November 2019


“Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons Learned”

Robert Maloney, MD


At the 2019 ASCRS ASOA Annual Meeting in San Diego, the Refractive Surgery Clinical Committee hosted a roundtable. The roundtable was chaired by John Vukich, MD, and Vance Thompson, MD. They were joined by Daniel Chang, MD, Eric Donnenfeld, MD, Kerry Solomon, MD, Robert Maloney, MD, George Waring IV, MD, and William Wiley, MD. What follows are highlights from a transcript, edited for length, from the second part of the discussion. The final part of the discussion will be shared in the next issue of EyeWorld.

Dr. Vukich: What might a refractive cataract practice anticipate as an enhancement rate?

Dr. Solomon: I think the enhancement rates are probably under estimated. We’ll show patients who are 20/25 and 20/30, we show them the 20/20s, because the truth is patients might tell you and the staff that they’re happy and then they leave and tell everyone else, “You know what, this really kind of sucks. I paid all this money and I’m not really getting what I want.” So, we’ll show them what’s possible and some patients may say, “It’s not that big enough of a difference, I’m fine”—that’s great. Others might say, “You know, I love that, let’s do that.” People are concerned their enhancement rates would go up with that and it really hasn’t, at least in our practice. I would say our enhancement rates are easily 10% and may be as high as 15%.

Dr. Donnenfeld: The misconception is that happy patients build busy practices. It’s actually patients whose expectation has been exceeded. A happy patient is the bare minimum of what you need to be in practice. I’m very aggressive about offering patients enhancements even when they’re happy, because if they’re happy with 20/25 vision, think how happy they’ll be with 20/15 vision. Those are the patients that appreciate the extra effort you’re willing to put in to achieve those results to become an exceptional refractive cataract practice.

Dr. Vukich: Most of us have a global fee for our patients. How long is that global fee effective? Is there any end point at which you no longer would do an enhancement?

Dr. Chang: When it comes to the global period, I don’t differentiate between astigmatism and presbyopia correction. My global period is roughly 1 year. “One year” because that’s plenty of time for refractive change, any enhancements, and neuroadaptation to stabilize. “Roughly 1 year” because if the process is taking longer—for example if the patient is traveling or busy with life for a few months—I want them to go use their vision instead of worrying about the timing of any additional care or procedures they might need. Perhaps they miss an appointment or two, need a YAG laser capsulotomy, then an excimer laser enhancement, and it runs into the second year. It rarely does but my general attitude is: they’ve paid me, I’ll do what I need to do to make them happy.

Dr. Thompson: We’re the same way, we have a global fee. It’s the same period of time as yours. Early on, I didn’t have a global fee. I charged for the enhancement, and I had more patients frustrated. They thought at 20/25 they didn’t want to pay the extra for the enhancement, so they thought ‘I’ll just live with this,’ but they never experienced the joy of getting to 20/20. Now that we’ve incorporated the enhancement into the global fee, they take advantage of it when we show them. I think having a global fee leads to higher patient satisfaction.

Dr. Vukich: Does the global fee include a YAG capsulotomy and at what point does that expire? If a patient comes back after premium surgery at 3 years and requires a capsulotomy, how do you handle that?

Dr. Thompson: We have a refractive capsulotomy and a therapeutic capsulotomy. A therapeutic capsulotomy has to meet the visual criteria, but a refractive capsulotomy, when you’re trying to make the judgement, is it really doing anything—they’re seeing 20/20, maybe it’s affecting their image quality a little bit, and they have a multifocal implant—and you’re just wondering will this refractive endpoint with the capsulotomy, we’ll do those capsulotomies for nothing, they’re part of the package. The only time we charge for a capsulotomy is when it meets the visual criteria.

Dr. Chang: We should probably not put a therapeutic capsulotomy into a refractive package because it could be argued that you’re charging cash for a Medicare-covered service. But there is no Medicare coverage for a refractive capsulotomy, so you can put your own price for that or package that in.

Dr. Thompson: I think that as you peel back the onion and get into refractive cataract surgery, this is a delicate timepoint. When it is capsulotomy time, I ask the patient, how are we doing for joy? If they’re not very happy, I know residual refractive error is going to be really important. If I do a capsulotomy, it’s going to be a lot tougher to do an IOL exchange. I will say that, as we all know, IOL exchanges are a lot less likely with modern-day technology, but when I get to that 3-month timepoint and we’re thinking about a fine tune and we’re doing a refraction and they’re kind of wishing their image quality was just a little bit better, and I’m starting to see a little PCO, and we know the
technology that splits light, anything else that splits light, like dry eye, epithelial issues, or residual refractive error, PCO, we need to take care of. But if they’re not close to joy, I’m not doing a capsulotomy until they really understand that means an IOL exchange is more difficult and carries higher risk, if an exchange is needed. This is an important part of informed consent and the patient really appreciates knowing this.

Editors’ note: This roundtable discussion began in the September issue and will conclude in the next issue of EyeWorld.

About the doctors

Daniel Chang, MD
Empire Eye and Laser Center
Bakersfield, California

Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Rockville Centre, New York

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles

Kerry Solomon, MD
Carolina EyeCare Physicians
Mount Pleasant, South Carolina

Vance Thompson, MD
Vance Thompson Vision
Sioux Falls, South Dakota

John Vukich, MD
SSM Dean Clinic
Madison, Wisconsin

George Waring IV, MD
Waring Vision Institute
Charleston, South Carolina

William Wiley, MD
Cleveland Eye Clinic
Brecksville, Ohio

Relevant financial interests

Chang: Johnson & Johnson, Carl Zeiss Meditec
Donnenfeld: Alcon, Allergan, Johnson & Johnson, Novartis,
Carl Zeiss Meditec
Maloney: None
Solomon: Alcon, Allergan, Bausch + Lomb, Johnson & Johsnon Vision, Carl Zeiss Meditec
Thompson: Alcon, Johnson & Johnson Vision, Bausch + Lomb, Mynosys
Vukich: Johnson & Johnson Vision, Carl Zeiss Meditec
Waring: None
Wiley: RX Sight, Alcon, Bausch + Lomb, Johnson & Johnson, Carl Zeiss Meditec

Contact information


“Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons Learned” “Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons
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