Lacs. od cme. september 18, 2011 (1)

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?