At issue: Financial, ethical concerns

Orlando, FL-The advent of femtosecond laser technology for cataract surgery has resulted in myriad issues for ophthalmologists to face: the actual benefits of the laser versus the cost to patients, establishment of the patient share of the costs, associated financial risks for the practice and ambulatory surgery center (ASC), advertising, and patient satisfaction. David F. Chang, MD, delved into these issues during the Late Breakers Symposium at the annual meeting of the American Academy of Ophthalmology.

While Dr. Chang considers the technology "exquisite," paying for it might be a major roadblock, he said.

He offered a simple hypothetical situation in which the femtosecond laser carried a one-time purchase fee of $100,000 with no click fees attached and the physician could decide when to use the device.

In a recent survey of ophthalmologists that Dr.Chang conducted, the biggest physician concern by far was financial viability, for three-quarters of the respondents (n = >1,000).

In addition to cost, he cited other concerns. Specifically, will the technology meet patient expectations considering that they are paying for the refractive benefits of the technology; will the cost create financial pressures and conflicts of interest that can lead to misleading claims and advertising; and will the advertising claims trivialize the surgery not only in the minds of the public but also for third-party payers and legislators being told that optometrists can perform some surgeries?

"If, as some predict, the femtosecond laser technology will become the future of cataract surgery, there are a number of challenges to be met," Dr. Chang said. These include:

"Although we all anticipate certain clinical benefits that the femtosecond laser will provide, they remain hypothetical at this time with respect to both complication rates and refractive outcomes," he said. "We are going to need large clinical trials to obtain comparative outcome data against what we are already doing."

Regarding cost, if the patients pay a premium for refractive benefits, other issues arise.

"First, what will the Centers for Medicare and Medicaid Services (CMS) allow to be billed and, therefore, what will the value-added proposition be? Will the procedure be desirable and affordable enough, and will it meet the expectations it creates?" Dr. Chang queried.

He pointed out that with respect to the CMS safe harbors there is uncertainty in some areas- particularly with refractive IOLs.

Currently, according to Dr. Chang, "There seems to be good consensus that Medicare patients cannot be billed extra just because the more expensive femtosecond laser technology is used to perform the steps of cataract surgery."

However, a tiered fee is acceptable for treating astigmatism with the femtosecond laser, compared with a diamond blade.