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EW MEETING REPORTER 86 September 2011 Consulting Group, San Bernardino, Calif., gave details about covered and non-covered services. Covered services include the exam or consul- tation, biometry, K-readings, B-scan, endothelial cell count, the surgery and post-op care, a conventional IOL, facility fee, and anesthesia. Re- fraction, tests for emmetropia, screening, refractive surgery, IOL up- grade, added facility fee, and ex- panded post-op care are non-covered services. "If you decide you want to bill for those things above and beyond (covered serv- ices), that's where we get into the murky area," Mr. Corcoran said. So how do surgeons go about setting up professional fees for laser refractive cataract surgery? "You need to think of a number you can defend," Mr. Corcoran said. Controversies and potential trouble will arise if sur- geons charge patients extra money to discuss treatment options, use more than one IOL formula, place the corneal incision where it works best, use a femtosecond laser for any part of the cataract surgery, perform services of dubious value, do routine cataract surgery, or circumvent as- signment rules. "You already have professional fees for what you do. They also apply in the context of re- fractive surgery. Extraordinary or distorted fees are suspect," he said. Is femtosecond cataract surgery cost effective for the practice and the patient? Before the second session began, Edward J. Holland, M.D., Cincin- nati, moderator, posed a question to the audience: Are you confident pa- tients will pay the fees (for femtosec- ond cataract surgery)? Currently in the U.S., experts agree only astigma- tism correction, which is also per- formed by the femtosecond laser and not a covered procedure under Medicare, can be billed to the pa- tient. Sixty-two percent of those who responded said "no," followed by 68% who said they didn't believe the economics would work in their practice. Stephen S. Lane, M.D., Stillwater, Minn., presented the pros for adopting the technology now, including being the first to have it and being involved in the early de- velopments with regard to how it works, pricing, and workflow. "I think most of you believe, or you wouldn't be here, that this is some- thing that is going to go forward in the future," he said. "Our group has always been one of those practices that says the best way to predict the future is to create it." Cons include the cost and the emotion behind the decision, in- cluding the transition for staff with regard to changes in workflow, scheduling, and pricing, Dr. Lane said. "It will demand acceptance and buy-in by the MDs and a change in mindset for the program to be suc- cessful," he said. Dr. Lane used a manufacturer calculator to show the audience how to determine financial liability, and he said the number of cataract procedures performed in a practice is important. "It's very much volume dependent," he said about the decision to adopt femto for cataract technology in his prac- tice, which he shares with 10 other surgeons. The laser surgery would be used on patients with pre-existing astigmatism. "The potential patient population that has the greatest im- pact on helping to pay for this are those patients who have lower levels of astigmatism that you may not have been dealing with in the past, either with toric intraocular lenses or with manual arcuate incisions," Dr. Lane said, adding that money would have to be spent on market- ing the new technology. Stephen G. Phillips, M.D., a solo practitioner in Seattle, said he didn't think that small practices would be able to afford the expen- sive technology alone. "One guy alone is going to have trouble doing this," he said. "You are going to have to band together. If you are a cataract surgeon already, team up with a refractive surgeon. Those are natural partnerships. You need to have a refractive mindset, or it will not fly." Patients are the most im- portant element, Dr. Phillips said, echoing Dr. Lane's assertion that more patients equals better opportu- nities for success. Richard R. Lindstrom, M.D., Minneapolis, argued that patients would willingly seek out above ex- cellent refractive results. Currently, astigmatism correction performed by the femto laser, which is not a cov- ered procedure under Medicare, can be billed to the patient. Dr. Lindstrom decried low conversion rates to premium IOLs, adding that correcting astigmatism will help sharpen a premium patient's eye- sight. "I think it's because we sur- geons aren't up to the task," he said about why conversion rates are so low. "We aren't generating good enough refractive outcomes to gen- erate strong patient word-of-mouth referrals. We need to do significantly better … I think, in the end, it's re- ally the patient who is going to make the decision." Steven G. Safran, M.D., Lawrenceville, N.J., argued that laser-assisted cataract surgery is "not cost effective." "Ophthalmologists can't absorb the extra costs incurred by this technology," he said. "Even a projected slight decrease in enhance- ment rate won't come anywhere near paying for this." The idea that lasers are better is antiquated, Dr. Safran said. "What about macular degeneration?" he asked. "We used to treat it with a laser and now we treat it with a needle. Patients want what we recommend to them be- cause they trust us to choose what serves their best interests. Patients are not fixated on the laser." Dr. Safran pointed out that cataract sur- gery is the most successful procedure in the United States, and the results from both manual and femto surger- ies are practically identical. "I feel like we are trying to fix something that isn't broken and get money out of a system that is," Dr. Safran said. "We need better lenses. That is what is going to drive our conversion rates." "Dead wrong," Dr. Lindstrom countered. "It's not the technology —it's our ability to get to plano." Douglas Koch, M.D., Houston, added, "Any process that takes away the potential for human error de- serves a look. The irony of this whole discussion is the people who are going to use it are the people who do beautiful surgery as it is." D. Brian Kim, M.D., Dalton, Ga., who spoke from the audience, agreed, and put the question out there: Will newly trained surgeons ever learn how to perform manual surgery or Reporting live from the ASCRS/ EyeWorld Town Hall Meeting on Laser- Assisted Cataract Surgery, Chicago, July 14-17, 2011 Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team. continued on page 88

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