PAYING FOR FEMTOSECOND LASER CATARACT SURGERY

Cataract surgeons in both private and public practice will probably require some form of co-payment from the patient if they are to avail of the new femtosecond laser cataract surgery systems for the time being, although that may change if the laser systems prove superior to conventional phacoemulsification in terms of safety, according to speakers at a symposium at the XXX Congress of the ESCRS.

Richard Lindstrom MD Minneapolis, Minnesota, US, noted that although femtosecond laser systems for cataract surgery have only been commercially available for a year, there already appears to be a wide consensus that they are here to stay. Notably, the business prognosticator, Marketscope, has stated that it sees an exponential proliferation of the new technology over the next five years. However, the high expense of the devices may put them out of reach of patients who rely completely on Medicare to pay for their cataract procedures. Furthermore, 82 per cent of surgeons participating in a survey conducted at last year’s ASCRS Congress cited the expense of the systems as their main reason for reluctance to adopt the technology.

“The femtosecond laser is really a computer-driven precise scalpel which creates very precise incisions and imageguided intraocular surgery. If we believe that has some value, then it makes sense for us to offer it to patients, but there really is a cost involved,†Dr Lindstrom said. On the other hand, he pointed out that since 2005 it has been possible for patients in the US on Medicare to pay the excess charges for technology that enhances refractive outcomes. That includes such things as multifocal and toric IOLs.

“Our position is that the femtosecond laser enhances refractive accuracy both in terms of defocus and astigmatism. And if you're implanting multifocal or toric IOLs postoperative refraction, half a dioptre of target is necessary to get the best possible performance from the lenses,†Dr Lindstrom said. He added that when provided with the option, 30 per cent of his patients choose to undergo femtosecond laser cataract surgery despite the extra cost. At that rate, a cataract surgeon would have to be performing around 1,000 procedures per year for the femtosecond laser to be a profitable investment. “There are reasons why a patient would want to pay this additional fee: the predictable outcomes, increased precision and safety. We really are entering a new era as patients become aware of this technology,†Dr Lindstrom added.

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Co-payment in public hospitals

 It is mainly the potential safety advantages, rather than those relating to visual outcome, that could lead to the gradual adoption of femtosecond cataract surgery into use for public patients at public institutions, said Roberto Bellucci MD. “The more precise final refraction Richard Lindstrom was pointing out is of somewhat less interest to the public system, and the better results that we might achieve with premium IOLs are also not a consideration since we will not be using the lenses in public patients and the public system,†Dr Bellucci said.

Of greater interest to a public health system would be a reduction in intraoperative complications when compared to ultrasound phacoemulsification. That could in turn reduce some costs and possible litigation so that the new technology could pay for itself to some degree. Similarly, the precision in creation of capsulotomies that the lasers afford could reduce the chance of late dislocations and the need for interventions to treat them, he noted. However, even if the early evidence of a safety advantage is borne out as data accumulates, some form of co-payment for using the technology may be the economic reality for the time being, given the overstretched resources of the healthcare systems of many countries with socialised medicine.

“Femtosecond laser cataract surgery will increase costs because the equipment is more expensive and the machines require the perfect control of the ambient air. It also requires additional training for the surgeons and assistants, you also need trained laser personnel. The surgical time is increased for nurses, for doctors, and probably there are hidden costs,†Dr Bellucci said. In Italy, the new technology will probably first enter public health systems by way of scientific institutes or universities which are affiliated with public hospitals that receive special funding to test and implement new devices, machines and procedures. However, the general adoption of the laser systems into public medicine is likely to be a more drawn-out process and whether they are treated at private or public institutions, patients may have to provide some sort of co-payment to avail of the technology for the foreseeable future.

“Recent legislation now permits co-payment in Italy but is not yet implemented. So the fact that two hospitals in Italy have co-payment does not mean that co-payment is the current reality in our country. Also there are ethical and practical problems that need solutions and we're far from having co-payment as a standard practice in Europe,†Dr Bellucci commented. In the discussion that followed, Sheraz Daya FRCS, UK argued that co-payment policies that deliver the safest and most effective treatment only to those wealthy enough to afford it run contrary to the goal of safe and equitable cataract surgery.

“These patients put their trust in us, so if this is the best device to use it is best to use it in everyone and spread the cost evenly across the patient population. It also makes economical sense since it would increase the cost by a reasonable amount for everyone instead of increasing the cost astronomically for a few,†Dr Daya said.