Why Aren't Surgery Centers Buying Femtosecond Lasers?
Many cataract surgeons believe the new femtosecond laser could revolutionize cataract surgery, but very few of the machines, which would usually be purchased by ambulatory surgery centers, have been sold. The reason for this weak demand, cataract surgeons say, is more complicated than just the eye-popping price tag of the machine, at roughly half a million dollars.
Kerry Solomon, MD, a cataract surgeon at Physicians' Eye Surgery Center in Charleston, S.C., recently bought Alcon's LenSx femtosecond laser, which he says was launched some time in the early spring. "This device is a breakthrough for cataract patients on par with LASIK," he says. But Dr. Solomon concedes that at last count, only 10-14 LenSx units had been sold, and he can name just about every physician who bought one.
Many in the cataract world are fascinated with this new device. Mark Packer, MD, cataract surgeon at Drs. Fine, Hoffman & Packer in Eugene, Ore., says he plans to acquire LensAR's version of the femtosecond laser, a similarly expensive piece of technology has received FDA approval. "The femtosecond laser could change the way we do things in a major way," Dr. Packer says. "It could produce better outcomes, especially in terms of not needing glasses after cataract surgery." But he concedes many obstacles have to be cleared before femtosecond takes hold of the market. The chief problem, he says, is, "How do you pay for it?"
Extra costs would have to be picked up by ASCs
In addition to the steep sales price, Dr. Packer says manufacturers will probably charge a per-click fee, perhaps in the range of $200-$400, each time the machine is used. Buyers of the device typically won't be able to raise charges to cover these steep costs because the vast majority of cataract patients are under Medicare, which pays a set amount and won't allow providers to charge patients extra in many cases. This means providers using femtosecond would have to carefully select patients, based on ability to pay.
Since most cataract surgery in the United States is done in ASCs, cataract surgeons will be asking their surgery centers to buy this expensive technology for them, says R. Bruce Wallace III, MD, a cataract surgeon who is president of the Outpatient Ophthalmic Surgery Society, which represents surgeons who work in ophthalmic ASCs. "The ASC would have to purchase the femtosecond on behalf of its cataract surgeons," he says, but he adds, "It doesn't make a lot of sense to buy one."
Dr. Wallace, medical director of Wallace Eye Surgery in Alexandria, La., says he may eventually buy one, but he is not in a hurry. "There may not be a lot to be gained by being an early adopter of the femtosecond," he says. "The technology will progress. The first piece of equipment out there may be limited, compared with the devices currently under investigation."
In addition to LenSx and LensAR, OptiMedica and Technolas Perfect Vision are planning their own versions of the femtosecond, he says. "This may be a case of the industry driving the doctors to buy new technology, instead of doctors going out and demanding a new product," Dr. Wallace says. He questions the need for new technology right now. While the femtosecond is supposed to improve surgical outcomes, "results of cataract surgery have been improving and are already very good," he says.
However, Dr. Wallace also recognizes that major technological shifts aren't totally driven by provider demand. "Over the years, I've learned that in the long run, new technology wins," he says. "When phacoemulsification was introduced, for example, a lot of surgeons said, 'I don't need it,' but they migrated to it, all the same. The same phenomenon could happen here."
Dr. Wallace also raises a perplexing irony about the new device. The femtosecond laser creates very precise incisions, which the surgeon then opens very quickly with just a blunt blade, thus allowing the surgeon can make very accurate incisions in less time. Dr. Wallace says this advantage would be most useful for the least efficient cataract surgeons –– the surgeons who are least able to afford this expensive machine. Meanwhile, the most efficient surgeons, who need it the least, are more likely to have the money for fork over for it, he says.
Changes in surgery center flow
Dr. Packer says another problem slowing physician acceptance of the femtosecond has to do with patient flow and ASC architecture. Femtosecond is used on patients before they enter the OR. The machine typically stands outside the OR in new space, which might be hard to find in a cramped facility, he says.
Also, while the femtosecond allows the surgeon to work faster in the OR, it does add a new step to the process, Dr. Wallace says. "The additional step is inefficient," he says. "It's going to slow everything down in the ASC."
Dr. Solomon, who actually uses the femtosecond, disagrees that it is less efficient. "While the overall time for the patient is longer than regular cataract surgery, time in the OR is shorter," he says. An assistant can operate the femtosecond laser. He adds, however, that because of the extra step, femtosecond cases have to be staggered on the OR schedule, with one such case for every 3-4 regular cataract cases.
How it could be made affordable
Putting aside all the other issues about the femtosecond, cost still looms large. Dr. Packer says Medicare won't let providers charge extra for this new technology, except in one important instance. Medicare allows extra charges for cataract patients when premium intraocular lenses are inserted, so if the femtosecond is used in conjunction with premium IOL insertion, Dr. Packer says femtosecond providers would be able to cover their costs.
Instead of charging $2,000 an eye for the premium IOL, as cataract surgeons now generally do, Dr. Packer says they might raise the charge to $3,000 for a premium IOL plus femtosecond. "This can be justified because the femtosecond would reduce the chance of a miss in the refractive outcome, which is paramount to achieving independence from glasses," he says.
However, this loophole of a sort means femtosecond's costs could only be justified for cataract patients getting premium IOLs. "Medicare cataract patients who only want the femtosecond laser and no premium IOLs could not be charged extra," Dr. Packer says. The obvious solution, he says, is to convince CMS to carve out the same exception for femtosecond that it has made for premium IOLs. But he concedes it's not clear whether CMS is prepared to do that.
All in all, Dr. Packer thinks femtosecond could afford a brighter future for cataract surgery. If providers are allowed to charge more for the femtosecond, the new technology could save the specialty from the crippling reimbursement cuts it has undergone in recent years. "It surprises me that cataract surgeons are not jumping on the opportunity in a bigger way," Dr. Packer says. "In a future of diminished Medicare reimbursements for ophthalmology, it may turn out that the femtosecond is the saving grace."
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