No fees paid after initial surgery
Eric D. Donnenfeld
Patients who request refractive cornea/cataract surgery overwhelmingly
have a specific goal of being less dependent on or eliminating their need to
wear glasses for visual rehabilitation. As part of the informed consent
process, I tell every patient considering surgery that there is a possibility
they will require additional procedures to achieve their refractive goals, and
I will give them a percentage chance, based on my experience, that this may be
Despite this education, the majority of patients who do not achieve
their desired refractive outcome are disappointed and at some level view their
procedure as having been unsuccessful and hold the surgeon responsible. These
are the most important patients refractive surgeons need to make happy to have
a successful refractive practice. They need to be re-educated, and the
enhancement procedure should be performed as soon as possible. The patients
should never feel abandoned, and in my experience, asking these patients for
additional funds for a secondary procedure is a guarantee that I will take a
patient who is by definition unhappy and make them more discontented.
Bundling my refractive enhancements into the cost of the primary
procedure has eliminated this problem and a potential barrier to the
patients final visual rehabilitation, which is my primary goal. I apply
this philosophy to every patient in my practice, even the refractive outliers
who have an overwhelmingly high likelihood of requiring additional surgery. In
these rare cases, I inform the patient they will need two procedures and I
charge the patient for both of the surgeries before the first procedure. If
they do not require a second procedure, I return the cost of the second
procedure. In my experience, refractive patients have specific expectations and
exceeding these expectations is my goal as a refractive surgeon. Asking the
unhappy patient who requires a surgical enhancement for additional fees should
not be a barrier to achieving the patients refractive goal.
Eric D. Donnenfeld, MD, is an OSN Cornea/External Disease
Editorial Board Member. Disclosure: No products or companies are mentioned that
would require financial disclosure.
Fee helps to cover unparalleled refractive outcomes
Thomas W. Samuelson
One of the distinct advantages of ophthalmic surgery in the post-excimer
era is the vast array of technologies available to enhance refractive outcomes.
I am constantly reassuring patients that, with rare exception, we have the
tools to improve on the already stellar outcomes of modern cataract surgery.
Our practice, Minnesota Eye Consultants, has five excimer lasers at
offices scattered throughout the Minneapolis-St. Paul metro area available to
fine-tune our refractive outcomes after cataract surgery. Whether or not I
charge a fee for excimer refinement depends largely on the reason an
enhancement was necessary in the first place. Much of the time, the patient is
aware that a goal of emmetropia may be a two-step process. For example, for a
patient who desires a multifocal IOL but has significant corneal astigmatism, I
thoroughly explain that a planned two-stage approach will be needed. The first
stage is meticulous phacoemulsification with multifocal IOL implantation, while
the second step is excimer enhancement with either iLASIK (Abbott Medical
Optics) or PRK. I generally prefer this approach over a manual limbal relaxing
incision approach. We also have a LenSx femtosecond laser (Alcon). With this
new technology, we may be able to accomplish the desired result in a single
Whether or not femtosecond laser-assisted astigmatic keratotomy during
cataract surgery can deliver results comparable to secondary excimer
enhancements remains to be seen. Yet, each method provides a wonderful strategy
to improve our refractive outcomes in cataract surgery. Do I charge for this
service? Yes, with exception for unusual circumstances for example,
biometry error I charge a fee for the incredible technology that allows
for unparalleled refractive outcomes.
Thomas W. Samuelson, MD, is OSN Glaucoma Section Editor.
Disclosure: Dr. Samuelson is a consultant to AMO and Alcon Surgical.
Risk of overcharging most patients
Karl G. Stonecipher
After many years of refractive surgery and refractive cataract surgery,
we have been back and forth on the issue of charging for enhancements. The
bottom line is experience means you have done it wrong before and will do it
wrong again if you continue to operate.
What I mean by that is, this varies from surgeon to surgeon based on
laser vision correction or refractive cataract surgery. First, with laser
vision correction, the industry has essentially established free enhancements
as the standard of care, and the debate seems to revolve around a
lifetime commitment. Typically, the debate is whether it is the
lifetime of the surgeon, the patient or the company. Our current laser vision
correction policy is enhancements are free, and we offer a lifetime
With refractive cataract surgery, for most surgeons this can present a
logistics challenge. Who owns the laser? If it is the surgeon, then free
enhancements is more fluidic. However, if the center the surgeon uses is owned
by someone else, then this becomes a cost barrier. So if the surgeon adds in an
additional cost to the patient, then every patient must bear that cost even if
the surgeons enhancement rate is 5% to 10%. This additional cost to a patient
can present a legal issue when talking about premium lenses with or without
astigmatic correction in a Medicare patient. You are essentially overcharging
90% to 95% of your patients if you charge a premium to have enhancements
covered as part of the original fee. It is for this reason that in our premium
patient population we charge a nominal enhancement fee for use of the laser and
the facility. The doctor charges the patient nothing for the enhancement.
We all know the old saying the evil of good is better.
Trying to make someone 20/happy is what we all want. However, we know that may
not be 20/20 in every case. So when patients come in with a less-than-optimal
outcome, in their eyes they may not always equate making them better with an
enhancement. Sometimes that additional cost will help you help them make the
choice that they have a great outcome without the need to risk additional
Karl G. Stonecipher, MD, is the director of The Laser Center
in Greensboro, N.C. Disclosure: No products or companies are mentioned that
would require financial disclosure.