I have witnessed a concerning trend in the past year. Health insurance companies are starting to practicing medicine themselves!!  They are making decisions regarding how surgery is done by deciding which materials they will and wont pay for at the time of surgery.  Similiarly, they have started to not pay at all for some antibiotic drops used  before and after surgery.   Let me be more specific.  Pterygium surgery can be done using either the patients tissue (autograft) or donor tissue (Amniograft).  I prefer to always use Amniograft as there is only one incision to remove the pterygium vs two incisions when the patient's own tissue is used to fill the space where the pterygium was removed.  The final outcome as far as recurrence and aesthetic outcome is probably no different.  However, the amount of postoperative discomfort using the Amniograft is much less than using the autograft.  This has been confirmed by our patients where they can compare their experiences with one type of graft in one eye and the other type in the fellow eye. These patients ALWAYS find the Amniograft experience far superior to when an autograft is used.  Recently, I had a patient with a very large "double-header" pterygium.  There was a large pterygium on both the lateral and medial aspect of the cornea.  The patient didn't have enough bulbar conjunctiva to use for donor tissue, yet the insurance company would not allow the use of Amniograft .  The patient also was not able to pay out of pocket for the Amniograft  as the surgical facility accepts assignment and participates with the insurance company.  The only way for the procedure to be done was for the patient to pay for the ENTIRE procedure out of pocket.

   Health insurance companies, similiarly, are trying to cut costs on the pharma side .  In the past six months, some of the insurance plans have stopped paying for fourth generation fluoroquinolones completely.  These drops used to be paid at a higher tier level and greater out of pocket copay.  In order to further boost corporate profits, the next step was taken where they presently aren't covered at all.  Patients now call back our office for second and third generation antibiotics with a greater bacterial resistance level and in our opinion, a higher theoretical  risk of endophthalmitis after intraocular surgery.  We are unfortunately probably going to have patients who choose these second and third generation antibiotics, sign a release explaining the increased risk of these older agents, helping to indemnify us from liability should they develop a post-operative infection.

   Unfortunately, the Affordable Care Act did nothing to rein in the practice of medicine by health insurance companies.  If anything, it has probably accelerated their practice of medicine.  All these maneuvers are allowing these companies to better leverage their balance sheets in anticipation of the mandated Affordable Care Act medical loss ratio rules. These rules have been in place since the beginning of this year and will define what percentage of costs are overhead vs the actual payment of medical services.   Ironically, more and more doctors will be leaving and no longer participating in these health plans, further exacerbating the health care access issues the Affordable Care Act was supposed to address.

                              

                JOHN C BALDINGER MD

We are all familiar with prostaglandins, but Merck just released a new, non-preserved prostaglandin analog.  Zioptan (tafluprost ophthalmic solution) 0.0015% is the newest addition to the prostaglandin analogs with indication for POAG as well as ocular hypertension.  This medication claims to have similar efficacy to Xalatan but is non-preserved.  It is supplied in single use containers, 10 to a pack (3 packs per month).  Packs must be refrigerated until opened, and discarded after 28 days of non-refrigeration

 

   The side effects are similar to the other prostaglandins with redness, longer and darker lashes, iris darkening, peri-orbital skin darkening, CME, etc.  Although it is not stated, I suspect, that we will also see  prostaglandin- associated periorbitopathy (PAP).  I call these Xalatan eyes and often notice them at grocery stores or The Home Depot.  This little known side effect is evident through deepening of the upper eyelid sulcus, relative enophthalmos, loss of the lower eyelid fullness, and involution of dermatochalasis.  It is most noticeable in younger patients or those treated unilaterally.  It is demonstrable on MRI.  Keep this in mind for unilateral ptosis and proptosis cases.  Fortunately, this is at least partially reversible when drops are discontinued.  It is important that clinicians report cases of PAP as an adverse event to all of the PGA manufacturers and the FDA (www.eyedrugregistry.com).

 

  So, in a truly BAK sensitive patient, we now have another drug in our armamentarium.

 

                JAMES MATTERN OD

 

Thank you for your diligence in reporting post-op cataract and refractive surgery post-op exam findings.  We track surgical outcomes and can only do it with your help.  Also, your up-to-date Fax number allows us to communicate with you through our new Electronic Medical Record (EMR) system (Greenway Primesuite)

From Ophthalmology Times (July 15, 2011, p.25).  A second trial of Restasis may provide clinical benefit in patients with chronic dry eye who have failed a first round of the drug. 80% of patients whose treatment failed the first course of Restasis were successful in a second trial as a result of proper education.

 But isnt Restasis expensive?  No, not nearly as pricey as you may think.  If you want to see how the top 5 insurance plans in your area cover Restasis, go to www.Restasiscopay.com and enter your zip code.  You will immediately see the Restasis copay for your patients.  Combine that with discount coupons and it is very affordable.  I would also remind you to treat the lids if needed in conjunction with or before the Restasis and be slow to insert punctal plugs until the tear film is of good quality. 

 

 

Founded in 1986 by doctors of optometry in Northern Virginia, Capital Eye Consultants has provided 25 years of quality and comprehensive consultative/surgical co-management services for the optometrists and their patients in the Northern Virginia area.