/ KFF Health News
Tammy Chalala, a retired dietitian in New York, was thrilled with the results of her cataract surgeries, which left her with close to 20/20 vision.
She said she paid nearly $4,000 out-of-pocket for her two surgeries last year because she opted to have her doctor use a laser to assist with the procedure.
Chalala, 69, chose that method over the traditional scalpel after doing research online and consulting with her doctors, believing it would give her the best outcome. "It seemed like the better option," she said.
Cataract surgery — one of the most common operations paid for by Medicare — typically leaves enrollees owing a few hundred dollars. Some patients pay more to have their vision corrected during the procedure.
But, like Chalala, a growing number of those patients are paying even more out-of-pocket simply because they agree to have their doctor use a laser rather than the scalpel method.
Both methods are safe and can significantly reduce or eliminate the need for patients to wear glasses.
However, many doctors say the laser helps make more precise cuts than the scalpel. The laser method gives patients more options, they say, and recoups more revenue as Medicare has gradually cut what it pays doctors for cataract surgery.
Others, such as Oliver Schein, an ophthalmologist at Johns Hopkins Medicine, point out the strong financial incentive to use the laser, as the equipment can cost a practice up to $500,000.
Schein said his colleagues used the laser a few years after it came out but did not see any benefit over traditional cataract surgery. Still, the laser doesn't cause harm and provides patients with good results.
"That's a powerful combination for a surgeon," Schein said. But in the end, he added, most patients believe paying more will yield a better result.
Medicare pays doctors about $520 for a standard cataract procedure, down about 20% in the past decade. The fee includes pre- and postoperative visits.
While Medicare generally prohibits doctors from billing patients above what the government program pays, doctors are allowed to bill patients extra when using the laser only when it is used to improve vision, because most vision correction is not covered by traditional Medicare.
Specifically, doctors may bill patients when using the laser to insert premium lenses or fix astigmatism. Doctors typically charge $1,000 to $3,000 per eye for use of the laser.
Medicare enrollees also pay out-of-pocket for the premium lenses that can eliminate their need for reading or distance glasses, with charges ranging from $1,000 to $4,000.
Private insurers, including those operating Medicare Advantage plans, typically follow Medicare benefit rules.
Research shows the laser does not provide better outcomes than the scalpel for a standard cataract procedure.
The American Academy of Ophthalmology, the world's largest organization of eye physicians and surgeons, says on its website: "Studies do not show that laser surgery results in fewer complications. Also, studies haven't found that laser surgery provides better outcomes."
Nearly 12% of the 5 million annual cataract surgeries performed nationally are laser-assisted, and that number has been growing, according to the St. Louis-based ophthalmic market data company Market Scope.
"It's a win-win for patient and doctor," said Kevin Miller, a UCLA ophthalmology professor. "Doctor makes a little more money on top of the Medicare reimbursement; the industry gets money to develop new technology; and society benefits because these patients are not going for eyeglasses anymore."
By age 80, more than half of Americans have had cataracts, a condition that causes blurred vision and poor night vision. Most cataracts develop slowly as part of the aging process when proteins and fibers in the eye's lens break down and clump together.
Doctors for decades have used scalpels to perform cataract surgery, which involves removing the cataract and replacing the cloudy natural lens with a clear artificial one.
Barbara Cobuzzi, 71, a medical billing consultant with traditional Medicare coverage, needed cataract surgery last year. When her eye doctor in New Jersey recommended she get the surgery using a laser at a cost to her of $1,500 per eye, she went looking for a second opinion. "I felt like he was trying to pull a fast one."
Cobuzzi said the second doctor performed her procedure without a laser, and she was happy with the results, including no longer needing glasses for distance vision.
"Doctors are using the laser as a moneymaker," she said.
Vance Thompson, an ophthalmologist who is a past president of the American Society of Cataract and Refractive Surgery, said some patients want the laser because it provides a more precise way of doing the surger,y while others choose it to avoid the need for glasses.
He said he talks to patients about the advantages of the laser and lets them decide which method is right for them. "They deserve to be educated on all their options," Thompson said.
He said about half his patients at his Sioux Falls, South Dakota, practice choose the laser, up from about 10% a decade ago.
The laser is not suitable for all patients, though, including those who have corneal scarring or a small pupil, Thompson said.
It's challenging to illustrate the benefit of the laser because traditional cataract surgery is already safe and effective, with low infection rates, said Barrett Eubanks, a U.S.-trained ophthalmologist in Toronto.
He said he's found that, compared with the older method, using the laser makes it easier to implant premium lenses or remove certain types of cataracts. That's because the laser can make the exact cut it's programmed to make, unlike the human hand.
Miller, the UCLA ophthalmologist, said the laser helps bring money to his practice as Medicare reimbursement continues to decline. "One of the problems with ophthalmology is everybody is scrambling to keep the lights on," he said.
Miller said his practice has offered laser cataract surgery for several years. He compares the choice to buying a Toyota Camry or buying a Lexus. "Both will get you where you want to go, but one will get you there with a premium feel and leather seats," he said.
He said his patients know they can choose the surgery without a laser. "We do not pressure anybody to do anything," Miller said.
At his practice in an affluent part of Los Angeles, he said, 80% of patients opt for laser cataract surgery. "What you buy with a laser is precision and reproducibility, as every laser cut looks exactly the same," he said. "It does not make vision better."
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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