Coupling Surgeries May Be Cost Effective

Spectacles remain the most common way of correcting refractive error after cataract surgery, but they are no longer considered state of the art. Patients are increasingly undergoing cataract surgery with the expectation of not wearing glasses postoperatively, partly because of how LASIK has been marketed and due to advances in cataract surgery and IOL technology. Many patients want the best possible UCVA they can achieve. At our practice, my colleagues and I offer customized cataract surgery with good UCVA as a specific postoperative goal, through presbyopia-correcting IOLs as well as aspheric lenses, monovision, and laser refractive enhancements.

DISCUSSION OF PROCEDURES WITH PATIENTS
Options
All of our prospective cataract patients receive literature that prepares them for a discussion about presbyopia-correcting lenses and monovision. The handouts and discussion educate patients about their options and stipulate that some treatments represent additional costs. When the patient comes in for an evaluation, the technician tells him about the option of having additional testing and/or procedures to optimize his vision so he can be less dependent on glasses. If the patient is not interested in getting rid of his glasses, the discussion ends there, and we perform no additional diagnostic tests.

Customized Cataract Surgery
For patients who choose customized cataract surgery, we develop a treatment plan that typically includes two or possibly three steps. The first step is cataract surgery and the implantation of an IOL, which may be a multifocal or accommodating lens or a monofocal IOL with a monovision target. The second step is typically a Visx Customvue (Advanced Medical Optics, Inc., Santa Ana, CA) PRK procedure to correct any residual sphere or cylinder. In a mature population (eg, individuals with cataracts), I prefer PRK over LASIK due to dry eyes, basement membrane dystrophy, and other issues that may compromise the epithelium. Generally, the treatment amount is small, which makes PRK a safe and effective approach.

Whenever possible, we perform a wavefront-guided Visx Customvue PRK procedure. In our corneal refractive practice, customized surgery offers the best results, lowest enhancement rate, and most accurate application of the excimer laser to correct refractive error. In my experience, Customvue is effective in pseudophakic patients as well. In addition to wavefront technology, Visx Customvue offers an entire package of technological improvements compared with conventional laser treatments, including pupil centration, iris registration, a variable spot size, and a variable rate of repetition.

Costs
The Centers for Medicare & Medicaid Services' ruling about presbyopia-correcting IOLs has prompted my colleagues and me to re-examine how we charge for the uncovered services we provide along with monofocal IOLs. In the past, we typically did not charge for limbal relaxing incisions (LRIs) performed at the time of surgery due to the administrative effort and bureaucracy involved in billing the patient. If an astigmatic keratotomy was performed postoperatively as a separate procedure, however, we did charge for it, but our policy and fees were inconsistent.

We decided to establish consistent rates and policies for refractive correction associated with cataract surgery, regardless of the type of lens implanted. I believe it is important for physicians who offer refractive surgery to their cataract patients to clearly explain that this is a value-added service. It is reasonable and appropriate to charge for LRIs and other enhancements, and it is important to do so consistently.

THE CUSTOMIZED PACKAGE
Expect to Perform Additional Postcataract Procedures
As noted earlier, my colleagues and I prepare every patient undergoing customized cataract surgery for the likelihood that he will require more than one surgical procedure toward his goal of spectacle independence. As part of our treatment plan, we schedule a laser enhancement for the 6-week postoperative visit. If the patient's goal of spectacle independence is achieved after IOL implantation alone, the second procedure is cancelled, and the patient is not charged for an enhancement.

Make Patients Happy
Informing patients that they may require more than one surgical procedure is a good strategy for several reasons. Patients are quite happy if they achieve their goal with fewer procedures and a lower cost than anticipated. They participate in the decision by assessing for themselves the value of additional surgery at every point in the process. A patient who is -0.50/ 1.00 D may be pleased and not opt for an enhancement, although another patient who is plano 0.75 D may decide he wants to improve his outcome. Knowing that there are several steps in the process also diffuses patients' expectations of perfection on day 1 following the implantation of a presbyopia-correcting IOL implant. They understand from the beginning that they need to have the second implant surgery and possibly a laser enhancement before reaching their goals.

Bill for the Treatment Plan and Additional Services
The preoperative treatment plan outlines the timing and costs of all associated testing and procedures to achieve an agreed upon refractive goal. Patients are billed at the time of the surgery only for services we actually perform. We have a separate informed consent for each procedure so the patient understands in advance his risks and benefits as well as the charges not covered by Medicare. We chose this approach over an actuarial or global fee in which the specific services provided are not broken out. For any refractive service for which the patient pays out of pocket, it is critical to have him sign a notice of exclusion of Medicare benefits to indicate that he understands why he is paying for these services.

Our menu of additional refractive services includes preoperative testing and the technical evaluation of those tests, intraoperative procedures such as LRIs, and postoperative components such as additional follow-up, astigmatic keratotomy, mini-RK, or laser procedures. Most of these services are relevant to both monofocal and multifocal IOL patients who desire greater spectacle independence.

SUMMARY

I encourage surgeons to give cataract surgery patients the option to reduce their dependence on glasses. Ideally, patients should be offered not only presbyopia-correcting lenses but also the choice of precise surgical enhancements that offer the very best chance of spectacle independence. Many of today's cataract patients no longer assume that refractive error is a lifelong condition. Once they have set a goal of minimizing their dependence on glasses, they accept the additional surgery and costs as providing something of value.

John A. Vukich, MD, is Surgical Director of the Davis Duehr Dean Center for Refractive Surgery in Madison, Wisconsin. He is a consultant to Advanced Medical Optic, Inc. Dr. Vukich may be reached at (608) 282-2000; javukich@hotmail.com.