The Economics of Femtosecond Laser-Assisted Cataract Surgery

Abstract and Introduction

Abstract

Purpose of review Femtosecond lasers for use during cataract surgery carry significant purchase and use costs. The aim of this article is to help surgeons and surgery centers anticipate financial issues related to implementing femtosecond laser-assisted cataract surgery (FLACS). Such scenarios hopefully can help to inform decision making around the purchase and use of these lasers.

Recent findings FLACS has several potential advantages over traditional phacoemulsification. However, although studies have demonstrated noninferiority of FLACS, there continues to be few data to support significantly improved visual outcomes. The literature does show a significantly higher cost for FLACS. As this cost can be passed on to patients under Medicare rules, there is the potential for increased physician revenue, which can be a motivator for adoption of this new technology. The magnitude of this increase is heavily influenced by the financial details of the implementation, like the cost of the laser, the volume of surgery performed, and the incremental increase in revenue.

Summary A financial analysis should be performed prior to purchasing a femtosecond laser. This analysis can help predict if FLACS is going to be a financial windfall or a money loser.

Introduction

Cataract continues to be the most common surgery in the USA for patients of Medicare age with an estimated 3 million procedures per year.^[1] Given the projected increase in the cataract segment of the population to 50 million people in the USA over the next couple of decades, and the concomitant increase number of cataract surgeries, demographic factors present an unprecedented economic opportunity for ophthalmologists but also presents significant economic challenges and risks. The Centers for Medicare and Medicaid Services (CMS) have been looking to control and contain the costs of cataract surgery for decades and this has caused significant downward pressure on cataract surgeon reimbursement for the procedure.^[2]

Although increased volume could provide increased revenue, physician reimbursement per surgery has steadily decreased over decades. Comparing the 1985 surgeon reimbursement of US $2000 per case to the 2012 US $761 reimbursement, surgeons have seen a decline in surgical fees of 62% in real dollars, but when adjusted for inflation the decrease is calculated at an astounding 89%.^[3] Understandably, many cataract surgeons have become concerned that they may be put out of business because of declining reimbursement.

In 2005 and 2007, CMS Rulings provided an avenue for generating additional revenue during cataract surgery by allowing providers to provide 'premium' refractive services, the correction of astigmatism, or the placement of astigmatism or presbyopia correcting intraocular lenses, at additional out-of-pocket cost to the patient.^[4,5]

Since these Medicare rulings, many cataract surgeons have seen a significant increase in revenue fueled by refractive fees, but there are limits. Many patients are not candidates for multifocal lenses or are unwilling to accept the limitations of these types of lenses in terms of glare and halo. Many patients have lower levels of astigmatism and do not require toric astigmatism-correcting lenses. As a result, only about 11–15% of patients nationwide receive premium lenses.^[6,7] This leaves a significant number of cases reimbursing at the much lower regular surgery rate. From a financial standpoint this creates a strong incentive to find a way for these remaining patients to qualify, and pay for, refractive surgery fees. Femtosecond laser-assisted cataract surgery (FLACS) offers one potential way to command these additional refractive fees in a significantly greater percentage of patients with cataract.