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Lacs. od cme. september 18, 2011 (1)
 

Lacs. od cme. september 18, 2011 (1)

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    Lacs. od cme. september 18, 2011 (1) Lacs. od cme. september 18, 2011 (1) Presentation Transcript

    • Laser Assisted Cataract Surgery
      J. Alberto Martinez, M.D.
      Visionary Ophthalmology
      September 18, 2011
    • OUTLINE
      LACS technique
      Who is a good candidate for LACS?
      Getting paid for LACS
      Is LACS cost effective for patient and doctor?
      Who is operating the laser? Implications
      Ethical Considerations
    • Landmark Events in Cataract Surgery
      Intraocular lenses
      Phacoemulsification
      femtosecond Assisted Cataract
      Surgery?
    • Current limitations of manual cataract surgery
      Visual Outcomes: Distance accuracy 1/2 of that achieved with LASIK
      Unpredictable astigmatism correction
      Effective lens power IOL-capsulorhexis
      Safety: 10x more complications than LASIK
      Ultrasound complications (endothelial cell loss)
    • LensX Animation
    • Anterior Capsulotomy
    • Lens Fragmentation
    • Lens Aspiration
    • Why jump into LACS?
      Mounting evidence of better efficacy and safety from day one
      IOLs and phaco took years to become safe and effective
      LACS learning curve is very short: “like going from analog to digital”
      Better for hypermature lenses, weak zonules, endothelial dystrophies
      Downsides: Increased cost and time
    • LACS: Patients Perspective
      Add BLADELESS to needleless (topical) stitchless (clear cornea, self sealing)
      True laser cataract surgery
      Improved predictability
      Improved safety
      Latest technology
      More predictable outcomes/quality of life
      Patient confidence
    • Medical Coverage Advisory Committee
      Reviews quality of the the evidence about evidence of a procedure
      Explores many sources of evidence
      Is routine use in clinical practice
      Bias?
      Is there a need and what is the size of the healthcare benefit?
      Should we go with it, or should we wait?
    • Medicare Reimbursement Realities
      Work: pre-op, intra-op and post-op
      Takes into account only skin to skin
      Covered: incision, capsulorhexis, fragmentation
      Cannot bill for anything else
      Can bill for: astigmatism
      Long term reimbursement: quality, outcomes, efficiencies
      Based on QUALITY and EFFICIENCY
      BUDGET neutral (no more money into the system)
    • Medicare reimbursement realities
      Somebody gets a bonus? Somebody else gets a reduction ( to maintain neutrality)
      CE is the most successful procedure
      We are in the process of evaluating quality
      Summary: cannot bill for anything COVERED UNDER MEDICARE
      Careful word choice: quicker? (less time, less reimbursement) easier? (why pay more?) these words jeopardize reimbursement
    • Practice Management Considerations
      Where will the laser be used?: critical. Enormous implications
      ASC?: Better (have a relationship with CMS)
      Patients’ expectations? (no glasses, does not care either way)
      For covered procedures: must follow some rules
      Covered: CE and IOL, physician: CE
      Non-covered: deluxe IOL, refractive care (by MD)
    • Practice Management Considerations
      Covered: exam (no mater how long is it), measurement of eye, surgery (incision, capsulorhexis, phaco, IOL)
      Endothelial cell photography? Yes! For pre-op evaluation
      Facility fee: not included: premium IOL, astigmatism
      Astigmatism correction (refractive keratoplasty) considered cosmetic
      Not covered: refraction, tests for ametropia, screening, refractive surgery, IOL upgrade
    • Astigmatism
      Iatrogenic IS covered LRI, wedge, etc
      Fee must be a number that can be defended
      List of tasks (refraction, topo, pachy, wavefront, LRI, enhancement) needed to correct astigmatism
      Contingency for enhancements
      Assign fee (need to be defensible, justifiable)
    • Controversies
      Is CE with FS safer/better
      Is Astigmatism correction with FS safer/better
      FS: expensive, slower, ASC only can charge for refractive surgery
    • Discussion on Reimbursement
      Is it a good result that the patient ends up wearing glasses?
      Should we pursue emmetropia?
      Elective: refractive (no glasses)
      Patients have decided that price for getting rid of glasses is about $2000 +/-
      If patient is happy with glasses, you can’t charge
    • Financial Viability
      Pros:
      Will it happen? Yes, we are convinced it will become a standard
      Break-even: 15 cases/month
      Open the ability to bring other providers to Fempto facility?
    • Financial Viability
      Cons:
      Emotional. Moving cheese for staff
      Some physicians reluctant
      Cost
      Change in flow (slow down things)
      Cannibalize premium IOLs
      Projected rates of conversion: unclear
    • Positioning (S. Lane)
      Educate ALL patients — even non-candidates
      Choice for all patients with pre-existing astigmatism (desire only distance or both)
      Happy patients? Treat to within 0.5 D of astigmatism
    • Overhead at the ASC
      Increase volume?
      Increase overhead?
      Decrease premium IOL conversion?
      Increase for astigmatism conversion?
      Increase bottom line?
    • Marketing Expenditures
      PR
      Educational materials
      Careful about making false claims
      Under promise/over deliver
    • Why small practices will not be able to do it alone and what can be done
      If alone: band together, talk about it, get people thinking about it)
      Practice without walls
      Must have enough patients!
      Could one ophthalmologist run the femto while the other does the phaco?
      Cataract and refractive surgeons should partner
      Must have a refractive mindset
      Bottom line: need Vision and Business expertise
      Total expenditure from scratch: 1.5 to 2 million dollars!
    • Why patients will pay (Lindstrom)
      Cataract surgery market is growing
      Want to get rid of your glasses? 50% yes
      Want to pay additional fees? 50% yes
      Why is conversion low? Need better refractive outcomes: < 0.5 D astigmatism
      Need to get people off glasses!
    • How are we going to pay for? ( Lindstrom)
      Refractive surgery
      Want to get rid of glasses:
      How much: price similar to LASIK
      Doctors debate, patients decide
      He feels is viable
    • Why not cost effective ( Steve Safran)
      Not cost effective
    • It will not work? ( S. Safran)
      Not cost effective
      Concerns: waiting time for acutal removal of lens material: antigen sensitizing more CME second eye?
      Inability to cut through dense lenses
      An very expensive tool to do a simple task (capsulorhexis)
    • Who is not a candidate?
      Does not dilate past 6.5 mm
      Retinal and optic nerve disease: h/o AION
      Advanced glaucoma w/ VF loss
      Effects of IOP elevation during docking?
      Fuch’s/ corneal edema
      Not a problem if one can visualize iris detail
      AN ADVANTAGE with Fuch’s (easier capsulorhexis), reduction in endothelial cell loss
    • Relative contraindications
      Inability to dock:
      Corneal surface irreg, conjuntivochalasis, trabec bleb, unusual orbital anatomy (small, deep, excess retropulsion),
      agitated patients
      Poor dilation
    • Not So Good Candidates
      Small ( not large pterygia) ok
      <6.0 mm pupil
      Posterior synechia
      Subluxated lens
      Black cataracts (absorb the energy)
      Too small palpebral fissures
      IN SUM: applicable to most patients
    • Unmet need: Astigmatic correction
      Lasik has set a higher standard for Astigmatic correction
      53% of patients > 0.75 D astigmatism ( warren Hill)
      Vast majority of surgeons feel this astigmatism should be corrected
    • IDEAL PROCEDURE FOR ASTIG
      CHEAP, REPRODUCIBLE, accurate easy to do
      LASIK: the best, but: a separate surgery
      TORIC IOL: staar vs. acrysoft
      Toric plus LRI? Effective
      Need perfect axis placement
    • femtoSECOND LRI
      Automated
      They are an art, unpredictable in younger patients,, need age-based nomogram
      Intra-operative aberrometer helpful
      femtosecond more accurate than manual
      Manual LRI are not as reproducible. femto LRI will allow for better studies and increase the reproducibility of the procedure
    • HOW I HAVE SET UP MY FLOW. STEPHEN LANE
      Where place the laser: Best outside OR
      Inside ASC firewall, not in the OR
      Right-size the room (10X10 space)
      Clean, not sterile room
      Took a pre-op bay to place the Laser
      Minor construction
      No transfer of patients from one bed to another
    • Who should operate the femto? (S. Safran)
      OD? No? surgery be done by surgeons
      OK technician assisted with MD present
      Must avoid delays between femto and phaco
      Recc two MD.s one for femto, one for phaco
      Dr. Lane: OD’s should be operators!
      Kentucky and Oklahoma allow use of lasers by OD’s
      Not really going inside the eye. (bladeless)
    • Who should operate the fempto? a technician (Dr UY)
      5 reasons for a technician
      Computer controlled, automated
      Docking not as hard as phaco
      Imaging easy to operate
      Low risk, not as invasive
      Technician cheaper need back up
      Increase utilization of femto
      Medico-legal. Who is responsible
    • Ethical Considerations/ John Banja
      Lack of clinical freedom. If I want to use the femto because is clinically better but I don’t get paid, what to do?
      What if is indicated, you don’t do it, get into trouble and lawyer says why didn’t you?
      Once data available that clearly shows femto is better, should non-femto surgeons refer to femto surgeon?