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Should National Health Services reimburse for premium IOLs?
Reimburse for well-documented indications
 Simonetta Morselli |
The National Health Service should reimburse for premium IOLs whenever there are the indications and when the reasons for this choice are clearly stated by the surgeon. Of course, this entails a responsible attitude on behalf of us as ophthalmologists. There are patients in whom these lenses are a wonderful way to restore the quality of vision and quality of life of which they had been deprived by specific disease conditions. I am talking about young or fairly young patients with cataract who need a fast rehabilitation and have a chance, thanks to these lenses, to regain full functional vision for their daily activities.
On the other hand, there are patients in whom a premium IOL would be wasted. Age and an old, consolidated habit to wear spectacles would prevent full appreciation of the functional benefits of these implants and even create serious problems of adaptation. Clear lens exchange is also not allowed as a NHS-reimbursed practice for the same reasons that make breast reconstruction reimbursable after mastectomy but not for aesthetic purposes.
A NHS ruling is not yet clear in Italy. We have an extremely variegated situation, where even within the same region hospitals may or may not allow covered services for premium IOLs. Administration boards set a budget that is variable from place to place, and can be too limited to pay the extra price of these implants.
In my hospital, the use and reimbursement of premium IOLs are allowed. They are considered a special service for specific cases. As the head of the department, I must produce a well-documented application that justifies my choice, but I do not consider this a burden or a waste of time. It is an obvious, necessary request. Quite often I implant toric lenses to correct high astigmatism of more than 2 D to 3 D, and phakic IOLs for high myopia. I have also been implanting a few multifocal lenses and, occasionally, accommodative IOLs. Altogether, premium IOLs are 5% of the total number of lenses we implant.
I believe they should remain, however, a special choice for a minority of cases, and they should always be widely discussed with the patient. They can produce results that go beyond expectations, but also unpredictable negative outcomes if a precise patient selection, evaluating all parameters, is not carried out.
Simonetta Morselli, MD, is head of the ophthalmology unit at Bassano del Grappa City Hospital, Italy.
New technology brings new billing challenges
 Béatrice Cochener |
The technology of premium IOLs undoubtedly offers attractive benefits to patients. It also poses new challenges for billing and reimbursement. Personally, I think a National Health System should reimburse, as it does, the cost of cataract surgery with implantation of a standard lens and nothing beyond this. On the other hand, patients should be allowed to pay the additional price of a premium lens with out-of-pocket funds in public hospitals.
Cataract surgery with implantation of a premium IOL is a refractive approach and therefore a personal choice of the patient, a specific option for those who do not want spectacles and are prepared to pay an extra cost for this. These forms of “patient share billing” are a good compromise that does not impose to the NHS any extra burden and, on the other hand, does not force patients who want premium lenses to necessarily go to a private practice and pay for the entire cost of the procedure.
At the University of Brest, where I work, this opportunity is offered to patients. We perform 15 to 20 cataracts a week, and one-third to one-half of the patients are implanted with multifocal or accommodative lenses. However, in France, there are no well-established rules on this practice at the moment. There are hospitals where co-payment is accepted and hospitals where patients are not allowed to pay extra, even if they were willing and able to do so. It all depends on the internal policy of the administrative boards.
The minimum age for cataract is also a controversial matter. Most places do not consider early cataract, before the age of 55 to 60 years old, as a necessary, reimbursable operation. Using the word “cataract” for lens extraction at an earlier age could give way to investigation from health authorities and, possibly, to legal action. The French Society of Ophthalmology and the unions are working together to obtain clearer, uniform regulations that reflect modern needs.
Béatrice Cochener, MD, is an OSN Europe Edition Board Member and a professor of ophthalmology at University of Brest, France.