March 2016




Chief medical editors corner of the world

The Eye-Q test

by Eric Donnenfeld, MD, EyeWorld chief medical editor



I cannot recall a time in ophthalmology when there has been a more rapid change in the use of medications than their utilization around cataract surgery over the last several years. In the past, we prescribed branded medications that were reasonably priced and efficacious. Often kits were provided that included a customized bag, sunglasses, tears, and a sample of one of the medications at no cost to the patient. Patient deductibles were low, and the medications were almost always covered by insurance. Our patients and staff were happy with the system. Today my patients are outraged at the cost of cataract surgery medications, and my staff is considering mutiny after fielding dozens of calls a week to resolve medication cost and insurance approval issues. You know when the cost of medications approaches the surgeons insurance reimbursement for the procedure that something is wrong. In speaking with my colleagues, I know that I am not alone. So how did we get to where we are today in regard to ophthalmic pharmaceuticals? There are several possibilities to consider. In its wisdom, the FDA decided that a free patient kit was bad for patients as an inducement, just the way giving out pens could sway our concern for patient care. Insurance companies continue to rake in obscene profits and executive reimbursement while acting as a middleman between patients and physicians and providing little service. In addition, while insurance premiums continue to skyrocket, deductibles are increasing in the same manner. In the past, patients had deductibles that were reasonable. Now deductibles can be several thousand dollars a year, and patients pay for the complete cost of a procedure, including the pharmaceuticals. I had never heard the term donut hole until recently. Just a few short years ago, Alcon (Fort Worth, Texas), Allergan (Dublin), and Bausch + Lomb (Bridgewater, N.J.) were independent organizations. Now they respectively belong to the conglomerates Novartis (Basel, Switzerland), Pfizer (New York), and Valeant Pharmaceuticals (Laval, Canada) and are part of big pharma. In the past, generic medications were truly inexpensive compared to their branded colleagues, but over the past several years the cost of these generics has increased dramatically, and I just dont know why. Although I am certain there are other issues, I have noticed that pharmacists are not only changing my patients from branded to generic, they are also switching them to different medications completely.

Cataract surgery is the most commonly performed operation in the U.S. today. I want to optimize my results and give patients the best opportunity to achieve a superlative outcome by reducing the risk of infection, maintaining pupil dilation, and managing postoperative inflammation and pain. My number 1 priority is to do what is best for the patient, and when I prescribe medications in general, I look at 4 different aspectssafety, efficacy, compliance, and cost. All 4 are important to patients, but I have to understand the patients needs as well. So if cost is an overriding concern, that takes precedence. On the other hand, safety and efficacy are what I am most concerned about as I am looking at the long-term well-being of my patients. Generic medications are often very reasonable, and I give every patient that option, but I also consider if the generic medication is really less expensive than the branded as the cost of generics has increased markedly. In my practice, generics are often more expensive than branded medications. I call this the Eye-Q test. Why use a medication that is less tested, may be less efficacious, used 4 times a day rather than once or twice, is more toxic, and costs more? Recently Allergan, Alcon, and Bausch + Lomb have adopted a coupon system that dramatically reduces the cost to patients for branded medications and brings them down to a more reasonable level. This system has to become more seamless as my staff and I continue to want to do what is best for patients, but do not want to be handing out coupons all day. Bausch + Lomb is exploring a partnership with Walgreens that may simplify these concerns and reduce copays. In addition, compounding pharmacies are creating new combination products that can be injected into the vitreous or placed topically. Their efficacy has not been firmly established but may present another opportunity. Finally, all cataract perioperative medications are moving intracamerally, with many new products being developed that can be placed in the eye at the time of surgery rather than on top of the cornea postoperatively. One thing that I know for certain is that medication use around cataract surgery is changing.

Contact information


The Eye-Q test The Eye-Q test
Ophthalmology News - EyeWorld Magazine
283 110
220 230
True, 3