Article

Viewpoint

FROM THE CHIEF MEDICAL EDITOR

House hunting for FLACS

There is a business saying that to compete, your product should be better, faster and cheaper than the competition’s. Realistically you can have two of the three. Nordstrom has better quality clothing than Wal-Mart’s, but it’s not cheaper. Wal-Mart’s food is cheaper than Whole Foods’, but it’s not necessarily better. And as for faster, it all depends on who is in front of you at check out.

Ophthalmology is somewhat analogous, nowhere more so than with its laser refractive practices. Some physicians advertise incomprehensibly low prices, but few if any who respond to those ads expect high quality, and they might not meet the surgeon until right before the procedure. More upscale practices will shower the patient with love, time, attention and all the newest gadgetry, but no patient goes to that practice expecting “buy one, get one free.”

I say somewhat analogous because medicine is an aberration, especially with the existence of third-party payers. Patients want the best quality and extremely prompt service, and then prefer to pay nothing at all! Take anti-VEGF intravitreal injections. Recent studies suggest that in some cases, brand-name drugs perform better than the compounded drugs but can cost up to 40 times more. If your insurance covers it, why not request the more expensive option?

Here is the other extreme: the use of femtosecond laser-assisted cataract surgery (FLACS). We can all agree it’s not cheaper. Most places charge at least a few hundred dollars extra. If you’re doing it yourself, it’s really a stretch to say it’s faster. Yes, it can slightly increase the speed of the cataract surgery, but you still must do the laser treatment.

But is it better than manual? While honest doctors argue about whether the laser helps with “routine” cataract surgery, most agree indications exist in which the laser can really make a difference. Patients with very dense, translucent, nuclear cataracts can have significant reductions in phaco time and energy with FLACS. I prefer using the laser with white cataracts to give a perfect capsulotomy and doing away with Argentinian flags. The capsulotomy feature is also great with pseudoexfoliation, especially on those with possible zonular instability.

Here’s the rub: the very people who need this technology tend to be the very people who can’t afford the out-of-pocket-expense. These people often care little about the refractive surgery, even though Medicare requires us to perform that surgery so we can legally charge for the technology and the other benefits.

To solve this problem, I propose that we seek medical indications, backed by clinical research, for the use of FLACS that would eventually be covered by insurance, completely separate from refractive surgery. This coverage would go a long way in allowing those who could benefit from the technology to access it.

Cheaper? With a little luck, maybe. Faster? If it’s a nuclear cataract, possibly. Better? If it were my cataract, yes. OM