Eyeworld

EW Ophthalmology Business 54 July 2011 by Jena Passut EyeWorld Staff Writer Panel discusses ethics of femto for cataract M uch has been said about the features of femtosecond cataract surgery, but surgeons who are prodded by patients to acquire or use the expen- sive technology may be faced with a dilemma. What do you say to Medicare patients who want you to employ the femtosecond laser during their cataract surgery, even though you can't charge them extra for using it? Mark Packer, M.D., clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, mod- erated a discussion on ethics during this spring's ASCRS Symposium & Congress in San Diego. Part of the discussion included talking about femto cataract surgery and the fol- lowing scenario. A 67-year-old Medicare patient desires femtosecond laser surgery with a standard monofocal IOL be- cause he has been told he has a shal- low anterior chamber where the capsulorhexis will probably be more challenging than usual. He also has been told that using the femtosec- ond laser will increase the safety of the procedure by eliminating the chance of a capsulorhexis tear out or other damage to the capsule. The pa- tient prefers to wear glasses after sur- gery and his pre-op keratometry is 44.00 X 44.50. Documented surgi- cally induced astigmatism is 0.5 @ 90. Dr. Packer said he created the scenario to include little to no re- fractive component in this case. Panelist David F. Chang, M.D., clinical professor of ophthalmology, University of California, San Fran- cisco, and in private practice, Los Altos, Calif., said that surgeons can not use the femtosecond technology purely based on implications of its heightened safety value. "As it currently stands, you can- not charge for anything extra that enhances safety," Dr. Chang said. "An example would be a capsule tension ring. That's an expensive in- strument that we cannot charge for, even though we understand that it clearly would make the outcome better. That's a problem, unfortu- nately, that we have to live with, [considering] the economic system we have by accepting Medicare pa- tients." When the audience was asked, "When I believe that a femtosecond laser can do a better operation than I can with a phaco machine, I will …" 35% of respondees said they would use the laser, while 23% said they would refer the patient to someone who has a femtosecond laser. Eight- een percent of the audience who re- sponded said they would continue to use ultrasound anyway, while 8% joked that they would retire. Steven H. Dewey, M.D., Col- orado Springs, Colo., said he doesn't have a problem referring patients to someone who has a femto laser for cataract "if they are insistent that this is the technology they want." Ultimately, however, he said he is still waiting to read published data that demonstrates better outcomes and thinks the issue boils down to trust in the patient-doctor relation- ship. "… I think, as a physician, your job is to explain to the patient that yes, we have this technology. Yes, it may do better in a large series of patients, but the odds are, in my hands, you're going to do just fine." But John D. Banja, Ph.D., pro- fessor, Department of Rehabilitation Medicine, and medical ethicist, Center of Ethics, Emory University, Atlanta, suggested that lobbying Medicare for a change in the pay- ment structure might alleviate this ethical question. But, he admitted, that's a tall order. "When I teach research ethics at Emory, I review the story of Merck [Whitehouse Station, N.J.] getting Medicare to pay for Fosamax [alen- dronate], which is a drug for osteo- porosis," Dr. Banja said. "They got Medicare to pay for Fosamax to use it prophylactically." "I guess the easy answer to this one is to see if you can convince Medicare to cover the cost. Of course, what you're going to need in order to do that is the outcome data that would justify that expenditure." That outcome data would in- clude the efficacy of the laser, as well as reduced complications due to its use, he said. "The terrifically interesting, maybe unanswerable, question is how much better does the new drug or device need to be, relative to what's already out there, to get a payer source like Medicare to reim- burse you for using it?" Dr. Banja asked. EW Editors' note: Dr. Banja has no finan- cial interests related to his comments. Dr. Chang has a financial interest with Alcon (Fort Worth, Texas) and LensAR (Winter Park, Fla.). Dr. Dewey has fi- nancial interests with Alcon. Dr. Packer has financial interests with LensAR. Contact information Banja: 404-712-4804, jbanja@emory.edu Chang: 650-948-9123, dceye@earthlink.net Dewey: 719-471-4139, deweys@prodigy.net Packer: 541-687-2110, mpacker@finemd.com Mark Packer, M.D. David F. Chang, M.D. John D. Banja, Ph.D. Steven H. Dewey, M.D.

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