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"What do you mean I don't have enough astigmatism to have laser cataract surgery, Senator?"
There are many questions in physicians' minds about the application of femtosecond lasers for routine cataract surgery. Among them is the degree of safety added and the amount of cost incurred with these procedures. Another is the reimbursement model. To defray the cost of a $500,000 laser and disposables that cost several hundred dollars per eye, there clearly must be a significant added cost to the patient or third-party payer, but Medicare's rules do not allow us to charge more to complete the steps of cataract surgery, no matter how expensive the "scalpel" we use.
Currently, laser manufacturers are talking about charging patients added fees for astigmatism correction, which the same lasers can also accomplish, while the steps (capsulotomy, lens fragmentation, incisions) that are part and parcel of cataract surgery will not be charged to the patient.
This really makes no sense at all and is just a workaround for a payment system that currently fails to recognize the added value of laser cataract surgery.
What do we do for a patient who has exactly 0.5 D of astigmatism, steep at the horizontal axis where we routinely make our primary incision? After a routine incision, one would anticipate no residual astigmatism. Therefore, the lasers used cannot be justified because there are no additional limbal relaxing incisions to be made. Do we not offer these patients laser cataract surgery because they don't have enough astigmatism?
Healthcare systems have to change in response to changing technology. Data on the benefits of laser cataract surgery is surely to accumulate and create a convincing case for the adoption of this technology. Limiting its use to patients with just the right amount of astigmatism just for reimbursement purposes just isn't a long-term solution.
We as physicians will need to encourage patients to step forward and speak to lawmakers and insist that better technology be made available, even if the costs are out of pocket. This is exactly what happened with presbyopia-correcting implants in 2005, when CMS was forced to recognize that these lenses did more, cost more and could not be provided for in the meager allowance for IOL reimbursement in the cataract surgery facility fee schedule. Medicare's free ruling allowed patients to receive these more modern lenses as an optional, self-pay upgrade from traditional cataract surgery. A similar ruling is needed for laser cataract surgery, distinguishing it as a "refractive cataract procedure" as opposed to a more traditional procedure.