Putting premium IOLs in your practice

Seven years later, however, many ophthalmologists have yet to embrace the role of "refractive" cataract surgeon by offering premium refractive IOLs to their patients. David F. Chang, MD, addressed the questions of "why" and "how" to become a refractive cataract surgeon.

Although many potential factors have kept surgeons from offering premium refractive IOLs, Dr. Chang focused on the many ways that cataract surgeons must transform their office practice.

"They continually express surprise at how quick the operation seemed, at how good the eye looks and feels, and at how few physical restrictions are imposed," he said. "The brightness and clarity of their vision, and how quickly this improvement occurs, seem to surprise most patients."

All of this changes with premium refractive IOLs, because the patient must now pay a significant out-of-pocket cost.

"As with any significant elective expenditure, now patients have more of a consumer mentality and want to hear and ask questions about all of the options," Dr. Chang said. "They need more time to reach a decision and want to research the options [by searching] the Internet or by asking friends. Furthermore, they develop specific expectations that are not always met. Finally, there are the awkward logistics of having to discuss fees with patients."

With such a contrast to conventional cataract surgery, it is understandable why many ophthalmologists would rather not deal with the increased pressure and demands of implanting premium refractive IOLs.

Aside from the fact that patients want and should be given these options, Dr. Chang believes there are other important reasons why ophthalmologists should embrace the opportunity to provide refractive cataract surgery.

"Premium IOLs are the patient value-added proposition that restores proper value to our skills as surgeons and clinicians," he said.

Dr. Chang referred to the business definition of value, which is what someone would be willing to trade for that service or product, and cited an observation by Andy Corley that when control of the physician-patient relationship was transferred to third-party insurers, cataract surgery ultimately became a commodity.

"Cataract surgery is one of the most successful operations in all of medicine, with more than a 98% success rate," Dr. Chang said. According to cost utility studies, the procedure has a current value of $95,000, which is far higher than that for other common treatments, such as breast cancer ($20,000) or myocardial infarction ($70,000).

"However, the U.S. government is the primary purchaser of cataract surgery, which is the number one line item expense in the Medicare budget," he said. According to Dr. Chang, since the relative value scale system was introduced in 1992, there has been a 42% decrease in the 66984 reimbursement, without adjusting for inflation.

"The patient was removed from the value proposition, and the resulting Medicare payment is far below what the true value should be for permanently reversing a progressive blinding condition," Dr. Chang said.

With premium IOLs, the patient becomes the decision maker for the value proposition.

"Now, for a change, the party that derives the benefit is able to determine the value of the service, and this arrangement financially rewards excellence," he said. "However, the value is not just in the new IOL technology but also in the services and the physician's cognitive decision making."

Dr. Chang cited the additional testing, evaluation, education, and counseling that must be part of any recommendation about refractive IOLs and services. Furthermore, he said that the patient does not judge value based on the additional time needed to perform an astigmatic keratotomy, or implant a multifocal IOL.

"What the patient really values is the surgeon's knowledge, experience, preparation, clinical judgment, compassion, and integrity," he said.