Transcript
Laser Assisted Cataract Surgery
J. Alberto Martinez, M.D.
Visionary Ophthalmology September 18, 2011
OUTLINE
LACS technique
Who is a good candidate for LACS?
Getting paid for LACS
Is LACS cost effective for patient and doctor?
Who is operating the laser? Implications
Ethical Considerations
Landmark Events in Cataract Surgery
Intraocular lenses
Phacoemulsification
femtosecond Assisted Cataract
Surgery?
Current limitations of manual cataract surgery
Visual Outcomes: Distance accuracy 1/2 of that achieved with LASIK
Unpredictable astigmatism correction
Effective lens power IOL-capsulorhexis
Safety: 10x more complications than LASIK
Ultrasound complications (endothelial cell loss)
LensX Animation
Anterior Capsulotomy
Lens Fragmentation
Lens Aspiration
Why jump into LACS?
Mounting evidence of better efficacy and safety from day one
IOLs and phaco took years to become safe and effective
LACS learning curve is very short: “like going from analog to digital”
Better for hypermature lenses, weak zonules, endothelial dystrophies
Downsides: Increased cost and time
LACS: Patients Perspective
Add BLADELESS to needleless (topical) stitchless (clear cornea, self sealing)
True laser cataract surgery
Improved predictability
Improved safety
Latest technology
More predictable outcomes/quality of life
Patient confidence
Medical Coverage Advisory Committee
Reviews quality of the the evidence about evidence of a procedure
Explores many sources of evidence
Is routine use in clinical practice
Bias?
Is there a need and what is the size of the healthcare benefit?
Should we go with it, or should we wait?
Medicare Reimbursement Realities
Work: pre-op, intra-op and post-op
Takes into account only skin to skin
Covered: incision, capsulorhexis, fragmentation
Cannot bill for anything else
Can bill for: astigmatism
Long term reimbursement: quality, outcomes, efficiencies
Based on QUALITY and EFFICIENCY
BUDGET neutral (no more money into the system)
Medicare reimbursement realities
Somebody gets a bonus? Somebody else gets a reduction ( to maintain neutrality)
CE is the most successful procedure
We are in the process of evaluating quality
Summary: cannot bill for anything COVERED UNDER MEDICARE
Careful word choice: quicker? (less time, less reimbursement) easier? (why pay more?) these words jeopardize reimbursement
Practice Management Considerations
Where will the laser be used?: critical. Enormous implications
ASC?: Better (have a relationship with CMS)
Patients’ expectations? (no glasses, does not care either way)
For covered procedures: must follow some rules
Covered: CE and IOL, physician: CE
Non-covered: deluxe IOL, refractive care (by MD)
Covered: exam (no mater how long is it), measurement of eye, surgery (incision, capsulorhexis, phaco, IOL)
Endothelial cell photography? Yes! For pre-op evaluation
Facility fee: not included: premium IOL, astigmatism
Astigmatism correction (refractive keratoplasty) considered cosmetic
Not covered: refraction, tests for ametropia, screening, refractive surgery, IOL upgrade
Practice Management Considerations
AstigmatismIatrogenic IS covered LRI, wedge, etc
Fee must be a number that can be defended
List of tasks (refraction, topo, pachy, wavefront, LRI, enhancement) needed to correct astigmatism
Contingency for enhancements
Assign fee (need to be defensible, justifiable)
Controversies
Is CE with FS safer/better
Is Astigmatism correction with FS safer/better
FS: expensive, slower, ASC only can charge for refractive surgery
Discussion on Reimbursement
Is it a good result that the patient ends up wearing glasses?
Should we pursue emmetropia?
Elective: refractive (no glasses)
Patients have decided that price for getting rid of glasses is about $2000 +/-
If patient is happy with glasses, you can’t charge
Financial ViabilityPros:
Will it happen? Yes, we are convinced it will become a standard
Break-even: 15 cases/month
Open the ability to bring other providers to Fempto facility?
Financial ViabilityCons:
Emotional. Moving cheese for staff
Some physicians reluctant
Cost
Change in flow (slow down things)
Cannibalize premium IOLs
Projected rates of conversion: unclear
Positioning (S. Lane)
Educate ALL patients — even non-candidates
Choice for all patients with pre-existing astigmatism (desire only distance or both)
Happy patients? Treat to within 0.5 D of astigmatism
Overhead at the ASC
Increase volume?
Increase overhead?
Decrease premium IOL conversion?
Increase for astigmatism conversion?
Increase bottom line?
Marketing Expenditures
PR
Educational materials
Careful about making false claims
Under promise/over deliver
Why small practices will not be able to do it alone and what can be
doneIf alone: band together, talk about it, get people thinking about it)
Practice without walls
Must have enough patients!
Could one ophthalmologist run the femto while the other does the phaco?
Cataract and refractive surgeons should partner
Must have a refractive mindset
Bottom line: need Vision and Business expertise
Total expenditure from scratch: 1.5 to 2 million dollars!
Why patients will pay (Lindstrom)
Cataract surgery market is growing
Want to get rid of your glasses? 50% yes
Want to pay additional fees? 50% yes
Why is conversion low? Need better refractive outcomes: < 0.5 D astigmatism
Need to get people off glasses!
How are we going to pay for? ( Lindstrom)
Refractive surgery
Want to get rid of glasses:
How much: price similar to LASIK
Doctors debate, patients decide
He feels is viable
Why not cost effective ( Steve Safran)
Not cost effective
It will not work? ( S. Safran)
Not cost effective
Concerns: waiting time for acutal removal of lens material: antigen sensitizing more CME second eye?
Inability to cut through dense lenses
An very expensive tool to do a simple task (capsulorhexis)
Who is not a candidate?
Does not dilate past 6.5 mm
Retinal and optic nerve disease: h/o AION
Advanced glaucoma w/ VF loss
Effects of IOP elevation during docking?
Fuch’s/ corneal edema
Not a problem if one can visualize iris detail
AN ADVANTAGE with Fuch’s (easier capsulorhexis), reduction in endothelial cell loss
Relative contraindications
Inability to dock:
Corneal surface irreg, conjuntivochalasis, trabec bleb, unusual orbital anatomy (small, deep, excess retropulsion),
agitated patients
Poor dilation
Not So Good Candidates
Small ( not large pterygia) ok
<6.0 mm pupil
Posterior synechia
Subluxated lens
Black cataracts (absorb the energy)
Too small palpebral fissures
IN SUM: applicable to most patients
Unmet need: Astigmatic correction
Lasik has set a higher standard for Astigmatic correction
53% of patients > 0.75 D astigmatism ( warren Hill)
Vast majority of surgeons feel this astigmatism should be corrected
IDEAL PROCEDURE FOR
ASTIGCHEAP, REPRODUCIBLE, accurate easy to do
LASIK: the best, but: a separate surgery
TORIC IOL: staar vs. acrysoft
Toric plus LRI? Effective
Need perfect axis placement
femtoSECOND LRIAutomated
They are an art, unpredictable in younger patients,, need age-based nomogram
Intra-operative aberrometer helpful
femtosecond more accurate than manual
Manual LRI are not as reproducible. femto LRI will allow for better studies and increase the reproducibility of the procedure
HOW I HAVE SET UP MY FLOW. STEPHEN LANEWhere place the laser: Best outside OR
Inside ASC firewall, not in the OR
Right-size the room (10X10 space)
Clean, not sterile room
Took a pre-op bay to place the Laser
Minor construction
No transfer of patients from one bed to another
Who should operate the femto? (S. Safran)
OD? No? surgery be done by surgeons
OK technician assisted with MD present
Must avoid delays between femto and phaco
Recc two MD.s one for femto, one for phaco
Dr. Lane: OD’s should be operators!
Kentucky and Oklahoma allow use of lasers by OD’s
Not really going inside the eye. (bladeless)
Who should operate the fempto? a
technician (Dr UY)5 reasons for a technician
Computer controlled, automated
Docking not as hard as phaco
Imaging easy to operate
Low risk, not as invasive
Technician cheaper need back up
Increase utilization of femto
Medico-legal. Who is responsible
Ethical Considerations/ John Banja
Lack of clinical freedom. If I want to use the femto because is clinically better but I don’t get paid, what to do?
What if is indicated, you don’t do it, get into trouble and lawyer says why didn’t you?
Once data available that clearly shows femto is better, should non-femto surgeons refer to femto surgeon?
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