As we discuss in the cover story in this issue of Ocular Surgery News, glaucoma is becoming a more surgical disease, not just because of the new LiGHT study data on the value of primary selective laser trabeculoplasty, but because of the proliferation of drug delivery methods and MIGS procedures being performed by both glaucoma specialists and general ophthalmologists.
These forces are already beginning to influence our specialty in the following three ways:
1. Fewer new drugs. With the cost of developing a new drug product category exceeding $1 billion in the U.S., drug makers already face significant headwinds in competing for first-line therapy with generic latanoprost at just a few dollars a bottle. Latanoprost has its own shortcomings, to be sure. Coming from a variety of generic manufacturers, its preservative concentration is impossible to predict or control. We know this has a meaningful, long-term effect on the ocular surface with so many glaucoma patients developing intractable “dry eye,” which is actually caused by preservative-induced limbal stem cell deficiency. Still, from a cost standpoint, generic topical therapy will continue to reign as a first choice for payers and an appropriately popular one for patients.
2. Payers will increasingly push back. The grim reality is that we are already seeing evidence that payers care about cost above everything else. However effective, safe and free of compliance issues, any new surgical or sustained drug delivery therapy will face increasing pressure from payers. Just as we now see with prior authorizations for drugs — a time-consuming process meant to wear down the doctor’s resolve as an advocate for his patients — a greater burden of proof will accompany the newest, best treatments. Our professional societies and the FDA may play a role in setting standards for justifying these new technologies, and a uniform process of authorizing these procedures would actually be a benefit of any “Medicare for all” system being contemplated by our lawmakers. Either way, at least some burden will fall on doctors to show the need for these new technologies.
3. Glaucoma will increasingly be the domain of subspecialists. Where subspecialists (both ophthalmologists and medically oriented optometrists) are widely available, glaucoma patients will increasingly be filtered to these providers. Ophthalmologists specializing in glaucoma will increasingly perform just procedures while comanaging optometrists will handle more and more medically treated glaucoma. The standardization of treatment protocols, which is already developing as a byproduct of the precision imaging of the optic nerve, may well shift the business model of treating glaucoma to doctors who take at-risk (capitated) contracts and whose glaucoma volume allows economies of scale. One notable exception may well be MIGS performed together with cataract surgery, which is likely to remain the domain of the general ophthalmologist/cataract surgeon.
The biggest winner in these shifting practice patterns will be the well-informed patient who understands his or her condition and is willing to ask for the best of the many available treatment options. For us doctors, while our roles and responsibilities are likely to shift, ultimately, we too always win when patients do, and keeping abreast of these new developments and how they best serve our patients will always be worthwhile and ensure that our careers will be rewarding as stewards of our patients’ precious vision.
Disclosure: Hovanesian reports he is a consultant for and/or equity holder in a variety of companies offering glaucoma treatments.