DIALING BACK Dr. Hunter Newsom has limited the use of his laser and now sells his patients on refractice results.

Cataract surgeons are naturally drawn to the allure of using femtosecond laser technology to pulverize clouded lenses and make precise cuts in the anterior lens capsule, and most of their patients want to be operated on with the latest and greatest technology. Is it any wonder that eye centers are sinking hundreds of thousands of dollars into laser platforms that keep them on the cutting edge of care? Should you follow their lead, especially when manual cataract surgery is so safe and so effective? Like most difficult equipment purchasing decisions you face, it depends on the clinical goals of your surgeons, the expectations of your patients and the size of your capital equipment budget.

Cost considerations
Insurers and Medicare don't cover use of the laser, so its per-case cost is passed through to patients who pay out of pocket for premium services that include enhanced refractive outcomes. You need a significant pool of patients willing to pay for premium services in order to recoup the roughly half a million dollars you'll sink into the laser platform.

That means the femto laser is typically used in facilities where several surgeons are working together to keep up throughput, says surgeon Kevin Miller, MD, a professor and the Kolokotrones Chair in Ophthalmology at the David Geffen School of Medicine at UCLA. "In order to afford the laser, you must do volume," he adds. "Otherwise you'll just get killed and you end up eating the cost."

How quickly you amortize the laser depends on how long the system will be functioning and how many patients you operate on during that time. "Eye centers and surgeons don't know those exact numbers when they buy the laser," says Dr. Miller. But they might be able to come up with solid estimates. For example, Dr. Miller knows 85% of his patients will pay $1,400 out of pocket for astigmatism management. Using the laser costs Dr. Miller in time and effort, so he bumped the fee from $1,400 to $1,700. Adding the laser to the package tacks on an additional $800, a figure he negotiated with UCLA administrators. The cost of a premium lens is also $800. That means patients who want laser-assisted cataract surgery must fork over $3,300. Dr. Miller says about half of the patients who are willing to pay for astigmatism management sign up for the laser. He also points out those numbers are specific to the Los Angeles market.

Dr. Miller advocated for years to add a laser, and finally convinced UCLA to make the investment last August. Instead of purchasing the laser outright or securing a loan, the hospital opted for a lease-to-own arrangement with the manufacturer. It was a viable way for the facility to add the laser without a significant capital outlay. Surgeons must perform an agreed-upon amount of cases each month to use the laser. If they fall short of the number, the manufacturer carts the laser away. If they exceed it, the laser stays and a portion of the profits are applied to the purchase of the laser.

TIME MANAGEMENT The laser adds extra minutes to a procedure that demands efficiency.

Dr. Miller hopes UCLA is able to own the laser outright in roughly 4 years. He figures his practice will enjoy another 4 years beyond that of use before the platform becomes obsolete. "After that," he says, "it becomes an expensive paperweight."

You'd better believe surgeons who spend $500,000 on a laser learn to sell it to patients, says T. Hunter Newsom, MD, founder of Newsom Eye & Laser Center in Tampa, Fla. He charges patients the same premium for enhanced refractive outcomes, whether he uses the laser or not. "We tell patients we'll utilize lasers in whatever capacity is needed to give them the best results," he explains. "We don't sell them on a tool, we sell them on our quality results."

Dr. Newsom believes those docs should be able to easily transition to selling post-op results instead of the laser technology, if they choose. "The day after surgery, patients don't care about the laser as long as they can see better."

Financing and lease-to-buy options are much more accessible now than they were 4 or 5 years ago, and the case volume threshold is lower because laser manufacturers are still trying to place their platforms, points out James Dawes, MHA, CMPE, COE, president and founder of the J. Dawes Group, an ophthalmology consulting group based on Sarasota, Fla. Mr. Dawes learned the business side of premium refractive service as the former CEO of the Center For Sight, a large ophthalmology practice in Sarasota.

"A center that's doing 500 cataracts could easily justify the expense of a laser and could structure an agreement where it could be paid for through a lease agreement on a monthly basis," he says.

Partnering with an outsourcing company that brings the laser to your facility, sets it up before surgery and breaks it down afterward is a great option for facilities that will never have sufficient numbers to invest in a laser, that want to test the laser's feasibility in their market or that need to build up their case volume before committing to the technology.

"The outsourcing companies are professional and do a great job," says Mr. Dawes. "Their technologies are well kept, and I think they provide a fantastic service for a facility that's trying to get their foot in the door."

Clinical questions remain
Dr. Newsom was an early adopter of laser-assisted surgery for astigmatism correction, but is using the technology less and less. That's because his own research found that the laser resulted in a statistically significant reduction in the amount of astigmatism, compared with manual technique, but the difference in post-op visual acuity was only 1 letter on the eye chart.

The laser makes lens fragmentation easier, and it's a little gentler on the cornea, but that doesn't necessarily provide a better outcome, says Dr. Newsom. He acknowledges there's potential benefit of using a laser to create a perfectly formed capsulorhexis — the large circular incision in the anterior lens capsule. "But as the body heals, that perfect circle changes shape," says Dr. Newsom. "It's not the same 3 months after surgery. I never bought into the concept that a perfect capsulorhexis results in better refraction."

He also cites a recent study in the journal Ophthalmology that shows laser cataract surgery does not result in improved refractive results, and that it actually increases risks of complications of cystoid macular edema and capsular tears, compared with manual surgery (osmag.net/ZEBzg6).

Dr. Newsome says the 2-step laser surgery process — surgeons break up the lens with the laser before moving the patient to the surgical table for extraction of the fragmented pieces and implantation of the new lens — turns rapid 6-minute procedures into 22-minute marathons (by cataract surgery standards). That extra time adds up and turned 1 surgical day into 2 for Dr. Newsom, who would routinely use the laser on 20 to 30 premium eye patients a day.

"That's when we said, Wait a minute, taking all this time, opening up the OR on an additional day, is it really worth it?" he says. "That's when we cut back on using the laser and took a long look at if it was worth it financially for patients and for us as a business."

Future promise?
Dr. Miller says there are very few things he's done in his career that cost patients a lot of money, but that produce no direct benefit other than the perception of better care.

Perception, as they say, is reality. Some of Dr. Newsom's patients demand laser-assisted surgery, because they feel they're receiving suboptimal care if the laser isn't used. Many patients want to undergo surgery with the latest and hottest tool, which Dr. Newsom believes is one of the technology's strengths. He also believes it levels the playing field for novice surgeons who might not be as skilled with the blade in making the capsulorhexis.

Mr. Dawes says the femto laser is almost a must-have for surgeons who want to run a true refractive practice. Surgeons who are doing only basic cataract surgery have learned that they can get by without a laser by offering some level of astigmatism correction with limbal-relaxing incisions or a multifocal or accommodating lens package, according to Mr. Dawes. "But they're competing as cataract surgeons," he adds, "not as refractive surgeons."

Dr. Miller believes laser cataract surgery is around for the long haul. He's seen the story play out before when phacoemulsification hit the market in the early 1990s. "People were touting the technology, but couldn't show that it provided any major benefit," he says. "Sure it let you remove the cataract through a small incision, but then you'd open the incision to 7 or 8 mm to insert the lens implant. Phaco cost a heck of a lot back then, and for what? Then foldable lenses came along and no one looked back."

Lasers will follow a similar trajectory, says Dr. Miller. "Some lens technological advancement will come along and we'll say, Ah, that's why we have the laser." For example, he says, perhaps surgeons will someday be able to implant wavefront-correcting lenses because they'll know exactly where they'll sit on the X, Y and Z planes.

"If I look at my crystal ball, I believe the laser will be more widely adopted than it is now, and I've seen a lot of technologies fall off the radar," says Dr. Miller. "This isn't the end of the story for the laser. It's the beginning of its next phase." OSM