Survey: Femtosecond laser continues integration into premium cataract sector

A growing number of patients are choosing elective lens packages in conjunction with cataract surgery, according to a recent survey, and femtosecond laser plays a significant role in those choices.

Survey respondents used lasers in 27% of all cataract procedures and 55% of premium IOL procedures.

Ophthalmic business consultants Shareef Mahdavi and Matt Jensen hosted a webinar to discuss the spring 2014 user survey on femtosecond laser usage in cataract surgery and advanced diagnostics. Mahdavi is president of SM2 Strategic, and Jensen is CEO of Vance Thompson Vision; both serve as principals of Spectacle Network.

The survey, conducted for the third consecutive year, gathered data from 225 surgeons using 115 lasers across the U.S., a sample representing 35% of all lasers in use during some or all of 2013. Surgeons in the survey performed 166,871 cataract cases, 35,821 of which were done with femtosecond lasers.

According to Daniel S. Durrie, MD, OSN Refractive Surgery Section Editor, surgeons are adopting femtosecond laser technology, premium IOLs and intraoperative wavefront aberrometry to improve outcomes and boost their bottom lines.

 

“We want to use all of the technologies we can because it improves the results and lowers our enhancements, which, therefore, lowers our costs. We make sure that our fees are appropriate for what we’re giving the patients,” Durrie said.

Louis D. “Skip” Nichamin, MD, OSN Cataract Surgery Board Member, noted that at Kiawah Eye 2014, 35% to 40% of attending surgeons expressed interest in adopting femtosecond laser-assisted cataract surgery, up from 5% to 10% just 2 years ago.

“We’re going to see a steady increase in the usage and refinement of this technology in lens-based surgery,” Nichamin said. “I believe that we are truly just scratching the surface, and we will see what will begin to be an exponential adoption.”

 

Robert P. Rivera, MD, said that refractive cataract surgery is becoming the procedure of choice in terms of postoperative outcomes.

“I firmly believe that combining the refractive approach with cataract surgery is going to be the absolute best … when we’re looking at outcomes of things like this,” Rivera said.

Mitchell A. Jackson, MD, OSN Refractive Surgery Board Member, said patient expectations are rising, especially among those who have had previous laser refractive surgery.

“Patients want similar type of vision they had with their LASIK … so they’re going to expect that [LASIK] type of vision [after cataract surgery],” Jackson said. “Coming into it, everybody has an expectation. You have to set expectations and make sure you meet expectations.”

Surgical methods and lens types

The average surgeon performed 742 cataract cases, according to the survey. Overall, 79% of all cataract cases involved monofocal IOLs and 21% involved premium IOLs (11% presbyopic IOLs and 10% toric IOLs). The 21% penetration of premium IOLs in the overall survey population was slightly higher than the national average of 15%, Mahdavi said.

“For those of you trying to understand what’s a reasonable expectation for what percentage of your cataract cases would be done using a laser, it has been in that 25% to 30% range now for the last couple of years and where it seems to be settling out,” he said. “And barring any major disruptive shift in the marketplace, where either revenue assumptions change or cost assumptions change, you would expect it to stay at that level.”

Sixty-seven percent of surgeons said the number of patients choosing an elective lens package increased since they started offering laser cataract surgery. The number of patients choosing elective lens packages stayed the same for 30% of surgeons and decreased for 3%, Mahdavi said.

“The trend we observed is that consumer willingness to pay out of pocket is increasing. There is a patient desire for refractive benefits above traditional cataract surgery in seeing better without glasses of some form,” he said. “That bodes well for the future of this category.”

 

Among laser cataract procedures, 57% involved monofocal IOLs, 19% involved toric IOLs and 24% involved presbyopic IOLs, Mahdavi said. In 2011, 43% of laser cataract procedures involved monofocal IOLs, 20% involved toric IOLs and 37% involved presbyopic IOLs. In 2012, 48% of laser procedures involved monofocal IOLs, 20% involved toric IOLs and 32% involved presbyopic IOLs.

“This is not the case that presbyopic or toric lens use is going down. … It’s simply that when viewed as a mix of a fixed pie, we see the monofocal usage increasing to 57%, up from 43% several years ago,” Mahdavi said.

Durrie said that, in some cases, monofocal lenses can play a role in presbyopia correction, for example, to achieve blended vision or monovision.

“In our practice we use all three lenses in patients whom we’re using femtosecond lasers for,” Durrie said.

Rivera said that many of his patients who undergo femtosecond laser cataract surgery still opt for monofocal IOLs.

“What the laser has allowed us to do is see that its acceptance as a very integral part of the refractive cataract procedure has climbed significantly in that monofocal group,” Rivera said.

Nichamin said that the survey results on lens types were similar to totals accounted for in his own practice.

“My general experience and numbers are in line with these survey data,” Nichamin said. “I use slightly fewer torics than what was listed because I’m just more of a limbal relaxing incision-based surgeon. But we have just folded in, if you will, laser technology into all of our upgraded options.”

Jackson said that a majority of the procedures performed in his practice involve patients who previously had laser refractive surgery. Therefore, the percentage of procedures in his practice involving femtosecond laser and ORA (WaveTec Vision) exceeds the averages shown in the study, he said.

 

“I’d say we’re approaching a 90% femtosecond uptake. In terms of advanced lenses, we’re probably at about a 50% to 60% uptake,” Jackson said. “With ORA, again, we’re about a 50% to 60% uptake. Remember, my practice is somewhat skewed, but I’d say about 40% to 50% are post-refractive surgery patients.”

Rivera also said his practice uses premium lenses more often than the survey respondents.

“Those numbers are probably similar to ours, but I think we’re a little bit higher with respect to the premium lenses overall that patients are selecting,” he said. “I’d say our torics are probably more along 15% to 20% and presbyopics are maybe another 15% to 20% as well.”

Intraoperative aberrometry

Survey results showed that 66% of all surgeons who used lasers also used intraoperative aberrometry; 88% of surgeons who used intraoperative aberrometry also used laser cataract technology.

Thirty-six percent of all cataract cases and 65% of laser cataract cases involved intraoperative aberrometry.

Seventy-six percent of intraoperative aberrometry users had separate fees for the diagnostic method in cases in which the patient did not want or need a refractive package, Mahdavi said.

Thirteen percent of surgeons said intraoperative aberrometry helped them avoid refractive surprises several times per day or week. Intraoperative aberrometry helped prevent refractive surprises at least once weekly for 42%, occasionally for 35% and rarely for 10%.

Ninety-seven percent of surgeons said intraoperative aberrometry somewhat or significantly improved surgical outcomes. Three percent of surgeons said it did not affect their outcomes.

According to Durrie, improved outcomes justify the investment in intraoperative aberrometry.

Fees and break-even threshold

The survey asked surgeons to describe their fee schedules for refractive cataract surgery. Analysis of the data showed that surgeons tend to promote their offering by the type of lens implant used along with other surgical tools, including the laser, optical coherence tomography and wavefront aberrometry. Respondents’ fees for monofocal lens packages increased an average of $999, toric IOL packages $557 and presbyopic IOL packages $443; the average fee increase overall was $782. Average fee increases were $945 in 2011 and $856 in 2012.

“It would be natural to see some type of pricing contraction as more and more people get into the marketplace and start offering the procedure,” Mahdavi said.

Using data from the survey, a pro forma analysis determined that a practice with a laser would need to perform 1,269 laser cases over 5 years to break even or recover its investment in a laser. That translated to 254 cases per year, or 21 cases per month. The analysis incorporates actuals as reported on incremental fees as well as costs associated with use of the laser. Comparable numbers from 2012 and 2011 over a 5-year period were 1,134 cases (19 per month) and 1,364 cases (23 per month), respectively.

“The break-even point has remained fairly consistent over the past 3 years. Assuming a 30% laser penetration of all cases, practices doing at least 900 to 1,000 total cataract cases should have sufficient volume to justify getting the technology,” Mahdavi said.

Among 65 fixed-location centers, 79% were at break-even or better, 18% did not reach break-even and 3% approached break-even status.

Average laser volume was 33 cases per month; 17 centers performed 19 to 40 cases per month.

“There is significant contrast with the exact same chart from last year, when the average laser volume was 57 cases per month,” Mahdavi said. “That was influenced by data in last year’s survey of some ultra-high-volume laser centers that were using the technology.”

Patients who pay out of pocket are most likely to undergo laser refractive cataract surgery, Durrie said.

“They’re paying out of pocket in three areas,” he said. “No. 1, if they don’t have a billable cataract, they’re paying out of pocket because this is a refractive lens exchange. No. 2, they’re paying out of pocket because we’re using a toric lens. And No. 3, they’re paying out of pocket because we’re using a presbyopia-correcting IOL. So, those three areas are where femtosecond lasers are going to be used.”

Jackson shared a similar observation.

“As the reimbursements continue to decline, we as surgeons have the pressures of maintaining advanced technologies to achieve the best outcomes for our patients,” Jackson said. “The good news is that there have been Centers for Medicare and Medicaid Services rulings allowing to charge patients under an appropriate advanced beneficiary notice for these advanced technologies in terms of astigmatism management and/or the digital imaging associated with such technologies.”

Branding and patient education

As the refractive cataract surgery market grows, clinicians and practice administrators are striving to properly label the procedure and inform patients about it.

Preferred names cited by respondents included “laser-assisted cataract surgery,” “laser cataract surgery,” “refractive laser-assisted cataract surgery (ReLACS),” “refractive cataract surgery,” “laser refractive cataract surgery” and “blade-free cataract surgery.”

“You can see that when asked what we call it at the point of service, we’re all over the board as an industry,” Jensen said.

Jackson said that his practice offers patients three treatment options: phacoemulsification with a basic lens, “driving vision” for astigmatism and “forever young vision” for presbyopia.

“With the forever young option and with the driving vision option, they’re getting WaveTec ORA, femtosecond Lensar, as well as a Tecnis toric lens (Abbott Medical Optics) or Crystalens (Bausch + Lomb)/Trulign (Bausch + Lomb)/Tecnis multifocal lens and/or limbal relaxing/astigmatism incision. But all that medical terminology, I never mention. I am offering driving vision or forever young vision. That’s all I tell them,” Jackson said. “The surgical coordinators review the details further with the patients when advance beneficiary notices are signed and the surgery is actually scheduled.”

A majority of respondents said the surgeon is responsible for educating patients about laser cataract surgery. A high percentage also said the surgery coordinator and technician are responsible for that task.

“As we get further and further back in the customer experience, from the optometrist who might do the pre-work or the phones or the front desk, very little communication is taking place there about this exciting technology,” Jensen said.

Nichamin said he expects responsibility for educating patients to be shared evenly in his practice.

“I can’t say that, in my practice, I’m solely responsible for that process. Ultimately, the decision comes down to the patient and I conferring, but I think we’ll more and more become more evenly distributed over the entire staff and practice as to who educates and communicates this option to the prospective patient,” Nichamin said.

According to Rivera, the surgeon should be most responsible for patient education.

“I firmly believe that the message coming from the surgeon trumps all other messages that the patient may hear throughout the course of their visit,” he said. “The surgeon really is the one that carries the authority that the patient seeks in terms of giving an opinion as to what the best procedure is.”

Results showed a few discrepancies between surgeons’ and patients’ opinions (collected in a separate survey of consumers) on the best reason for paying more for quality vision at any distance. For example, 70% of patients vs. 56% of surgeons said the best reason was that vision is very important. Also, 24% of patients vs. 55% of surgeons said an active lifestyle was the best reason, according to Jensen.

“[We] are still trying to find our way as an industry with how we properly communicate the benefits of this technology and the advanced diagnostics that couple alongside of it for patients’ best benefit in the practice,” he said.

In addition, 37% of patients and 27% of surgeons said safety was the most important reason for paying more for quality vision at any distance.

“Usually, safety, when it comes to surgery, is paramount to the patient,” Nichamin said. “I’m not quite sure what to make of it other than the fact that just the term ‘laser’ carries a lot of import with patients and that at this point there may be some superficial glamour to the procedure. Frankly, we have not yet demonstrated through careful clinical study that there is, indeed, that much greater safety and efficacy.” – by Matt Hasson