Download The economic impact of SLT in treating glaucoma

The economic impact of SLT in
treating glaucoma
Robert Noecker, MD, MBA
Selective laser trabeculoplasty (SLT) has been available in
the United State since 2001 for the treatment of glaucoma.
It has become a significant tool in glaucoma management
that has proven utility over the past 10 years. SLT has
the potential to reduce costs to patients, the health care
system at large and clinical practices. There are significant
costs with medical therapy for glaucoma, at all levels of
the system. SLT provides a potentially more cost effective
solution for reducing IOP and controlling glaucoma in many
patients.
For patients, the cost of glaucoma therapy has become
increasingly expensive. The annual costs for glaucoma
medications range from $150.81 for generic timolol maleate
to $873.98 for a three times daily dose of Alphagan P 0.15%
(brimonidine tartrate ophthalmic solution, Allergan, Irvine,
Calif.).1 Another study performed in Ontario, Canada and
published in the Canadian Journal of Ophthalmology in
2006, found that the use of SLT as primary therapy was
somewhat more cost effective than primary medication
therapy for open-angle glaucoma patients over the age of
65. In the scenario in which primary SLT provided good IOP
control over a two-year period, the relative cost savings
versus a regimen using one, two or three medications over
a six-year period was $206.54 dollars, $1668.64 dollars,
and $2992.67 dollars for a given patient respectively.
In the United States, the cost of medical therapy can vary
quite a bit due to large differences in formulary coverage
even among individual insurers. However, common prices
“SLT has the potential to reduce
costs to patients, the health
care system at large and clinical
practices”
for monthly prescription drug coverage are Tier 1 $10-15,
Tier 2 $20-$50 and Tier 3 $50-80. In contrast, the average
cost to a medicare patient undergoing SLT is $56-78. Even
assuming a relatively short lived duration of action of 6
months, which would be less than expected, the SLT will
save many patients money. If the duration of effect is for
years, the cost savings can be extremely significant.
The increased presence of generic preparations has
had a somewhat disruptive effect on clinical practice.
Since Xalatan became available in generic latanoprost
preparations in Spring 2011, there has been some
disruption to clinical operations. There are six approved
manufacturers of latanoprost ophthalmic preparations in
the United States and there appears to be some variability
in terms of packaging, i.e. bottle color, size and shape.
Some of my patients have experienced tolerability and
efficacy issues with the different generic preparations,
which did not exist while using the branded preparation.
Some of the issues may be related to the different bottles
that some patients have found to be different in terms of
how hard they need to squeeze the bottles. As a result, we
have had patients running out of their latanoprost sooner
than the allotted month allowed for each bottle and have
had to acquire a new bottle at the non-covered retail price,
resulting in higher costs than they experienced before.
At the practice level, the impact has been more phone calls
to clinical staff regarding formulary requests for either prior
authorization requests for branded medication or requests
to switch. We have had little success with requests for
branded medication, and change to another medication
has been necessary in many cases. After the switches, the
patients have required additional visits to ensure that the
change to the regimen has been successful. For patients
who have experienced new side effects, there have
been more unscheduled visits in addition to phone calls.
This disruption has led to the decision to pursue SLT as an
alternative to reduce both patient and practice difficulties
with medical therapy. Making their care more predictable
and consistent.
These disruptions both in the control of glaucoma in
individual patients and the disruption to practice operations
has led to the decision to pursue SLT as an alternative to
reduce both patient and practice difficulties with medical
therapy. Many clinicians have become frustrated enough
with this situation that they have begun to urge patients to
use SLT more and more as their primary glaucoma therapy
option. In addition, rather than forced to make switches
to medical therapy that may not be optimal, some of my
colleagues have instructed the staff to have patients come
in regarding a discussion about SLT. This seems to be making
their glaucoma care more predictable and consistent.
Indeed, while there is some initial expense for the machine
used for SLT, these lasers last a long time and can be used
on thousands of patients which makes it less expensive
than medical therapy.
“SLT offers an opportunity to increase
patient flow and treat glaucoma
patients in an efficient manner”
Besides the benefits to the patients receiving treatment
with the laser, SLT provides operational benefits to the
clinical practices that have increased its use. Use of the
SLT can improve patient flow, and the procedure can be
“the income generated from
performing this procedure [SLT] can
be significant”
intermixed with other patients during clinic hours. The
recently published SLT/Med study showed that while the
degree and rate of successful IOP lowering was similar using
medications or SLT as first line therapy, the number of steps
through the treatment algorithm was less in the SLT arm.
The rate of required additional steps in therapy over the
year-long study was 11% for SLT group versus 27% for the
SLT group of patients. The implication to clinical practice
is fewer visits for patients to become controlled and that
ophthalmic surgeons could spend their time performing
more higher value procedures.
Depending on which version of the laser a practice may
be using, SLT offers an opportunity to increase patient
flow and treat glaucoma patients in an efficient manner.
In situations, where the combined SLT and Nd:YAG lasers
are housed in the same unit, all of the common anterior
segment procedures (SLT, Nd;YAG capsulotomy, and Nd:YAG
iridotomy) can be performed in the same room. This may
reduce bottlenecks and minimize the transference of
patients from one room to another for procedures. This
in turns leads to efficiency and better through put during
clinic hours.
When I perform SLT in an ambulatory surgery center, the
SLT procedures can easily be intermingled with other cases
on the same day. The time that it takes to do an SLT seems
to fit very nicely with the turnover times between cataract
surgeries and glaucoma surgeries that I perform. Once
again, if the combination unit with the Nd;YAG is used, the
flow in the facility tends to be very smooth and efficient.
In other practice settings it makes the most sense to use
the portable SLT option. This version can attach to a HaagStreit® slit lamp and can be easily transported from office
to office. This can help to bring this technology to remote
locations such as satellite offices, the offices of referring
providers, long term care facilities and other underserved
areas where patients are limited in their access to SLT.
The economics for SLT at the practice level make this
technology an easy to acquire piece of equipment that does
not require a large amount of capital investment with a
long payment period. In a typical general practice with an
average sized glaucoma population, there are more than
enough patients who are candidates for SLT. In a practice
where even only a few procedures are performed on a
monthly basis, the investment in the laser breaks even
and if more are performed, the income generated from
performing this procedure can be significant.
The procedure is billed under the laser trabeculoplasty
65855 CPT code and the physician payment is $329 on
average if the procedure is done in the office setting. If
the SLT procedure is performed in an ASC or hospital the
physician payment is $291 on average. If the procedure is
done in an ambulatory surgery setting, the 2011 facility fee
is $172 on average and for hospitals it is $386. The global
period following the procedure is 10 days, which translates
into minimal unpaid clinic visits during the post-op period.
In my clinical practice, I will do treatment on one eye,
usually the one with the higher IOP first. I will schedule
the patient’s second eye (if necessary) for SLT two weeks
later. The patient can then be seen for a level 2 outpatient
follow-up visit for evaluation of the first eye’s success and
the second eye can be treated with SLT. If a given patient
does not have end stage disease or is not at high risk for IOP
spikes (pigmentary glaucoma patient) then the evaluation
of success is done at 6-8 weeks post-procedure. I have had
many patients who have undergone repeat SLT several
years after good initial success and have had favorable
responses to repeat treatment if they were good responders
with initial treatment. Operationally and billing wise, the
routine for SLT is the same as with the initial treatments.
“In my clinical practice, I see the
demand for SLT increasing steadily”
has increased, I have had more and more patients come
to me to have the procedure performed. SLT has been a
major source of glaucoma referrals from my optometric
colleagues as a means to avoid or minimize medical therapy
in patients with glaucoma. I have utilized the SLT in the
combination platform with the Nd: YAG, in a hospital, ASC
and office setting. I have also used the portable platform to
travel to different offices and have found it to be crucial.
The versatility of the platforms make the use of the laser
by multiple ophthalmologists for different applicationssometimes a beneficial feature in multi-specialty practices
when decisions to purchase equipment are being made.
SLT is one of the most economical ways to treat glaucoma
today. It is good for the health care system in terms of
controlling glaucoma with minimal morbidity compared
to surgery and has reduced medication costs. Its use saves
patients money that would be spent on medications,
and helps to minimize additional office visits due to side
effects of medical therapy. The post-op recovery is rapid
and patients can resume their daily activities almost
immediately. For surgeons, the procedure is reimbursed
at a level that makes the return on investment period
relatively short. It can provide a long-term revenue stream
for a practice treating glaucoma and can help to minimize
non-paying post-op patient encounters. For those doctors
performing SLT, it is a practice builder as a value added
procedure that should be considered for many if not most
glaucoma patients.
In my clinical practice, I see the demand for SLT increasing
steadily. Having performed it for over 10 year, it is something
that is extremely useful for an ophthalmologist to have
in the treatment armamentarium. As public awareness
REFERENCES:
1. AJO, January 2008
PB-1106570_A