March 2014




Femtosecond phaco techniques

Ethical dilemmas with femtosecond cataract surgery

by Ellen Stodola EyeWorld Staff Writer

Angel and devil

Femtosecond technology presents some ethical hurdles for surgeons

The femtosecond laser is a new technology that many are seeing the benefit of incorporating into surgeries; however, there are still issues to be ironed out with the technology, including the cost and the surgery time. Not all doctors have this technology readily available to patients, and in terms of cost, the extra fees for the femtosecond laser are specifically addressed under CMS guidelines, with the ability to charge only in certain circumstances. John Banja, PhD, Emory University Center for Ethics, Atlanta; Richard Hoffman, MD, clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Eugene, Ore.; and Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, Los Angeles, spoke about the ethical issues surrounding femtosecond cataract surgery.

Presenting femtosecond cataract surgery to patients

Despite not having a femtosecond laser where he works, Dr. Miller thinks the presentation of the technology is fairly simple. "If it's a cataract patient, you have to be doing a non-covered service to bill for the laser," he said. The only non-covered service that makes sense is the astigmatism service. He said that using a femtosecond laser for astigmatism management is a safe harbor for use of this technology, adding that another partially safe place is offering the technology when performing imaging as a necessary preparation for implantation of a premium lens. The latter, while approved by CMS, doesn't make much sense, thinks Dr. Miller, because the imaging is performed for the sole purpose of facilitating non-covered services such as the incisions, capsulorhexis, and lens softening. "You're only safe if you're offering astigmatism management as part of your non-covered package," Dr. Miller said. "A premium IOL could be in that package, but you can't price the premium IOL higher just because you want to use a femtosecond laser to make the incisions."

Dr. Banja said femtosecond technology should be presented to a patient only if his or her condition warrants it. Thus, using femto to "correct for astigmatism" in a patient who had only traces of it would hardly be ethically acceptable, not to mention the risk of that being discovered in an audit.

Dr. Hoffman said that he currently does not offer femtosecond laser cataract surgery to his patients. However, he would explain the situation to a patient if he or she were interested in the technology.

"I would explain that at this time, insurance and Medicare do not cover the laser treatment and due to Medicare regulations, we could not offer it unless they had astigmatism that would be treated at the same time," he said. "I do not believe that it offers significant enough advantages that there are any ethical concerns about not performing the surgery with the laser if a patient cannot afford it."

When patients could benefit but don't qualify for a femtosecond procedure

Dr. Hoffman said that a surgeon may come across an ethical dilemma if a patient could benefit from using the femtosecond laser but it is not indicated based on CMS guidelines. "Ethically, they should perform it and absorb the additional costs," he said.

Dr. Miller said one issue that arises is that under Medicare, you can't just pay for the femtosecond laser because you want it. "Medicare's guiding principle is the 'golden knife' principle," he said. "You can't charge a patient more just because you use a golden knife to make your incisions."

He said that so far, the major benefit that has been seen with the femtosecond laser is safety. Less phaco energy is expected and the capsulorhexis is rounder. But you won't get paid more for doing a safer procedure, he said.

Dr. Banja said there are several fundamental questions about the overall utility of femtosecond laser technology. The physician needs to determine how much benefit should be present to justify using the femto laser versus the manual procedure, what is the actual benefit, and how likely it is that the benefit of the femto laser would be different from a standard procedure. These questions also need certain data and research. "Until we have that data, I think the femto controversy will continue because ophthalmologists will only use their anecdotal experience, what they hear their colleagues saying, and their overall gut reaction to femto," Dr. Banja said.

When physicians don't provide femto

Femtosecond cataract surgery article summary

Despite the growing interest in the femtosecond laser, not everyone is using this technology just yet. If the patient is interested in the femtosecond laser but it is not provided by the physician, Dr. Hoffman thinks that it is the physician's responsibility to explain the possible benefits and additional costs to the patient. If the femtosecond laser is the choice for the surgery, physicians could then suggest a surgeon who is using that technology, he said.

"At present, an ethical ophthalmologist can only respond as he or she honestly sees femto playing out," Dr. Banja said. "If the doctor doesn't provide femto, he or she should inform the patient of that if the patient requests that technology." He also noted that if the ophthalmologist believes that femto doesn't make a significant difference in cataract outcomes or won't make a significant difference for a given patient, this should be explained to the patient who inquires about it. "The interesting ethical question would be if the ophthalmologist had come to believe that femto outcomes are substantially better than using a freehand technique but he didn't offer femto," he said. This could lead to a "struggle of conscience" for the physician who may not be offering what he's coming to think should be the "standard of care."

What to ethically present

Dr. Banja thinks that the best ethical justification for using femtosecond laser technology is if it's used to foster the patient's benefit or for the sake of the patient. "Ethical behavior is always other-directed, not self-interested," he said. "Consequently, if a physician withholds or distorts a piece of information, it should be for very compelling patient-centered reasons. And even then, the physician should think twice before doing it."

Editors' note: Drs. Hoffman, Miller, and Banja have no financial interests related to this article.

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