Cataract Laser Surgery Effective, but Expensive

Marcia Frellick

October 17, 2013

Femtosecond laser-assisted cataract surgery (FLACS), offers many benefits over the conventional phacoemulsification cataract surgery (PCS), including increased precision, improved effective lens positioning, and less damage to surrounding tissue. However, a cost-effectiveness analysis, published online October 11 in Ophthalmology, shows it remains much more expensive.

FLACS, including initial purchase and maintenance of equipment, costs about $4500 per case compared with $3500 for PCS, according to Robin G. Abell, MBBS, from the Tasmanian Eye Institute, and Brendan J. Vote, FRANZCO, from the Launceston Eye Institute, Tasmania, Australia.

The researchers used Medicare fees, Australian Medical Association–recommended fees, private health insurance annual reports, hospital data collection reports, and industry standards to evaluate the cost of intervention for both FLACS and PCS, as well as the costs saved by each, including those related to poor vision, blindness and other complications.

They found that FLACS is not cost-effective at its current price. The net utility gain was 0.06 quality-adjusted life-years (QALYs) for FLACS vs PCS, or 3 weeks of reasonable quality for a person with average life expectancy as a result of the FLACS intervention.

"To be considered reasonably cost-effective...health interventions should be less than US$50,000 to US$70,000 per QALY," Dr. Vote told Medscape Medical News in an email. "Standard PCS is highly cost effective at...US$3500 (in 2013) per QALY." He added that in contrast, the laser intervention does not meet cost-effectiveness thresholds at US$90,000 per QALY.

This lack of cost-effectiveness remained, despite the authors using a best-case scenario of laser surgery delivered perfectly in their model.

The researchers estimated that the FLACS procedure would need to cost the patient, insurer, or public healthcare provider only $300 to $500 more than current PCS, as opposed to the nearly $1000 more it costs now, to be considered reasonably cost-effective.

"Even at this cost, [FLACS] would remain nowhere near as cost-effective as PCS," Dr. Vote said.

FLACS was approved by the US Food and Drug Administration only 3 years ago, and clinical improvements from FLACS technology are still awaiting phase 3 clinical trials. The authors note that costs may come down with increased demand, competition, and advances in technology.

However, costs are not the only variable worth considering in comparing the 2 methods, according to Andrew F. Calman, MD, PhD, associate clinical professor of ophthalmology at the University of California San Francisco and past president of the California Academy of Eye Physicians and Surgeons.

"Another aspect is that [FLACS] generally takes longer than [PCS] because there are 2 separate procedures. There is a laser initial procedure, which has a patient sitting up...then you have to move the patient, often to a different room; have them lie down; and then do your cataract surgery, whereas with [PCS], it's just a single procedure usually in the 5- to 10-minute range."

That's one difference that has kept FLACS from penetrating the routine cataract surgery market, Dr. Calman said: Its niche in the United States is in the elective refractive surgery arena, where some people are willing to pay extra for the best, latest technology. So far, however, Medicare has not been among those willing to pay extra when there is already a proven, cost-effective alternative.

"The key problem we run into with many incremental increases in technology is who will pay for it. In this case, Medicare has made it clear that they are perfectly happy to have a surgeon use [PCS] or [FLACS], but they aren't going to pay [for the] difference in fees.... So [laser surgery] tends to go to places that have a pretty good volume of cash-paying, elective refractive lens exchange," Dr. Calman said.

Ophthalmology. Published online October 11, 2013. Abstract

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