One year after CMS ruling, surgeons still learning ins and outs of presbyopic IOLs

Cataract surgeons and industry leaders look back, and ahead, at the impact of the ruling.

William F. Maloney

One year after the Centers for Medicare and Medicaid Services ruled that patients undergoing cataract surgery could pay out of pocket for an “upgrade” to a presbyopia-correcting IOL, experts are still educating themselves on the use and legal aspects of these lenses.

Most agree that this education must continue in order to maintain the expanding adoption rate and the resulting improvement in patient service and physician compensation.

“The main process during the past year has really been to disseminate the information that was delineated in the CMS ruling and to establish certain procedures that are accepted under that ruling. That still is a work in progress, for sure,” William F. Maloney, MD said.

Educating the physician

“It’s a learning process for the doctors to get used to this whole idea,” said Richard L. Lindstrom, MD, Chief Medical Editor of OSN. “The surgeons will have to get educated about the premium channel and these different lenses and the options and how to use them properly.”

Richard L. Lindstrom

Moving from traditional cataract surgery into presbyopia-correcting IOLs requires physicians to learn the strengths and weaknesses of each lens and to connect with each patient about his or her needs, Dr. Maloney said.

He compared the surgeon’s new role to that of an architect, rather than a carpenter. The surgeon must now design the entire procedure and not just execute it, he said.

“It has made our decision-making process for each individual patient much more complicated,” Steven J. Dell, MD, said. “That’s because we have multiple options to offer many of our patients, and we have to get to know their visual demands much more intimately than we did with traditional IOLs.”

Dr. Dell explained that the surgeon must sit down with each patient to discuss his or her preferred zones of vision, which depend on each patient’s lifestyle choices, including participation in sports, reading habits and work requirements.

“These kinds of discussions have become much more important in individualizing the IOL for the particular patient,” Dr. Dell said.

Legal education

“I think the primary change that’s taken place is an overall education process,” said J. Andy Corley, chairman and CEO of eyeonics. “There was quite a bit of confusion and concern among ophthalmologists as they transferred from a Medicare-only practice to a practice that had a significant component of revenue generated privately.”

For physicians who have been reimbursed for cataract surgery by Medicare and insurance systems for much of their careers, the switch to patient compensation was difficult, Mr. Corley said.

“In this industry we’re so used to having a certain code and trying to get insurance to pay for something, it was a really hard transition to get doctors and their staffs to understand that the presbyopic IOLs are an uncovered service and you don’t deal with insurance,” said Jim Denning, CEO of Discover Vision Centers, a chain of eye care offices in the Kansas City area. Mr. Denning was enlisted to answer many practice management questions from physicians after the CMS ruling was announced, according to Mr. Corley.

Alan E. Reider, JD, expressed concern about the lack of government instruction for patient-share billing. He said there is the possibility that a surgeon could charge a patient for a service already covered by Medicare. And in the event of a billing error, he said, there is the possibility that a claim could be brought against a surgeon.

“That’s not the way you want to be educated. You don’t want to be educated through enforcement cases. You want to be educated through policy development and guidelines,” Mr. Reider said. “That at least allows people who want to follow the rules to follow the rules without risk of getting into trouble. There’s still a lot of room for clarification and for guidance here.”

Changing scope

“This is the first good opportunity for the cataract surgeon to be able to charge for [his or her] services in an open market fashion,” Dr. Lindstrom said. He said he expected cataract surgery with presbyopia correction to follow the example of LASIK.

Dr. Lindstrom said practices can differentiate themselves by being high-tech, high-touch or more efficient.

“As ophthalmologists taking care of our senior patients, we’ve almost been forced to focus on efficiency because there was no way to get compensated for high-tech or high-touch,” Dr. Lindstrom said. “Now we can kind of slow down and have a very high-touch, quality environment.”

Mr. Corley said he hoped the value of these procedures would only go up, rather than down, in the future.

“These are elective procedures that take a lifetime of skill and training for the surgeon to deliver, and the patient has a 30- to 50-year benefit,” he said.

IOL Economic Summit will address ethical, business issues of CMS ruling A panel of physicians and administrators, along with legal and industry experts, will convene in Las Vegas on June 9 for the IOL Economic Summit, to be held during OSN Vegas 2006, June 8-10. The IOL Economic Summit will discuss presbyopia-correcting IOLs 1 year after the historic CMS ruling. Hear point-counterpoint discussions on the ethical and business-related issues surrounding putting the ruling into practice. The IOL Economic Summit will include discussion on: Steps CMS took to make the decision What might be the next ruling similar to this in ophthalmology, and medicine? Physician adoption rate Financial impact to surgeon’s bottom line Explaining the cost/benefit to patients Importance of educating your staff Diagnostic testing Patient selection Pros and cons of offering these lenses The IOL Economic Summit will be held Friday, June 9, 2:00-3:15 p.m., at the Venetian Resort Hotel and Casino in Las Vegas. For more information: To register for OSN Vegas 2006, contact Registration Manager at Vindico Medical Education, toll free: 877-307-5225 (U.S. only); 856-994-9400; fax: 856-251-0278; www.OSNSuperSite.com/vegas.

Adopting the method

“Intellectually and emotionally, surgeons have clearly embraced the concept of presbyopia correction,” Dr. Maloney said. “In terms of actually proceeding and performing the surgeries, I think that we’re still in the very early stages.” (See related article, Dr. Maloney’s Lens-Based Refractive Surgery column.)

Adoption rate thus far is in the range of 2% to 5%, with expectations for it to double each year for the next 5 years, Mr. Corley said.

“In the short term, many practices have been slow to adopt presbyopia-correcting IOLs, and that has given an opportunity to those who are early adopters,” John A. Hovanesian, MD, said.

Dr. Lindstrom said he felt all cataract surgeons would eventually adopt the method into their practices. Mr. Denning said that of the surgeons who have already tried it, 30% to 40% have adopted it as a regular part of their practices.

“I think that it will be the rare ophthalmologist who will, 2 or 3 years from now, just say, ‘I won’t do any procedure in the premium channel,’” Dr. Lindstrom said.

Dr. Hovanesian said, “If their patients are aware of what is available, they will either adopt it or they’ll lose patients.”

Patient acceptance

“The next set of hurdles involve properly counseling [patients] to determine what their visual needs are, what they can reasonably expect after surgery, and providing a premium experience for the patient,” Dr. Dell said.

Patients seem to be accepting this opportunity and taking advantage of it if they are financially able, Dr. Maloney said.

“In my experience in my practice, the vast majority of cataract patients are very interested in this and that really surprised me,” Dr. Maloney said.

Dr. Hovanesian said interest in cataract surgery increased after the CMS ruling last year, prompting some patients to inquire about the procedure earlier than they otherwise would have. But he warned that patients’ expectations must be tempered.

“I think that in many ways patient expectations are completely out of control, and many of our patients come to us with completely unrealistic expectations,” Dr. Dell warned. “They may be under the impression that we can give them perfect vision at all distances under all lighting conditions, and no technology can do that at this point.”

Future impact

More perfect technology may not be far off, some said. All of the companies that now make presbyopia-correcting IOLs – Alcon, AMO and eyeonics – are working on advanced technologies and others have lenses in development, encouraged by the CMS decision.

“Prior to the CMS decision, the amount of investment that went into new IOL improvement was relatively scarce,” Mr. Corley said. “Now that the premium channel is available and that lenses can be sold at higher prices, there is a race among all of the industry leaders to produce better and better intraocular lenses that provide more and more patient benefits.”

Dr. Lindstrom said in the next 5 years, when he believes adoption of presbyopia-correcting IOLs may begin to plateau, the next generation of IOLs will come onto the market.

“The capabilities of those lenses will be far greater than what we have today, and our surgeons will be smarter in how they’re used,” Dr. Lindstrom said. “It’s not impossible that we could see this get up into being the most commonly performed treatment for cataract.”

“I think we’ll look back in 10 or 15 years, and this will be a watershed moment when the whole thing started to shift,” Dr. Lindstrom said. “It’s the beginning of a massive change in how we practice as far as taking care of our senior patients.”

Dr. Hovanesian said the CMS ruling has liberated the government to do what it can without overextending itself, so that surgeons can offer their patients the “most exciting technology since the excimer laser,” and patients can demand the highest quality treatment available.

“I see this as a triple-win. It’s a win for the doctor. It’s a win for industry. It’s a win for the patient. It’s pretty hard to beat that,” Dr. Lindstrom said.

For more information:

• William F. Maloney, MD, is head of Eye Surgery Associates of Vista, Calif., and a well-known teacher of cataract and lens-based refractive surgery techniques. He can be reached at 2023 West Vista Way, Suite A, Vista, CA 92083; e-mail: maloneyeye@yahoo.com. In the interest of objectivity, Dr. Maloney has no financial interest in any ophthalmic product and has no financial relationship with any ophthalmic company.
• Richard L. Lindstrom, MD, is the Chief Medical Editor of Ocular Surgery News. He is also in private practice at Minnesota Eye Consultants, 710 E. 24th St., Suite 106, Minneapolis, MN 55404-3810; 612-813-3600; fax: 612-813-3660; e-mail: rllindstrom@mneye.com.
• Steven J. Dell, MD, can be reached at Texan Eye Care, 1700 S. Mopac, Austin, TX 78746; 512-327-5200; fax: 512-327-5200; e-mail: sdell@austin.rr.com. Dr. Dell is a consultant to eyeonics.
• J. Andy Corley, president and CEO of eyeonics, can be reached at 6 Journey, Suite 125, Aliso Viejo, CA 92656; 866-393-6642; fax: 949-716-8362; Web site: www.eyeonics.com; e-mail: jacorley@eyeonics.com.
• Alan E. Reider, JD, can be reached at Arent Fox PLLC, 1050 Connecticut Ave. NW, Washington, DC 20036; 202-857-6462; fax: 202-857-6395; e-mail: reider.alan@arentfox.com.
• Jim Denning can be reached at Discover Vision Centers Corporate Office, 4741 S. Cochise Drive, Independence, MO 64055; 816-478-1230; fax: 816-478-4413.
• John A. Hovanesian, MD, FACS, is a clinical instructor at the UCLA Jules Stein Eye Institute and is in private practice in Laguna Hills, Calif. He can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com. Dr. Hovanesian is a paid consultant for eyeonics. He has no direct financial interest in the products mentioned in this article.

• Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.