OSN Europe: UEMS survey on premium IOLs highlights lack of uniform copayment policies

Copayment rates should take into account that premium procedures involve higher skills, extra work, increased responsibilities and risks for surgeons.

Copayment for cataract surgery with premium IOLs is allowed in half of the 28 European Union member states, but in no case, except Switzerland, is an extra fee allowed to cover the additional work and services provided by surgeons, according to a survey of the European Union of Medical Specialists.

When premium IOLs were introduced about 10 years ago, their use was strictly confined to the private sector. After intense discussion, a more open attitude prevailed in some countries, which allowed the use of these lenses in the public sector, with the extra cost of the lens paid out of pocket by the patient.

“This is the trend, which is likely to increase in future years, but not all countries in Europe are currently accepting this policy,” Marko Hawlina, MD, PhD, past vice president of the Ophthalmology Section of the European Union of Medical Specialists (UEMS), said. “As part of our mission towards uniform health care in Europe, we tested the ground to find out what the situation is, before we come out with proposals for political solutions.”

Copayments for IOLs

The questionnaire submitted to delegates of the 28 EU countries asked whether copayment is allowed and, if so, whether it covers multifocal IOLs, toric IOLs and a fee for the extra work of the surgeon. Another question asked delegates of individual countries about the arguments for adopting or not adopting copayment policies.

Fourteen of the 28 countries do not allow copayment. Eight have introduced it as a general policy over the entire national territory, while four allow it only in private centers that provide national health care services but not in the public sector. Two countries are federal states, where copayment policies have been introduced by some, but not all, regions.

“Countries that deny copayment justify their decision with the principle of equal rights, which constitutes the basis of universal health care. The public sector should provide the same standards of treatment for all and discourage practices that differentiate between the wealthier and the poorer,” Hawlina said.

On the other hand, the argument in favor of copayment policies is based on a different interpretation of equality and the right to free choice.

“Provided that the basic treatment is equally paid for all, patients should be granted the possibility to choose what type of lens they want implanted into their eyes and pay the extra cost out of pocket,” Hawlina said.

The additional workload also played a role in the decision of countries where premium IOLs can be implanted in private centers and patients are allowed to reimburse basic surgery.

“Responders said that public centers might be less under pressure and therefore able to invest more time on individual patients for premium procedures,” Hawlina said.

The UEMS objective is to foster and promote copayment policies and achieve a more uniform introduction of copayment provisions in Europe.

“The current situation results in quite a lot of patients seeking treatment abroad. The right to cross-border health care is granted by a EU directive but generates quite a lot of confusion and eventually introduces a new form of discrimination in this case. Those who can travel abroad have the premium lens implanted and can be reimbursed in their home country for the basic cost of the procedure. Those who cannot afford to travel abroad don’t have the same right at home,” Hawlina said.

An unjustified omission

Responses also showed that, in countries where copayment is allowed, no difference is made between multifocal and toric IOLs. Interestingly, however, none of the countries except one have included an extra fee for the doctor’s work. Coverage is provided as for standard cataract surgery, and the patient pays for the lens.

This is an unjustified omission in the provisions regarding copayment. From preoperative assessment to the surgical procedure to the follow-up, the time and care required to implant a premium lens rather than a standard lens are quantitatively and qualitatively much greater.

Premium IOLs are not a one size fits all, Hawlina said. Choosing the lens that better suits the lifestyle, needs and expectations of individual patients requires a lot of chair time as well as comprehensive objective testing with advanced technological equipment to accurately measure refraction, anterior and posterior corneal curvature, astigmatic axis and preferably OCT. This is a new era of femtosecond laser-assisted cataract surgery and automated axis display within the operating microscopes, in addition to increased standards for premium lens implantation, and this equipment is very costly.

“Surgery requires extra skills and expertise, a perfectly centered capsulorrhexis, and a perfect placing of the lens to avoid poor results and complications. During the follow-up, you may need to see the patients quite often to help them go through the neural adaptation process and potential problems with glare and halos. Everything ends well in most cases, but in a small percentage of unhappy patients, explantation or lens replacement might be needed, especially if the time pressure affected chair time and surgery,” he said.

Although small, this percentage is higher than with monofocal IOLs and exposes the surgeon to an increased risk for legal issues.

“Premium cataract surgery is not just the lens. The form of copayment, where only the lens is allowed to be paid for, only makes the manufacturers happy. Surgeons may not be motivated, as lack of recognition of extra work and instrumentation with increased responsibilities and risks involved might in fact discourage them from implanting premium IOLs if their extra work is not accounted for,” Hawlina said.

Rethinking copayment in terms of premium surgery and premium services rather than merely a premium product is mandatory to protect the rights of both patients and surgeons and promote a technology that has a significant impact on the lifestyle of patients, he said. – by Michela Cimberle

For more information:

Marko Hawlina, MD, PhD, can be reached at Eye Hospital, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; email: marko.hawlina@gmail.com.

Disclosure: Hawlina reports he has no relevant financial disclosures.

Click here to read the publication exclusive, Global Notebook, published in Ocular Surgery News Europe Edition, April 2015.

Copayment rates should take into account that premium procedures involve higher skills, extra work, increased responsibilities and risks for surgeons.

Copayment for cataract surgery with premium IOLs is allowed in half of the 28 European Union member states, but in no case, except Switzerland, is an extra fee allowed to cover the additional work and services provided by surgeons, according to a survey of the European Union of Medical Specialists.

When premium IOLs were introduced about 10 years ago, their use was strictly confined to the private sector. After intense discussion, a more open attitude prevailed in some countries, which allowed the use of these lenses in the public sector, with the extra cost of the lens paid out of pocket by the patient.

“This is the trend, which is likely to increase in future years, but not all countries in Europe are currently accepting this policy,” Marko Hawlina, MD, PhD, past vice president of the Ophthalmology Section of the European Union of Medical Specialists (UEMS), said. “As part of our mission towards uniform health care in Europe, we tested the ground to find out what the situation is, before we come out with proposals for political solutions.”

Copayments for IOLs

The questionnaire submitted to delegates of the 28 EU countries asked whether copayment is allowed and, if so, whether it covers multifocal IOLs, toric IOLs and a fee for the extra work of the surgeon. Another question asked delegates of individual countries about the arguments for adopting or not adopting copayment policies.

Fourteen of the 28 countries do not allow copayment. Eight have introduced it as a general policy over the entire national territory, while four allow it only in private centers that provide national health care services but not in the public sector. Two countries are federal states, where copayment policies have been introduced by some, but not all, regions.

“Countries that deny copayment justify their decision with the principle of equal rights, which constitutes the basis of universal health care. The public sector should provide the same standards of treatment for all and discourage practices that differentiate between the wealthier and the poorer,” Hawlina said.

On the other hand, the argument in favor of copayment policies is based on a different interpretation of equality and the right to free choice.

“Provided that the basic treatment is equally paid for all, patients should be granted the possibility to choose what type of lens they want implanted into their eyes and pay the extra cost out of pocket,” Hawlina said.

The additional workload also played a role in the decision of countries where premium IOLs can be implanted in private centers and patients are allowed to reimburse basic surgery.

“Responders said that public centers might be less under pressure and therefore able to invest more time on individual patients for premium procedures,” Hawlina said.

The UEMS objective is to foster and promote copayment policies and achieve a more uniform introduction of copayment provisions in Europe.

“The current situation results in quite a lot of patients seeking treatment abroad. The right to cross-border health care is granted by a EU directive but generates quite a lot of confusion and eventually introduces a new form of discrimination in this case. Those who can travel abroad have the premium lens implanted and can be reimbursed in their home country for the basic cost of the procedure. Those who cannot afford to travel abroad don’t have the same right at home,” Hawlina said.

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An unjustified omission

Responses also showed that, in countries where copayment is allowed, no difference is made between multifocal and toric IOLs. Interestingly, however, none of the countries except one have included an extra fee for the doctor’s work. Coverage is provided as for standard cataract surgery, and the patient pays for the lens.

This is an unjustified omission in the provisions regarding copayment. From preoperative assessment to the surgical procedure to the follow-up, the time and care required to implant a premium lens rather than a standard lens are quantitatively and qualitatively much greater.

Premium IOLs are not a one size fits all, Hawlina said. Choosing the lens that better suits the lifestyle, needs and expectations of individual patients requires a lot of chair time as well as comprehensive objective testing with advanced technological equipment to accurately measure refraction, anterior and posterior corneal curvature, astigmatic axis and preferably OCT. This is a new era of femtosecond laser-assisted cataract surgery and automated axis display within the operating microscopes, in addition to increased standards for premium lens implantation, and this equipment is very costly.

“Surgery requires extra skills and expertise, a perfectly centered capsulorrhexis, and a perfect placing of the lens to avoid poor results and complications. During the follow-up, you may need to see the patients quite often to help them go through the neural adaptation process and potential problems with glare and halos. Everything ends well in most cases, but in a small percentage of unhappy patients, explantation or lens replacement might be needed, especially if the time pressure affected chair time and surgery,” he said.

Although small, this percentage is higher than with monofocal IOLs and exposes the surgeon to an increased risk for legal issues.

“Premium cataract surgery is not just the lens. The form of copayment, where only the lens is allowed to be paid for, only makes the manufacturers happy. Surgeons may not be motivated, as lack of recognition of extra work and instrumentation with increased responsibilities and risks involved might in fact discourage them from implanting premium IOLs if their extra work is not accounted for,” Hawlina said.

Rethinking copayment in terms of premium surgery and premium services rather than merely a premium product is mandatory to protect the rights of both patients and surgeons and promote a technology that has a significant impact on the lifestyle of patients, he said. – by Michela Cimberle

For more information:

Marko Hawlina, MD, PhD, can be reached at Eye Hospital, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; email: marko.hawlina@gmail.com.

Disclosure: Hawlina reports he has no relevant financial disclosures.

Click here to read the publication exclusive, Global Notebook, published in Ocular Surgery News Europe Edition, April 2015.