Considering the Costs of Complex Cataracts

Ophthalmology

By: Daniel Cook

Published: 10/14/2019

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There's a case to be made for adding to the expense of procedures with already thin profit margins.


Complex cataracts are becoming more common as increasing numbers of patients show up for surgery with risk factors for poor pupil dilation — uveitis, diabetes, previous eye trauma and advanced age — and more men are opting to take Flomax, an alpha blocker that has been shown to constrict the iris sphincter muscle, to treat enlarged prostates.

Surgeons earn approximately $150 more for the time and effort it takes them to perform these complex cases, but the reimbursement remains the same for facilities — between $900 and $1,000 — that must pony up for the devices and drugs used to maintain mydriasis, hard costs that hit the bottom line in a specialty with IOL-thin profit margins. Surgeons, especially non-facility owners, often don't think twice about adding to the expense of cataract cases. Facility administrators in charge of monitoring the bottom line are more likely to take a long, hard look at the cost of the drugs and devices that are used to prevent pupils from constricting. Or are they?

"Look for savings elsewhere," says Jeannine Arcuri, BSN, administrator of the Cleveland Eye and Laser Surgery Center in Fairview Park, Ohio. "Don't skimp on giving surgeons the tools they want to meet the clinical needs of patients without jeopardizing the standard of care."

The access they need

HARD COSTS Pupil expansion devices give surgeons the access they need during difficult cases.   |  Pamela Bevelhymer, RN, BSN, CNOR

Surgeons can administer the intracameral medications shugarcaine or phenylephrine to keep pupils dilated during surgery. Shugarcaine is a lidocaine-epinephrine compound; injecting lidocaine into the eye paralyzes the pupil's sphincter muscle, causing the pupil to open wide.

If these agents prove ineffective, surgeons can reach for pupil expansion rings or pupil dilators to give them the access they need. There are several options available, ranging in price from $80 to $150. A reusable ring is available for approximately $400, which is an investment that might make good financial sense with the increasing numbers of complex cases your surgeons will perform in the coming years.

Pupil expansion solutions add what might seem like a significant expense to the cost of a cataract case, but don't discount the clinical advantages they provide.

"The devices save surgeons time, and lower the risk of vitreous loss and iris prolapse," says Jon-Marc Weston, MD, a surgeon at NVision Eye Center in Aliso Viejo, Calif. "Surgeons must put a device in as soon as they think they need it in order to maintain pupil retention during the case."

Dr. Weston can insert and remove his ring of choice in 1 to 2 minutes, a fraction of the 5 minutes he'd spend struggling to operate through a floppy iris. Saving close to 4 minutes of operative time is no small benefit in a volume-driven specialty.

He says reusable iris hooks are an inexpensive option, but surgeon preference may prevent their use. Plus, he adds, hooks can be harder to place than rings, a factor that extends OR time, which actually increases case costs. "Expansion rings can be less time-consuming to use and, if available, a reusable device can be cost effective if surgeons and reprocessing techs can manage it gently," says Dr. Weston.

Dilating drugs

Patients with established miosis require the use of a pupil expanding device. Patients with possible miosis, whose pupils dilate to 5 mm to 6 mm, are candidates for Omidria, an intraocular irrigating solution containing the NSAID ketorolac and the dilating agent phenylephrine. Omidria is administered through balanced saline solution during surgery. "If the pupil is a good size at the start of the case, Omidria will keep it big," says Dr. Weston.

Omidria, which is FDA approved to maintain pupil dilation and improve post-op healing, costs about $465 for a 4 ml bottle used during a case. Paying that price would be too expensive for routine use during cataract surgery, but CMS has granted Omidria pass-through status until Oct. 1, 2020. That means surgery centers and HOPDs can bill CMS separately from the cataract surgery for the cost of the drug.

HANDS IN Surgeons earn more for complex cataract cases, but should be aware of how much facilities spend on the devices they use.

Surgeons at NVision's surgery centers are not permitted to use Omidria routinely due to logistical concerns about having to purchase the drug up front, billing CMS for its use and collecting the pass-through reimbursement amount on the backend. Dr. Weston fought that decision and regrets losing out on the use of the medication. "I think having it available is a really good idea," he says. "The logistics and cash flow issues are small prices to pay for having access to the drug. Those seemed like reasonable tradeoffs."

Look for savings elsewhere before jeopardizing safe patient care.
— Jeannine Arcuri, BSN

Ms. Arcuri says her surgeons use Omidria during every case, not only for the complex variety. The facility buys the medication up-front and then bills CMS or commercial insurers who reimburse separately for the use of the drug. Ms. Arcuri admits figuring out how to best manage the purchasing and reimbursement process was challenging at first, but says it's easy to stay on top of now that they have an established program in place for purchasing Omidria and billing for its use.

Finding profits in patient safety

"Surgery centers profit from routine cataract cases, depending on how fast surgeons operate and how well the cost of staffing and overhead materials are controlled," says Dr. Weston. "A complex case stresses that profit margin."

Still, complex cataracts can be profitable if your surgeons perform efficient procedures, according to Dr. Weston. Their abilities to do so will impact the viability of your center as the volume of complex cataract cases continues to grow. "You need to be able to cover increasing overall costs and still be able to afford capital outlays," says Dr. Weston. OSM

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