Journal of Refractive Surgery

Original Article Supplemental Data

Influence of Co-payment Levels on Patient and Surgeon Acceptance of Advanced Technology Intraocular Lenses

Francesco Carones, MD; Michael C. Knorz, MD; Daniel Jackson, PhD; Ali Samiian, LLB, MBA

Abstract

PURPOSE:

To investigate patients’ willingness to pay for advanced technology intraocular lenses and surgeons’ willingness to recommend them.

METHODS:

In this study, 370 cataract surgeons and 700 patients undergoing cataract surgery from seven countries underwent online interviews in which they were shown unbranded profiles of three advanced technology intraocular lenses (ie, biconvex toric aspheric optic, symmetric biconvex diffractive optic, and biconvex diffractive aspheric toric) and asked to indicate their willingness to accept (for patients) or suggest (for surgeons) each lens. Acceptance was assessed assuming there was either no co-payment or co-payments of €500 to €1,500 +15%.

RESULTS:

All three lenses were widely accepted by patients, with 68% to 99% indicating acceptance when there was no co-payment. In contrast, surgeons’ willingness to suggest them was markedly lower (20% to 43%). Both patients’ acceptance of the lenses and surgeons’ willingness to suggest them decreased with increasing co-payment levels to 19% to 74% (patients) and 5% to 31% (surgeons) at the highest co-payment levels.

CONCLUSIONS:

There is a marked discrepancy between patients’ acceptance of the three lenses and surgeons’ willingness to suggest them. Although patients’ acceptance is high, it decreases with increasing out-of-pocket expenditure. Manufacturers should communicate the relative benefits and costs of their lenses to both surgeons and patients.

[J Refract Surg. 2014;30(4):278–281.]

From Carones Ophthalmology Center, Milan, Italy (FC); Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany (MCK); and Alcon Laboratories, Inc., Geneva, Switzerland (DJ, AS).

Funded by Alcon Laboratories, Inc. Medical writing assistance provided by Dr. Michael Shaw (Hove, UK).

Drs. Carones and Knorz are consultants for and Drs. Jackson and Samiian are employees of Alcon Laboratories, Inc.

AUTHOR CONTRIBUTIONS

Conception and design (DJ); analysis and interpretation of data (AS, DJ, FC, MCK); writing the manuscript (MCK); critical revision of the manuscript (AS, DJ, FC); administrative, technical, or material support (DJ); supervision (AS)

Correspondence: Francesco Carones, MD, Carones Ophthalmology Center, Via Pietro Mascagni 20, 20122 Milan, Italy. E-mail: fcarones@carones.com

Received: November 06, 2013
Accepted: December 05, 2013
Posted Online: April 04, 2014

Abstract

PURPOSE:

To investigate patients’ willingness to pay for advanced technology intraocular lenses and surgeons’ willingness to recommend them.

METHODS:

In this study, 370 cataract surgeons and 700 patients undergoing cataract surgery from seven countries underwent online interviews in which they were shown unbranded profiles of three advanced technology intraocular lenses (ie, biconvex toric aspheric optic, symmetric biconvex diffractive optic, and biconvex diffractive aspheric toric) and asked to indicate their willingness to accept (for patients) or suggest (for surgeons) each lens. Acceptance was assessed assuming there was either no co-payment or co-payments of €500 to €1,500 +15%.

RESULTS:

All three lenses were widely accepted by patients, with 68% to 99% indicating acceptance when there was no co-payment. In contrast, surgeons’ willingness to suggest them was markedly lower (20% to 43%). Both patients’ acceptance of the lenses and surgeons’ willingness to suggest them decreased with increasing co-payment levels to 19% to 74% (patients) and 5% to 31% (surgeons) at the highest co-payment levels.

CONCLUSIONS:

There is a marked discrepancy between patients’ acceptance of the three lenses and surgeons’ willingness to suggest them. Although patients’ acceptance is high, it decreases with increasing out-of-pocket expenditure. Manufacturers should communicate the relative benefits and costs of their lenses to both surgeons and patients.

[J Refract Surg. 2014;30(4):278–281.]

From Carones Ophthalmology Center, Milan, Italy (FC); Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany (MCK); and Alcon Laboratories, Inc., Geneva, Switzerland (DJ, AS).

Funded by Alcon Laboratories, Inc. Medical writing assistance provided by Dr. Michael Shaw (Hove, UK).

Drs. Carones and Knorz are consultants for and Drs. Jackson and Samiian are employees of Alcon Laboratories, Inc.

AUTHOR CONTRIBUTIONS

Conception and design (DJ); analysis and interpretation of data (AS, DJ, FC, MCK); writing the manuscript (MCK); critical revision of the manuscript (AS, DJ, FC); administrative, technical, or material support (DJ); supervision (AS)

Correspondence: Francesco Carones, MD, Carones Ophthalmology Center, Via Pietro Mascagni 20, 20122 Milan, Italy. E-mail: fcarones@carones.com

Received: November 06, 2013
Accepted: December 05, 2013
Posted Online: April 04, 2014

Studies of prescribing practices for optical products can provide useful data that may help product development decisions in different countries and enable surgeons to position their practice in a wider context.1 For example, such studies have shown that contact lenses are worn by approximately 7% to 15% of the population in various countries2 and that soft (ie, hydrogel or silicone hydrogel) lenses are most used.3 However, there is relatively little information about factors influencing the choice of advanced technology intraocular lenses (IOLs) (ie, toric aspheric monofocal, diffractive aspheric multifocal, and diffractive aspheric toric multifocal) for a given indication. Although there have been health economic assessments of different lenses,4 few studies have investigated patients’ willingness to pay for advanced technology IOLs or surgeons’ willingness to recommend them. Such information would help manufacturers determine the most appropriate pricing models. Thus, the current study was undertaken from both patient and prescriber perspectives to investigate the proportion of patients who would be prepared to pay a specific out-of-pocket cost for various advanced technology IOLs.

Patients and Methods

The study involved 370 surgeons and 700 patients undergoing cataract surgery from Canada, France, Germany, Italy, Spain, the Netherlands, and the United Kingdom. To participate, surgeons had to have been specializing in cataract surgery for 3 to 30 years and have performed at least 15 surgeries per month. Patients were recruited via an online panel and were required to have been diagnosed as having noncongenital cataracts at least 3 months prior and to be considering surgery after a recommendation from at least one physician. Patient recruitment was stratified according to activity levels and income.

All participants underwent 15-minute online interviews conducted in June and July 2012. Participants were shown unbranded profiles of three advanced technology IOLs labeled A (toric), B (multifocal), and C (toric multifocal) (Tables 12). In addition to correcting for cataracts, lens A (toric) was designed to correct for astigmatism, lens B (multifocal) for presbyopia, and lens C (toric multifocal) for both astigmatism and presbyopia. Profiles shown to surgeons focused on the technical aspects of each lens (Table 1), whereas those shown to patients focused on the potential benefits and risks of each lens compared to standard reimbursable lenses (Table 2). Patients were asked to assume that they had been diagnosed as having corneal astigmatism for lens A (toric), presbyopia for lens B (multifocal), or astigmatism with presbyopia for lens C (toric multifocal). Participants were shown only the profiles and then asked to indicate their willingness to pay for (for patients) or suggest (for surgeons) each lens with no co-payments or middle, high, and low co-payments (Lens A [toric]: €500 +15%; Lens B [multifocal]: €1,000 +15%; Lens C [toric multifocal]: €1,500 +15%); equivalent co-payment levels in the United Kingdom and Canada were also considered. Data analysis was purely descriptive and no statistical analysis was performed.

Lens Profiles Presented to Surgeons

Table 1:

Lens Profiles Presented to Surgeons

Lens Profiles Presented to Patients

Table 2:

Lens Profiles Presented to Patients

Results

The lenses were widely accepted by patients in all countries. The proportion of patients who indicated that they would accept the lens if it was suggested by their surgeon ranged from 82% to 99% for lens A (toric), 69% to 90% for lens B (multifocal), and 68% to 88% for lens C (toric multifocal) if there was no co-payment (Table A, available in the online version of this article). In all seven countries, lens A (toric) was the most widely accepted; mean acceptance was 90% compared to 74% and 78% for lenses B (multifocal) and C (toric multifocal), respectively. However, the proportion of surgeons prepared to suggest each lens was lower than that of patient acceptance if there was no co-payment, ranging from 24% to 39% for lens A (toric), 26% to 43% for lens B (multifocal), and 20% to 42% for lens C (toric multifocal) (Table B, available in the online version of this article). Mean acceptance was 39% for lens A (toric), 31% for lens B (multifocal), and 30% for lens C (toric multifocal). The combined data for the three lenses showed that the difference between patients’ acceptance of the lenses and surgeons’ willingness to suggest them ranged from 42% in Italy to 54% in France and Spain (Figure 1).

Difference between patients’ willingness to accept the three lenses and surgeons’ willingness to suggest them when there is no co-payment.

Figure 1.

Difference between patients’ willingness to accept the three lenses and surgeons’ willingness to suggest them when there is no co-payment.

Patient acceptance trends were similar when various co-payments were proposed, although acceptance levels were generally lower (Table A). Acceptance ranged from 47% to 85% for lens A (toric), 23% to 79% for lens B (multifocal), and 19% to 61% for lens C (toric multifocal) and decreased with increasing levels of co-payment. Surgeons’ willingness to suggest the lenses ranged from 7% to 35% for lens A (toric), 7% to 31% for lens B (multifocal), and 5% to 22% for lens C (toric multifocal) and again decreased with increasing levels of co-payment (Table B). At the middle co-payment level (ie, €500 for lens A [toric], €1,000 for lens B [multifocal], and €1,500 for lens C [toric multifocal]), the difference between patients’ acceptance of the lenses and surgeons’ willingness to suggest them ranged from 11% in the Netherlands to 45% in France (Figure 2). Irrespective of the co-payment level, lens A (toric) had the highest acceptance level and was most likely to be suggested.

Difference between patients’ willingness to accept the three lenses and surgeons’ willingness to suggest them at the middle co-payment level (ie, €500 for lens A [toric], €1,000 for lens B [multifocal], and €1,500 for lens C [toric multifocal]).

Figure 2.

Difference between patients’ willingness to accept the three lenses and surgeons’ willingness to suggest them at the middle co-payment level (ie, €500 for lens A [toric], €1,000 for lens B [multifocal], and €1,500 for lens C [toric multifocal]).

Discussion

A principal finding of this study is that there is a clear discrepancy between patients’ acceptance of the three advanced technology lenses and surgeons’ willingness to suggest them. Patients’ acceptance was generally high (approximately 70% to 99%) if there were no co-payments, which suggests that they recognized the potential benefits of the lenses. However, surgeons were willing to suggest the lenses for only approximately 20% to 45% of patients. This may suggest that surgeons perceived the lenses as offering only a moderate advantage over current reimbursable monofocal lenses because they did not seem relevant to patient needs. It is also possible that surgeons may not know what patients want from their lenses and how much they would be willing to pay. In addition, surgeons may not want to be perceived as selling lenses to their patients or may be concerned about the impact on their practice if a patient requests a specific lens that is not offered by public clinics. There were no clear relationships in this study between surgeons’ willingness to suggest the lenses, their familiarity with the lenses, or their experience; we do not know of any published data to suggest such a relationship.

In general, lens A (biconvex toric aspheric optic) was associated with higher patient acceptance and surgeon willingness to suggest than both lens B (symmetric biconvex diffractive optic) and lens C (biconvex diffractive aspheric toric). This may be partly due to concern for potential adverse events such as visual disturbances with the latter lenses.

Both patients’ acceptance of the lenses and surgeons’ willingness to suggest them decreased with increasing levels of co-payment. This indicates that the co-payments were higher than some patients were willing to pay despite recognizing the potential benefits of the lenses. Nevertheless, it is possible that surgeons may have been able to identify appropriate co-payment ranges from the product profiles and that the proposed co-payments were within the range that they would expect their patients to have to pay. Differences in healthcare systems and funding may have also contributed to the observed differences (eg, in Germany, advanced technology IOLs must be paid for by the patient and so it is possible that they may be accepted only by those with more severe astigmatism). Therefore, the declining acceptance with increasing co-payment levels suggests that manufacturers need to communicate the relative benefits and costs of their lenses to surgeons and patients. In this respect, it is noteworthy that several studies have shown that advanced technology IOLs are potentially cost-effective and reduce the need for spectacles and overall costs for the patient.4–7

References

  1. Morgan PB, Efron N, Helland M, et al. Demographics of international contact lens prescribing. Cont Lens Anterior Eye. 2010;33:27–29. doi:10.1016/j.clae.2009.09.006 [CrossRef]
  2. Morgan P. Taking stock of the UK contact lens market. Optician. 2009;238:36–38.
  3. Efron N. Obituary: rigid contact lenses. Cont Lens Anterior Eye. 2010;33:245–252. doi:10.1016/j.clae.2010.06.009 [CrossRef]
  4. Dolders MG, Nijkamp MD, Nuijts RM, et al. Cost effectiveness of foldable multifocal intraocular lenses compared to foldable monofocal intraocular lenses for cataract surgery. Br J Ophthalmol. 2004;88:1163–1168. doi:10.1136/bjo.2003.035527 [CrossRef]
  5. Cuq C, Lafuma A, Jeanbat V, Berdeaux G. A European survey of patient satisfaction with spectacles after cataract surgery and the associated costs in four European countries (France, Germany, Spain, and Italy). Ophthalmic Epidemiol. 2008;15:234–241. doi:10.1080/09286580801983237 [CrossRef]
  6. Pineda R, Denevich S, Lee WC, Waycaster C, Pashos CL. Economic evaluation of toric intraocular lens: a short- and long-term decision analytic model. Arch Ophthalmol. 2010;128:834–840. doi:10.1001/archophthalmol.2010.127 [CrossRef]
  7. De Vries NE, Laurendeau C, Lafuma A, Berdeaux G, Nuijts RM. Lifetime costs and effectiveness of ReSTOR compared with a monofocal IOL and Array-SA40 in the Netherlands. Eye (Lond). 2010;24:663–672. doi:10.1038/eye.2009.151 [CrossRef]

Lens Profiles Presented to Surgeons

Variable Lens A (Toric) Lens B (Multifocal) Lens C (Toric Multifocal)
Optic diameter (mm) 6.0 6.0 6.0
Length (mm) 13.0 13.0 13.0
Optic type Biconvex toric aspheric optic Symmetric biconvex diffractive optic Biconvex diffractive aspheric toric
IOL power spherical equivalent (D) +6.0 to +30.0 +6.0 to +34.0
Compensation for positive corneal spherical aberration Aspheric optic
Correction Near, intermediate, distance vision
Add power at spectacle plane (D) +2.5
Diopter range (D) +6.0 to +34.0
IOL cylinder power (D) 1.50 to 6.0 1.00 to 3.00
IOL design Single-piece Single-piece Single-piece
Haptic design Modified L-shape Modified L-shape Modified L-shape
Optic/haptic material Hydrophobic acrylic Hydrophobic acrylic Hydrophobic acrylic
Suggested A-constanta 119.0 118.9 118.9
Haptic angulation 0° (planar)
Refractive index 1.55 1.50 1.55

Lens Profiles Presented to Patients

Variable Lens A (Toric) Standard Lens Lens B (Multifocal) Standard Lens Lens C (Toric Multifocal) Standard Lens
Corrects for cataract Yes Yes Yes Yes Yes Yes
Corrects for astigmatism Yes No Yes No
Corrects for presbyopia Yes Yes Yes Yes
Glasses required for distance vision Unlikely Very likely
Reduces need for glasses or contact lenses and related costs Very likely, both for distance vision and reading Unlikely Very likely, both for distance vision and reading Unlikely
Material Soft, foldable acrylic Soft, foldable acrylic Soft, foldable acrylic Soft, foldable acrylic Soft, foldable acrylic Soft, foldable acrylic
Surgery for lens implantation Smaller incision, no need for stitches, fast recovery Smaller incision, no need for stitches, fast recovery Smaller incision, no need for stitches, fast recovery Smaller incision, no need for stitches, fast recovery Smaller incision, no need for stitches, fast recovery Smaller incision, no need for stitches, fast recovery
Risks Minimal risk Minimal risk Visual disturbances (ie, halos or radial lines around sources of light at night) Minimal risk Visual disturbances (ie, halos or radial lines around sources of light at night) Minimal risk
Financial contribution Yes No Yes No Yes No

10.3928/1081597X-20140320-07

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