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The era of denial: Why are so many patients delaying care?
New technologies are useful for patients who may put off their cataract surgery.
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With a larger number of people living longer, it is no surprise to see a similar rise in the number of patients having cataract surgery — currently around 3.3 million per year, which is expected to grow to nearly 5 million by 2030. And with one of the most historic presidential elections finally serving up the next U.S. president, many of our patients fear what lies ahead for their health care needs. At least currently, our patients are about to go through another open enrollment associated with the Affordable Care Act, aka Obamacare, by year end. As premium refractive cataract surgeons, we have experienced high deductibles for most of our patients and our own family coverage, and these high deductibles are expected to go even higher as we enter 2017. What really happened as a result of this act was the generation of a new trend in which patients are delaying their health care in what I call the “era of denial.”
Patient protection and Affordable Care Act
We all are very familiar with the federal statute enacted by President Barack Obama on March 23, 2010: It was intended to increase health insurance quality and affordability, lower the uninsured rate by expanding insurance coverage to accept all applicants through insurance exchanges, and reduce costs of health care. So far, many opponents of the ACA have pronounced it as a failure, with some of the large insurers already dropping out of the exchanges. President-elect Donald Trump has already announced that in his first 100 days in office he will attempt to have the ACA repealed.
Personally, I try to stay clear of all politics, but I am in agreement that the ACA has failed my patients in that many are delaying their health care needs due to the large deductibles that have to be met before coverage is effective. My typical cataract patient who is not seeking a premium IOL is no longer a LOCS III stage 2 or 3 cataract but on average LOCS III stage 5 or 6 cataract. Patients appear to be waiting longer to have their cataracts removed compared with before the time the ACA was enacted and implemented. I call these patients who procrastinate on their own health care as “ACA patients,” many of whom not only delay cataract removal but may also need cardiac clearance above and beyond the medical clearance for cataract surgery, all due to delaying care beyond their eye needs.
Technology to the rescue with ACA patients
The good news is I can demonstrate to patients objective assessment of the cataract stage using my AcuTarget HD (AcuFocus). The AcuTarget HD, through double-pass retinal imaging of a point source, can effectively identify lens changes through objective scatter index (OSI) scores highly correlated to the LOCS III staging of cataract severity. And due to the OSI correlation, I have personally seen most of my patients, especially this year, coming with OSI scores correlating to the later LOCS III cataract staging. And the scary part of these ACA patients is that most of them are still driving daily with best corrected visual acuities of 20/80 or worse.
In terms of how to deal with these denser cataracts, I am increasing my femtosecond utilization to help efficiently fragment the nuclei to lower my overall phacoemulsification times, as has been published. Personally, I use the Lensar platform, which through its augmented reality cataract density imaging (CDI) can identify the category and morphology of endonuclear, epinuclear and cortical structures within the cataract. This advantage enables preprogrammed surgeon-customized fragmentation patterns based on the LOCS III categories of cataract density, and it allows the ability to restrict the fragmentation treatment to the nucleus itself, which ultimately lowers unnecessary laser energy being delivered to the eye. Utilizing the Lensar fragmentation CDI advantage has also effectively lowered my effective phacoemulsification times in these denser cataracts of this subgroup of ACA patients. The timing of these technological advances has come at a very opportune time when patients are delaying their own cataract care.
Despite the technological advances, I am hoping that the ACA problem is solved soon and patients get back to being patients desiring earlier treatment for themselves. This roller coaster of health care in our country, in my opinion, has not really helped patients in the end; despite gaining health insurance coverage, these ACA patients just never use it until it is too late.
- References:
- Artal P, et al. PLoS One. 6(2): 2011;doi:10.1371/journal.pone.0016823.
- Galliot F, et al. J Refract Surg. 2016;doi:10.3928/1081597X-20151222-02.
- Harmon D. Ophthalmic Market Perspectives. June 16, 2010.
- Mayer WJ, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2013.09.017.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Disclosure: Jackson reports he is a consultant for AcuFocus and Lensar.