Ask any ASC material manager — drug prices are moving targets. With a few rare exceptions, the trajectory is always up, and in recent years, the ascent has been steep, rapid, and seemingly gratuitous.

“For me, the eye-opening moment was in August 2013, when two patients canceled their cataract surgeries because they couldn’t afford their post-op drops,” says Ahad Mahootchi, MD, medical director of The Eye Clinic of Florida in Zephyrhills. “When I investigated, I learned that two pharmacies were charging hundreds of dollars for drugs that were literally $20 just 2 years before. These drugs were generic when I was in high school. The pricing made absolutely no sense.”

These were not isolated incidents, as Larry E. Patterson, MD, medical director of Eye Centers of Tennessee, can attest.

“For a long time, it wasn’t so difficult for someone to get a steroid or an antibiotic drop for $10 or $20,” he says. “Then, all of a sudden, the cost jumped to $40, $60, even $100. When the cost of some antibiotics rose to $200, many surgeons went back to prescribing older antibiotics that their patients could afford. Patients were sometimes paying well over $400 per eye for their antibiotic, steroid, and NSAID drops, which was almost as much as surgeons were receiving for performing the surgery.”

Rising drug prices also were putting a strain on office staff, who were logging many hours per week, fielding phone calls from patients, pharmacies, and insurers, answering questions, and trying to find alternatives to the more costly drugs.

In their quest to contain costs while maintaining quality of care and excellent outcomes, both surgeons say that the availability of safe, economical, compounded medications has been a game-changer.

No More Post-op Drops

In recent years, some cataract surgeons have begun administering a compounded formulation of an antibiotic and a steroid intraoperatively, which, in most cases, eliminates the need for patients to instill drops at home. This approach results in a significant cost savings to patients and takes the question of whether or not a patient can or will adhere to a complex postoperative regimen off the table.

Dr. Patterson’s approach to minimizing and ultimately eliminating post-op drops has evolved over time and differs somewhat from the “dropless” techniques used by other surgeons.

“About 10 years ago, I started placing a drop of povidone iodine in the eye before and after cataract surgery,” Dr. Patterson says. “While that practice has been proven to reduce the risk of endophthalmitis,¹ the use of topical antibiotics in addition to that has not been shown to help. However, several studies have shown that intracameral antibiotics do make a significant difference in the reduction of endophthalmitis.^2,3 So, I started using intracameral antibiotics, and about 4 years ago, I stopped using post-op antibiotics altogether.

“I also stopped using NSAID drops a few years ago, because their utility continues to be debated, and they are expensive for patients,” Dr. Patterson says. “Today, we have a compounding pharmacy combine an antibiotic, a nonsteroidal, and two different dilating drops for preoperative topical use. One drop is all we typically use, although we may repeat that once or twice as needed.”

Dr. Patterson stopped using post-op steroid drops about 6 months ago.

“Based on a conversation with Dr. Jim Gills, I now administer a posterior sub-Tenon’s injection of 0.2 cc of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb). Dropless surgery, as I perform it, is a simple, inexpensive 2-step process.”

Dr. Mahootchi is a strong advocate for dropless or near-dropless cataract surgery.

“Whether we’re talking about science and how to avoid infection, minimizing corneal toxicity, economics, or building your practice, dropless wins every time,” he says. “I switched to using all Imprimis compounds, including Tri-Moxi (triamcinolone and moxifloxacin hydrochloride; ImprimisRx) to help prevent infection, and of course, when we use fewer drops, corneal toxicity is less likely to occur.”

As for economics, the cost of the drugs administered in the OR is not reimbursable and is bundled with the procedure, but it’s a small price to pay, Dr. Mahootchi says. “While my direct costs increase slightly — about $20 per eye — my indirect costs are reduced. I save almost a full-time equivalent employee or $30,000 to $40,000 a year in time spent by my staff on phone calls, medicine reconciliation, drops education, and the like.”

Says Dr. Patterson: “My surgery coordinators say their workload has reduced by about 30% since we stopped prescribing post-op drops. We can’t imagine ever going back to those drops. There would be a mutiny by staff, and I don’t see any reason to ever do that again.”

Both surgeons also agree that reducing or eliminating the need for post-op drops is a practice-builder.

Patients Seek You Out

Generally, patients seeking cataract surgery have some knowledge of what’s involved, having consulted “Dr. Google” and also discussed it with their peers who have had the surgery. The move toward drop-free surgery is a welcome advancement for them.

“Our patients are absolutely delighted when they find out they don’t have to use any drops after surgery,” says Dr. Patterson. “And it’s not just about the cost of the drops. These people lead busy lives. When we prescribe three drops four times a day over a period of several weeks, that’s asking quite a lot. We can now offer them a surgery with equally good if not better results than we had when patients used post-op drops.”

Some critics of dropless cataract surgery point out that patients experience floaters postoperatively; however, Dr. Mahootchi has found that with proper education, patients accept this transient side effect of the steroid.

“For the most part, the floaters are experienced only on the day of the surgery, and I tell patients that if they spend the day sitting up, they generally won’t have floaters that bother them,” says Dr. Mahootchi. “Patients have two options: 1) to have floaters for about a day and save $300 to $400 in drops or 2) spend hundreds of dollars for up to 130 doses of post-op drops and avoid the floaters. None of my patients ever take the second option, and I’ve found that experiencing floaters for a short time does not diminish the ‘Wow!’ factor of cataract surgery.”

Dr. Patterson notes that with his sub-Tenon’s steroid injection, patients don’t have floaters.

“Since we are no longer doing any intravitreal injections, the post-op side effects are negligible,” he says.

Dr. Mahootchi has also found his dropless approach attracts new patients.

“People will seek you out for their cataract surgery because you’re saving them a significant sum and the hassle of the drops,” he says. “While some patients may put that money in their pockets, many will put it toward advanced technology IOLs, an upgrade that will last them a lifetime. In fact, about 45% of my patients choose presbyopia-correcting lenses, which I believe is one of the best conversion rates in the country.”

Dr. Patterson encourages cataract surgeons to consider transitioning to a technique that minimizes or eliminates post-op drops.

“If the high cost of perioperative topical drops for cataract surgery is causing financial woes for patients and time woes for your staff, you can solve this problem by going to a totally dropless approach,” he says. “While there’s more than one way of doing it, I’ve been extremely satisfied with my approach. It really couldn’t have gone any better. We’re delightfully shocked at how easy this has been.”

Tap Your Consultant Pharmacist

“Going dropless” may represent a sea change for many cataract surgeons, and the transition may occur in stages over time. While the benefits are worthwhile for the long term, ASCs must also be prepared to act quickly to adjust to unexpected price increases and drug shortages. Dr. Mahootchi credits his consultant pharmacist with helping him stay ahead of these issues. (See “Tips from a Consultant Pharmacist”.)

“Our consultant pharmacist, James Martinez, BPharm, RCPH, has been excellent at telling us when to anticipate shortages of certain medicines,” he says. “It’s not so much the cost of the drugs as the rolling shortages, whether real or manufactured, that can have the most impact. Staying ahead of those issues and advising us when to buy product in advance has earned my consultant pharmacist a gold medal.”

Martinez also keeps track of automatic price increases. “It’s amazing to see several hundred percent increases that are built in over a couple of years,” he says. “Having a good consultant pharmacist who watches the market and sees what is happening is key.”

Dr. Mahootchi agrees. “Having a consultant pharmacist work with our team on monitoring drug cost and impending shortages before they are a problem is paramount. Breaking long-standing habits about drops or anesthesia regimens that don’t hold up to scrutiny helps. Having an open mind helps.” ■

References

1. Hosseini H, Ashraf MJ, Saleh M, et al. Effect of povidone-iodine concentration and exposure time on bacteria isolated from endophthalmitis cases. J Cataract Refract Surg. 2012;38:92-96.
2. Roach L. Intracameral antibiotics: what the evidence shows. 2013. Eyenet. https://www.aao.org/eyenet/article/intracameral-antibiotics-what-evidence-shows-2 . Accessed August 20, 2018.
3. Schwartz SG, Flynn HW Jr, Grzybowski A, Relhan N, Ferris FL 3rd. Intracameral antibiotics and cataract surgery: endophthalmitis rates, costs, and stewardship. Ophthalmology. 2016;123:1411-1413.