Los Altos, California
Fair reimbursement for surgeons and the IOL industry should include an optional but uncovered refractive premium that will be market driven. Otherwise, we are collectively giving these premium but optional products and services away for free, and such a scenario creates a subtle disincentive for surgeons to assume the higher expectations and risk of dissatisfaction that accompany advanced refractive technologies. Furthermore, if the premium product is bundled, patients are less able to differentiate its value from that of standard cataract surgery. I believe that as a profession, our huge mistake has been our failure to help patients and payers distinguish between what is integral to quality cataract surgery (the reversal of lens opacity) and what is an elective refractive enhancement (astigmatism reduction, or a multifocal or accommodating IOL to reduce spectacle dependence).
At issue is the right of Medicare beneficiaries to pay for elective refractive benefits that do nothing to enhance the safety of their cataract surgery. We should strive to make technologies that reduce complications (eg, capsular tension rings and a square edge on a foldable IOL) available to all patients. In other words, we should not create two standards of care, where a wealthier patient can pay extra for devices that make his operation safer. However, multifocal and toric IOLs do not reduce complications or improve ocular health, and our tax-subsidized Medicare program should not be covering elective refractive correction for all. Patients want and deserve the basic right to pay their own money for an optional refractive benefit. That this right is currently prohibited is an onerous, unfair, and unintended consequence of policies designed to prevent double standards of surgical quality and safety based upon patients' financial means.I. HOWARD FINE, MD
I believe that refractive surgery, and the devices involved in its application, should be priced by market forces and should reflect the skill, training, responsibility, and experience of the surgeon as well as its worth to the patient, rather than the dramatic devaluation of those same qualities and entities that has existed in Medicare's remuneration for cataract surgery. Ultimately, Medicare will have to allow balance billing for improved technological devices, as it already does for some, such as eyeglasses after cataract surgery and motorized wheelchairs for patients who require them. If Medicare policymakers do not respond to emerging technology with balance billing for recipients, they will have indeed created the situation that they were most determined to avoid: that of guaranteeing second-class medical care for Medicare recipients.ELIZABETH DAVIS, MD
I believe that new refractive IOL technology should be priced at a premium. The goal of cataract surgery is to improve the patient's best corrected acuity via the removal of a cataractous lens. It is not medically necessary that this result in the elimination of corrective lenses, although such an outcome may be desirable to the patient and is oftentimes an added benefit. Current and future IOL technology will have the potential to produce minimally aberrated vision with the elimination of refractive errors and presbyopia. Such developments include high-quality–optic IOLs as well as laser-adjustable, accommodative, multifocal, and toric IOLs. The research, development, and production of these implants will be worthwhile but expensive. Therefore, these lenses will be priced at a premium. Unfortunately, with the current healthcare crisis, it is unlikely that insurance carriers will pay for this technology for patients. Therefore, only a certain percentage of patients will be able to afford this added benefit. In my mind, refractive IOLs are no different than any other luxury commodity in the US. Large houses, fancy cars, and stylish clothing are available to but not attainable by all. However, they are also not necessary. Fortunately, current results in cataract surgery with standard monofocal IOLs are excellent in and of themselves. Having a “deluxe” IOL is simply icing on the cake, and therefore they may reasonably command a premium price.ROBERT M. KERSHNER, MD
First, I do not believe that premium pricing will restrict either the availability or the market drive for new refractive IOL technology. On the contrary, it will enhance the growth of the industry for providers and consumers alike. Ophthalmology, as a medical specialty and a profession, has for too long believed what the third-party payers have been telling us: namely, that if our technologies are so good and the speed at which we provide superior visual results is so immediate, then what we provide must not be worth anything. The reality, recognized by eye surgeons and their patients alike, is of course much different. Premium pricing spurs technological growth. It enhances a practitioner's ability and drive to provide state-of-the-art care. A patient's perception of the quality of technology and the medical care it demands are, unfortunately, not historically tied to pricing. This is because consumers of healthcare have been detached from the costs of obtaining it. This circumstance is in the process of changing. If perception is reality, then all you need to do is ask a consumer if his four-digit cash outlay for a dermatologic rejuvenation procedure was worth it. He will answer “yes” and return again and again for procedures that provide perceived lifestyle benefits, even if those procedures are not permanent. Our industry needs to catch up. We provide a permanent solution to one of humanity's most basic needs: clear vision. We should get used to charging and getting paid for what it is worth.SAMUEL MASKET, MD
Los Angeles, California
In the August 2000 American Journal of Ophthalmology,1 I published my concept for a health-plan initiative. I described a two-tiered national healthcare system, similar to the defunct Oregon health plan. The premises were (1) basic services would be paid for with public funds and be available to all Americans irrespective of means testing or age, (2) all services and procedures would be assigned a priority level according to their medical code, and (3) based upon available funds, those conditions of priority high enough to merit public funding would be so covered. As examples, hospitalization for an acute myocardial infarction would be a very high priority, whereas elective blepharoplasty would be a low priority.
Given the expense of developing and deploying new medical technology as well as the aging demographic trend of the US population, it is impossible to expect that the present Medicare system will be able to afford all of the care demanded by the population. To a certain extent, we must consider some form of rationing for publicly funded healthcare. As a result, the population must be more responsible, in part, for its own care. Healthcare is already 15% of the nation's gross domestic product, and if costs continue to spiral upward, clearly we will break the bank. My sense is that, although basic healthcare should be available for everyone, an elective level of care or technology should be funded either by private insurers or individuals themselves. Therefore, the concept of having newer-technology IOLs available for which patients could and would pay a premium is consistent with my beliefs.
What is inconsistent is placing the surgeon at financial risk for using new products. The current marketing model that Eyeonics, Inc. (Aliso Viejo, CA), has in place with the Crystalens Accommodating IOL requires a significant cash investment by the surgeon. This in turn forces him or her to sell that product to patients at a high price in order to recapture the cost. In my view, that marketing model is an artificial means by which to disseminate the product, and I oppose the concept. The last example of that business model was the intrastromal corneal ring segment (Intacs; Addition Technology, Inc., Des Plaines, IL). Based upon the merits of the product as well as the marketing model, that device has all but fallen into disuse and exists only as a very small niche product. Whether time will bring the same scenario for the Crystalens remains to be seen, but I am very much opposed to placing surgeons at financial risk in order to coerce them to use a product. However, I am greatly in favor of patients' having the opportunity to receive standard medical care with no out-of-pocket expense or alternatively choosing more advanced technology that is available at a premium.
Unfortunately, I realize that such a healthcare delivery system would give the wealthy greater access to more advanced medical technology. However, with the exception of medical care, Americans buy most everything based upon their desire as well as their ability to pay. People of low and modest incomes do occasionally buy high-end consumer goods, and there is no reason why healthcare cannot fit into that same parameter, so long as there is basic healthcare available to every US citizen.1. Masket S. Health, medicine, and ophthalmology. Am J Ophthalmology. 2000;130:379-380.
Y. Ralph Chu, MD
I feel it is technological advancements that drive our field forward by helping to improve the quality of patients' lives. Because it can cost millions of dollars to bring new technologies to market, I feel that higher reimbursements for new IOL technologies are necessary. Higher reimbursements may restrict access to these lenses in the short term, but over time, higher reimbursements will provide more resources and thus lead to more innovations that will ultimately advance the entire field of ophthalmology. Patients deserve a choice. If a healthcare system will only pay for one type of lens while other IOL technologies are available, patients should be allowed to pay for and choose the technologies they want.JOHN F. DOANE, MD
Kansas City, Missouri
As a practitioner of ophthalmic surgery, I want what is best for my patients, all other things being equal. It would be a dream that all individuals in an advanced society have the opportunity to obtain the highest level of care at no cost and instantaneously. Such a scenario, however, is not reality, nor will it ever be.
There are some basic variables for the cycle of medical advancement to operate healthily. Four essential parties must be served: patient, provider, technology company, and payor. New technology, be it high-fidelity, computerization, telecommunications, or ophthalmic devices, is developed by innovative financial risk-takers and based upon the premise that there will be a consumer (payor) who will fund the research investment and also provide a profit to the risk-takers. This cycle can work in a medical technology industry in a capitalistic society. It is highly unlikely to succeed long term in a purely socialistic society. On the other hand, the relationship may work in a combination system, which is what the US currently has.
When a technology's cost exceeds what traditional reimbursement rates for third-party payors (private or governmental) have as planned outlays, the device cannot be provided unless additional funds are “created.” The solutions for creating funds can be collective (raising taxes or premiums) or individual, with patients paying out of pocket for what they desire. Currently in the private sector and to a limited degree in the CMS/Medicare system, individuals can pay out of pocket to upgrade for a technology they consider to be advanced or beneficial beyond the baseline technology (ie, wheel chairs, spectacle frames, single-occupancy hospital rooms). Why shouldn't a patient be able to pay out of pocket for a device, its implantation, and the extra skill required of the practitioner pre- and postoperatively if the device is solving an uncovered service (presbyopia, in the case of one IOL category)?
Some individuals believe that giving patients the opportunity to pay for an advanced technology will threaten the established socialized medical delivery system. It appears clear at present that the current payor for our senior citizens will have to decrease reimbursements per case on an ongoing basis due to a fixed budget that cannot accommodate the ever expanding volume of surgical procedures. In other words, there are insufficient funds to cover the expansion of increasingly expensive medical services. Therefore, additional out-of-pocket payments for technological upgrades are the most logical ongoing driving force for medical advancements in the US. The huge plus is that such an arrangement costs the government and tax payers nothing and in fact reduces the cost to the government by $150 per case, because a refractive IOL will not be reimbursed by Centers for Medicare and Medicaid Services. Now, that is thinking outside the box for everyone's benefit!