lens that helped them accommodate, the lenses that aim to do this are still not perfect, and surgeons know that several types of patients aren’t likely to be successful with them, limiting the market. “My doctors only recommend it for patients who would legitimately benefit. If not, they recommend a standard lens,” says a Florida surgery center administrator.

Another issue is that the profit motive is weak or missing, at least for surgical facilities. Thirty percent of our respondents say these services are “somewhat profitable,” but half say they’re “not too profitable” or “not at all profitable.” Again, the big factor is patients’ ability to pay. Numerous facility leaders said they don’t mark up the cost of specialty lenses at all. “The majority of these patients are on a fixed income, so we only get the invoice price of the lens paid by them,” says a Midwestern ASC administrator. Another respondent says his facility charges cost plus 10 percent, “so it adds only $50 to $90 to the case in profitability.” “We are trying to keep the cost down so more patients can afford the upgraded experience,” says Claire Welliver, RN, clinical director of the Main Line Surgery Center, near Philadelphia.

Balance that against the “additional work for staff to arrange and code correctly for charge purposes, and it increases the time patients spend in post-op — which isn’t a billable expense,” says the director of perioperative services for a Southwestern hospital.

On the plus side, premium services take very little time. Even laser cataract surgery takes only an extra 5 minutes or so in most facilities, because the laser is located in a different room from where surgery will be done. Our respondents think the premium services are a little more profitable for the surgeons, although most say they’re not privy to what surgeons charge. Half say these services are somewhat profitable for surgeons and about one-fourth say they’re “very profitable.”

ATTACK ASTIGMATISM “Our toric patients are routinely ecstatic,” says a facility manager.

A lesson in economics
Despite the challenges, our survey respondents believe the demand is there for premium cataract surgery, and that it will grow. “As Boomers increase in age, cataract surgeries will increase and so will the desire for toric and presbyopic IOLs,” says the center director for a South Florida ASC. But until something changes with healthcare financing, the growth of the procedures will be limited by patients’ ability to pay.

“Patients want the better products and services. It is a shame that Medicare does not pay,” says Marie Frazier, RN, clinical manager of the Hibbeln Surgery Center in Avon, Ind. “Our senior citizens should get the premium products — they deserve it.”