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OPHTHALMOLOGY BUSINESS 78 June 2015 by David M. Dickman, MD vestment or volume of patients that is not realistic for a comprehensive ophthalmologist. Equipment that has multiple uses makes a lot of sense economi- cally, and with the IQ 532 laser you can perform multiple procedures for retina disorders and glaucoma in both continuous-wave and Micro- Pulse modes. For a comprehensive ophthalmologist, it makes sense. EW References 1. Gershenbaum E, Martidis A, Najarian L. Starting cold: Three ophthalmologists who did it their way. Review of Ophthalmology 2008. Retrieved from www.reviewofophthalmology. com/content/d/features/i/1230/c/23146. 2. Ogata N, Tombran-Tink J, Jo N, Mrazek D, Matsumura M. Upregulation of pigment epithe- lium-derived factor after laser photocoagula- tion. Am J Ophthalmol 2001;132(3):427–9. 3. Binz N, Graham CE, Simpson K, Lai YK, Shen WY, Lai CM, Speed TP, Rakoczy PE. Long-term effect of therapeutic laser photocoagulation on gene expression in the eye. FASEB J 2006;20(2):383–5. 4. Yu AK, Merrill KD, Truong SN, Forward KM, Morse LS, Telander DG. The comparative histo- logic effects of subthreshold 532- and 810-nm diode micropulse laser on the retina. Invest Ophthalmol Vis Sci 2013;54(3):2216–2224. 5. Fea AM, et al. Micropulse diode laser trabec- uloplasty (MDLT): A phase II clinical study with 12 months follow-up. Clin Ophthalmol. Jun 2008; 2(2):247–252. 6. Data available to subscribers of the Epocrates medical application. 7. Shingleton BJ, et al. Long-term efficacy of argon laser trabeculoplasty. A 10-year follow-up study. Ophthalmology. 1993 Sep;100(9):1324–9. Considering the significant portion of the population with glau- coma, a potential savings of greater than 50% in total cost to the health- care system is of enormous propor- tions. In addition to providing the patient an effective treatment that saves money, the physician has an opportunity to earn a greater reim- bursement. Offering MLT as an option to pharmaceutical therapy To all of my patients who do not have a contraindication to laser therapy, I present both the phar- maceutical and the laser surgery options to control their glauco- ma. I inform them of the benefits and risks of each option. Laser is a treatment option that may prevent the need for hypotensive drops for a few years, but there is a 20% chance it will not be effective. Glauco- ma medications are effective in a higher percentage of patients, but only when the patient uses them as directed. Medications may also cause side effects such as eye irritation, darkening of the skin around the eye or even a change of eye color. Patients who have low copays and feel they are compliant with medi- cation regimens often choose to go that route. However, about 50% of my patients, either with high copays or a great distaste for daily drops, elect laser treatment. A comprehensive approach The purchase of equipment to per- form selective laser trabeculoplasty requires a large capital expenditure, and it is a single-purpose laser. There are a variety of new, minimally in- vasive glaucoma procedures coming to market, but training to become proficient at new procedures can be very time-intensive, and some manufacturers require an initial in- Reducing costs The Iridex IQ 532 laser system has both continuous-wave and Micro- Pulse mode options to treat many glaucoma and retinal disorders, but I will discuss just the economics of glaucoma here. While the cost of glaucoma medications for patients often makes the news, the price of medicating a glaucoma patient for the healthcare system is discussed less frequently. According to the Epocrates medical application, the yearly cost of prostaglandin medi- cations ranges from $388 to $1,441, with an average cost for prostaglan- dins at $1,043/year. 6 The burden of payment is split between patient copays and insurance companies. Medicare reimbursement for trabec- uloplasty by laser surgery (CPT code 65855) averages $315 for a single treatment. According to long-term argon laser trabeculoplasty studies, to which MLT has been found to be equally effective, the probability of success is 77% at 1 year and 49% at 5 years. 7 Treating 100 glaucoma patients with MLT plus providing prostaglan- din therapy for 1 year to the 23% of non-responders has a cost to the healthcare system of approximately $55,489. The cost of simply provid- ing prostaglandin therapy to those same 100 patients for 1 year costs approximately $104,300, mak- ing a difference of $48,811 in the first year. However, the cost to the healthcare system in years 2–5 drops significantly, as prostaglandin ther- apy only has to be provided to the non-responders, a group that grows by about 7% annually. Prostaglandin therapy for 100 patients for 5 years costs a total of $521,500, compared to $224,455 for treating all 100 patients with MLT and then only providing pharmaceutical therapy to those who fail laser therapy. W e are all very aware that an overall de- crease in reimburse- ment rates is coincid- ing with an increase in capital expenditures for new tech- nology. To make it more concrete, a comprehensive ophthalmologist could open a practice in 1989 with a $30,000 loan for equipment and expect to earn an average of $1,600 (adjusted to 2013 dollars for infla- tion) per case simply for being an assistant on cataract surgery. 1 Today, a single optical coherence tomogra- phy unit can cost $60,000, and the reimbursement rate for cataract sur- gery has dropped to $720. Finding treatment methodologies that make economic sense, as well as produce desired outcomes, is a must. I have found that MicroPulse laser therapy (Iridex, Mountain View, Calif.) fits the bill. Changing paradigm Laser therapy has been an accepted treatment for several decades for diseases as varied as diabetic macular edema, central serous retinopathy, and even glaucoma. While newer pharmacotherapy options have taken center stage for some of these diseases recently, increased knowl- edge about the mechanism of thera- peutic action and the development of sublethal treatment modalities is increasing the popularity of laser treatments once again. Rather than coagulating tissue, controlled dosage of laser heats tissue just enough to elicit a stress response. This induces beneficial intracellular biological fac- tors, such as PEDF, TSPI, SDFI, and beta-Actin, which are primarily anti-angiogenic and restorative. 2,3,4 MicroPulse technology "chops" a continuous wave laser emission into a series of evenly spaced, repetitive laser pulses that improve control of the photothermal effects of treatment. A lower amount of energy is emitted with each pulse, and the pauses between pulses allow the tissue to cool. This treatment modality allows the tissue to remain viable and thus initiate a therapeutic stress response. MicroPulse laser tra- beculoplasty (MLT) achieves equiv- alent clinical outcomes as continu- ous-wave laser modalities without causing clinically visible damage, intraoperative side effects or postop side effects. 5 The economic value of MicroPulse laser therapy for the comprehensive ophthalmologist Dr. Dickman is a compre- hensive ophthalmologist specializing in cataract surgery, diabetic eyecare, glaucoma, and refractive surgery. He is the owner and principle at Universal Eye Center in Rolesville, N.C. He can be contacted at dmdmd@universaleyecenter.com. About the author MLT savings to healthcare system Year 1 Year 2 Year 3 Year 4 Year 5 Prostaglandin therapy for MLT non-responders (23% non-responders for year 1 with ~7% annual growth) $1,043/pp x 23 non- responders= $23,989 $1,043/pp x 30 non- responders =$31,290 $1,043/pp x 37 non-responders =$38,591 $1,043/pp x 44 non-responders =$45,892 $1,043/pp x 51 non- responders =$53,193 MLT monotherapy: 100 patients $315 x 100 patients treated = $31,500 $0 $0 $0 $0 Total cost to treat with MLT and supplemental prostaglandin for MLT non-responders $55,489 $31,290 $38,591 $45,892 $53,193 Prostaglandin monotherapy: 100 patients $104,300 $104,300 $104,300 $104,300 $104,300 Annual savings of MLT $48,811 $73,010 $65,709 $58,408 $51,107

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