FEMTOCAT ECONOMICS

While femtosecond laser cataract surgery is currently very expensive it will become more cost-effective as it becomes more established and its future looks bright, according to Paul Rosen FRCS, FRCOphth, consultant ophthalmic surgeon, Oxford Eye Hospital, UK.

Dr Rosen discussed the economics of the surgery during a presentation at the XXXVII UKISCRS Congress in Manchester, maintaining that there are a number of variables that need to be considered when weighing up whether it is currently economically viable.

Pros

As the latest big thing in ophthalmology, many are now looking at the option of introducing femto-laser surgery in their private and public practices. The pros of acquiring this technology include its potential benefits for the patient, the improved efficiency of surgery, the competitive advantage in having a femto machine before others, the increased revenue/profit potential and the fact it is a logical add-on to premium IOLs, Dr Rosen commented.

While the machines are expensive, carrying out larger volumes of the surgery makes the procedure cheaper on a per-case basis, he said.

Costs

The revenue potential depends on who the payer is – ie, if it is the patient, health insurance companies or the Government. The value proposition for private practice leans more towards quality, ie, can the patient see better, while in public practice the emphasis is on efficiency and cost-effectiveness, Dr Rosen stated.

When practices are assessing the cost of introducing femtosecond surgery, Dr Rosen said there are many factors that have to be included beyond the cost of the physical machine, which include financing arrangements, maintenance, training, marketing costs, extra staff, consumables and potential loss of income if (but unlikely) the procedure takes longer. There are also other cost-effectiveness components that need to be considered such as potential savings from less complications and the calculation of the cost per quality-adjusted life years (QALY), Dr Rosen added.

Dr Rosen provided a number of cost breakdowns for what femto would cost in a private versus a public practice. He estimated the costs of the machine at around ï¿¡400,000 (GBP), financing at 4.5 per cent per annum, maintenance at ï¿¡30,000 a year, consumables at ï¿¡300 per eye, plus all the other aforementioned costs have to be considered.

“Remember all the laser and click fees are not absolutes; they are subject to negotiation. And when you do buy a laser you need to have an ‘evergreen’ contract because it is a rapidly changing technology which you will need to upgrade,” he told the congress. When pricing the procedure, practices should add up all the outlined costs and then look at a price that creates an approximate 25 per cent profit margin, Dr Rosen said.

Giving a costing example, Dr Rosen said in a public system, such as the NHS, in a practice carrying out 25 femto cases a month/4hr theatre session/week (the NHS standard) the price differential would be ï¿¡700 more expensive than standard phaco, but if 50 cases were performed a month that would drop to ï¿¡500, and with 100 cases a month (using two operating theatres simultaneously) it would be ï¿¡300.

Thus, the more cases that are performed the more the cost decreases, Dr Rosen said, and if the "click fee" could be brought down to ï¿¡100 it would become cost-effective. However, he also stressed that it is not just about the absolute procedure cost; surgical technology can help drive productivity and sustainable quality.

Is it better?

The big question in relation to femto is – is it actually better? While still a relatively new technology, Dr Rosen said the data to date shows femto-assisted phaco surgery has fewer complications, patients heal faster and it is potentially safer, with more reproducible, accurate outcomes. It also may manage astigmatism. However, he acknowledged that in the absence of longerterm studies, much remains to be confirmed about the longer-term outcomes and risk increases/decreases.

“Femto is an enabling technology that enables all surgeons to be as good as the most highly skilled surgeons,” Dr Rosen said, adding that it also would have an impact on training, for example facilitating capsulorhexis when required allowing the trainee to concentrate on the other parts of the procedure in the initial stages of learning. In addition, he pointed out that Europe has an increasing elderly population, which will mean increased demand for cataract surgery, and currently there appear to be less cataract surgeons than before.

Acknowledging that currently the costs of femto in private practice are still too much for some healthcare systems, Dr Rosen suggested that co-payments and placement in multi-surgeon practices could be the answer. “While it is difficult to predict the future and the speed of progress, the potential for femto-assisted phaco is very bright,” he concluded.