If a patient has a poor visual result after cataract surgery, do you charge an additional fee for enhancement?

No fees paid after initial surgery

Eric D. Donnenfeld

Patients who request refractive cornea/cataract surgery overwhelmingly have a specific goal of being less dependent on or eliminating their need to wear glasses for visual rehabilitation. As part of the informed consent process, I tell every patient considering surgery that there is a possibility they will require additional procedures to achieve their refractive goals, and I will give them a percentage chance, based on my experience, that this may be necessary.

Despite this education, the majority of patients who do not achieve their desired refractive outcome are disappointed and at some level view their procedure as having been unsuccessful and hold the surgeon responsible. These are the most important patients refractive surgeons need to make happy to have a successful refractive practice. They need to be re-educated, and the enhancement procedure should be performed as soon as possible. The patients should never feel abandoned, and in my experience, asking these patients for additional funds for a secondary procedure is a guarantee that I will take a patient who is by definition unhappy and make them more discontented.

Bundling my refractive enhancements into the cost of the primary procedure has eliminated this problem and a potential barrier to the patient’s final visual rehabilitation, which is my primary goal. I apply this philosophy to every patient in my practice, even the refractive outliers who have an overwhelmingly high likelihood of requiring additional surgery. In these rare cases, I inform the patient they will need two procedures and I charge the patient for both of the surgeries before the first procedure. If they do not require a second procedure, I return the cost of the second procedure. In my experience, refractive patients have specific expectations and exceeding these expectations is my goal as a refractive surgeon. Asking the unhappy patient who requires a surgical enhancement for additional fees should not be a barrier to achieving the patient’s refractive goal.

Eric D. Donnenfeld, MD, is an OSN Cornea/External Disease Editorial Board Member. Disclosure: No products or companies are mentioned that would require financial disclosure.

Fee helps to cover ‘unparalleled’ refractive outcomes

Thomas W. Samuelson

One of the distinct advantages of ophthalmic surgery in the post-excimer era is the vast array of technologies available to enhance refractive outcomes. I am constantly reassuring patients that, with rare exception, we have the tools to improve on the already stellar outcomes of modern cataract surgery.

Our practice, Minnesota Eye Consultants, has five excimer lasers at offices scattered throughout the Minneapolis-St. Paul metro area available to fine-tune our refractive outcomes after cataract surgery. Whether or not I charge a fee for excimer refinement depends largely on the reason an enhancement was necessary in the first place. Much of the time, the patient is aware that a goal of emmetropia may be a two-step process. For example, for a patient who desires a multifocal IOL but has significant corneal astigmatism, I thoroughly explain that a planned two-stage approach will be needed. The first stage is meticulous phacoemulsification with multifocal IOL implantation, while the second step is excimer enhancement with either iLASIK (Abbott Medical Optics) or PRK. I generally prefer this approach over a manual limbal relaxing incision approach. We also have a LenSx femtosecond laser (Alcon). With this new technology, we may be able to accomplish the desired result in a single procedure.

Whether or not femtosecond laser-assisted astigmatic keratotomy during cataract surgery can deliver results comparable to secondary excimer enhancements remains to be seen. Yet, each method provides a wonderful strategy to improve our refractive outcomes in cataract surgery. Do I charge for this service? Yes, with exception for unusual circumstances — for example, biometry error — I charge a fee for the incredible technology that allows for unparalleled refractive outcomes.

Thomas W. Samuelson, MD, is OSN Glaucoma Section Editor. Disclosure: Dr. Samuelson is a consultant to AMO and Alcon Surgical.

Risk of overcharging most patients

Karl G. Stonecipher

After many years of refractive surgery and refractive cataract surgery, we have been back and forth on the issue of charging for enhancements. The bottom line is experience means you have done it wrong before and will do it wrong again if you continue to operate.

What I mean by that is, this varies from surgeon to surgeon based on laser vision correction or refractive cataract surgery. First, with laser vision correction, the industry has essentially established free enhancements as the standard of care, and the debate seems to revolve around a “lifetime commitment.” Typically, the debate is whether it is the lifetime of the surgeon, the patient or the company. Our current laser vision correction policy is enhancements are free, and we offer a lifetime commitment.

With refractive cataract surgery, for most surgeons this can present a logistics challenge. Who owns the laser? If it is the surgeon, then free enhancements is more fluidic. However, if the center the surgeon uses is owned by someone else, then this becomes a cost barrier. So if the surgeon adds in an additional cost to the patient, then every patient must bear that cost even if the surgeons enhancement rate is 5% to 10%. This additional cost to a patient can present a legal issue when talking about premium lenses with or without astigmatic correction in a Medicare patient. You are essentially overcharging 90% to 95% of your patients if you charge a premium to have enhancements covered as part of the original fee. It is for this reason that in our premium patient population we charge a nominal enhancement fee for use of the laser and the facility. The doctor charges the patient nothing for the enhancement.

We all know the old saying “the evil of good is better.” Trying to make someone 20/happy is what we all want. However, we know that may not be 20/20 in every case. So when patients come in with a less-than-optimal outcome, in their eyes they may not always equate making them better with an enhancement. Sometimes that additional cost will help you help them make the choice that they have a great outcome without the need to risk additional intervention.

Karl G. Stonecipher, MD, is the director of The Laser Center in Greensboro, N.C. Disclosure: No products or companies are mentioned that would require financial disclosure.