Disclosures: Yuen reports he serves as a paid consultant for Johnson & Johnson.
January 08, 2021
3 min read
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Premium IOLs help your patients and your practice

A surgeon explains how patients will benefit visually over the long term while practices offset factors such as Medicare fee cuts.

Disclosures: Yuen reports he serves as a paid consultant for Johnson & Johnson.
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If I implant a monofocal IOL in a cataract surgery patient with significant astigmatism and achieve a plano sphere result, I can pat myself on the back for a perfect surgery, but the patient still will not be able to see without glasses.

Similarly, for patients who are wearing progressive spectacles, a presbyopia-correcting IOL is not only a lifestyle and convenience benefit, but a safety issue. Walking down stairs with a 2.75 D reading add increases the risk for falls, which contribute to hospitalizations, a move to a nursing home or even death.

I do not think it is acceptable to tell patients after surgery, “Oh, I didn’t think you would be interested in paying more for a premium lens.” I educate every patient before surgery about their options, so they can decide for themselves whether they value spectacle independence. I believe this strategy is best for my patients, and it is also an important part of keeping our practices financially healthy over the long term.

Premium IOLs through a reimbursement lens

In 2020, ophthalmology absorbed a 15% cut in reimbursement for cataract surgery. Nationally, overhead in an ophthalmic practice is in the range of 50% to 55%, and in high-cost-of-living areas such as New York, San Francisco, or Hawaii, it can be as high as 70%. The 15% cut comes out of the 30% to 50% of revenue that is left after overhead. That means the current Medicare cuts could represent as much as a 50% reduction in cataract surgery income for surgeons.

Ophthalmology has faced other cuts as well. Several diagnostic tests that used to be billed for each eye (eg, extended ophthalmoscopy, OCT) are now considered bilateral. The trend in reimbursement is clearly downward. At the same time, we have an aging population and growing incidence of age-related eye disease, so the demand for ophthalmic services is high. Throwing in the towel or retiring early is not the answer.

Rather, I think the solution is to diversify, balancing our traditional cataract surgery offerings with other services, from ocular surface disease management to oculoplastics to refractive cataract surgery. I see my role in the practice as one that encompasses not only being a good surgeon, but also demonstrating leadership in keeping the practice viable and sustainable so that we can continue to serve our community and provide our employees with good jobs.

Let’s do the math. A surgeon who performs 100 cataract surgeries with standard monofocal IOLs will have a maximum collection of $55,000, down from $65,000 in 2019. If all those patients who are candidates are offered premium IOLs, the picture starts to change. If just five patients elect bilateral toric IOLs with femtosecond laser surgery, that would represent an extra $10,000 in revenue for the same 100 eyes, not including any presbyopia correction. If 60 of them choose toric or presbyopia-correcting IOLs, you can quickly see how much revenue increases. Not only are we fulfilling our calling of restoring vision, but our years of education and surgical expertise are more appropriately valued, the overhead per case decreases, and the reduction in Medicare fees is less traumatic for the practice.

Presbyopia correction in my practice

Approximately 50% of my cataract patients elect for a presbyopia-correcting IOL. Most patients are unwilling to sacrifice distance vision for improved near vision; they want excellent distance vision with improved continuous range and a bright, crisp image overall. I usually implant a Tecnis Symfony extended depth of focus IOL (Johnson & Johnson Vision) in the first eye. If the patient is completely satisfied, I will implant the same lens in the second eye. If they want stronger near vision, I will take a personalized vision approach, implanting a mid-add multifocal in the second eye.

With this EDOF lens, 92% of the light is transmitted to the retina, providing good contrast acuity. This makes me comfortable that whatever happens to the patient in the future to decrease contrast — whether it is simply older age or the development of glaucoma, age-related macular degeneration or epiretinal membrane — I have given them a lens that will continue to provide the highest possible retinal image quality.

Of course, to get to a presbyopia-correcting IOL rate of 50% or higher, it is essential to perform good biometry. Surgeons need to have topography, OCT or optical biometry, and some way to evaluate and treat the meibomian glands and ocular surface. With these measures, plus consistent patient education, I think you will find that many patients will choose greater spectacle independence.