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


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

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