Achieving Financial Success in Glaucoma Surgery

Technological advances are positioning surgeons to offer patients with glaucoma the real hope of an improved quality of life.

By James D. Dawes

As a “business guy” working in medicine for over 25 years, I am often asked to talk about methods of achieving financial success with various health care delivery models. I have always felt uncomfortable about approaching medicine through the metrics of financial success. Complicated reimbursement scenarios involving private and government-sponsored health care insurance may not always correlate to the best care for a patient or to financial success for providers. The field of glaucoma is not immune to this reimbursement problem, but this brief article explains why recent developments have encouraged me to feel that this subspecialty is headed in a new direction.


Refractive and cosmetic surgeons have long witnessed the beauty of the free market for determining the economics of price, demand, and supply. The economic model for elective medicine is highly dependent upon the following: patients’ outcomes, satisfaction, and experience.

Refractive surgeons have been able to provide patients with treatment options that may enhance their quality of life by improving their vision and decreasing their dependence on glasses and contact lenses. During the past decade, the field of refractive surgery has expanded from corneal procedures to include treatments for astigmatism and presbyopia for patients presenting with cataracts and dysfunctional lenses. Ongoing technological advances provide refractive surgeons with a growing number of tools to improve patients’ vision and quality of life through surgical procedures. Now, glaucoma surgeons have a similar opportunity: microinvasive glaucoma surgery (MIGS).

With MIGS, surgeons are in a position to offer patients suffering from glaucoma the real hope of an improved quality of life. Generally speaking, MIGS procedures coupled with technological advances in medical devices have the potential to improve management of the disease by lowering IOP while at the same time reducing patients’ dependence on topical medication and enhancing their visual outcomes. This formula sounds a lot like refractive surgery to me.

Although the free market has not caught up to the technological advances in glaucoma surgery, the evolving payer market has started to embrace outcome measurements and pay-for-performance methodologies for reimbursement. Specifically, reimbursement models are shifting to allow providers greater influence, risk, and rewards for population-based health management. Technologies and procedures proven to provide better outcomes, higher rates of compliance, and an improved quality of life for lower long-term costs will replace many treatment options that do not necessarily achieve these objectives.


A discussion of the intricacies of reimbursement and the variations within regional US payer markets as they relate to MIGS is beyond the scope of this article. Nor will I cover the clinical effectiveness of the various MIGS devices being implanted by glaucoma surgeons inside and outside the United States.

In general, I have seen positive reimbursement trends with Medicare and private insurance when MIGS is combined with cataract surgery. If I assume that 10% to 20% of the nearly 3.5 million cataract cases performed annually in this country involve patients with glaucoma, a staggeringly large number of individuals might benefit from MIGS.

Payers still have to sort out details on the technology, including the optimal number of devices that might be implanted, how multiple devices might or might not be reimbursed, and what patients can pay for directly. The payer markets also have yet to address the potential benefits to patients, payers, and providers with regard to patients who have a grade of cataract for which surgery is not medically necessary and pseudophakic patients with mild glaucoma. Suffice it to say that, as patients and health care providers assume more of the financial risk via population-based health management that works off reimbursement models, MIGS will become a costeffective and efficacious tool. I expect MIGS procedures to fundamentally change the practice patterns of glaucoma surgeons, much as the availability of femtosecond laser systems, intraoperative imaging devices, and premium IOLs is influencing cataract surgeons.


I may be a dreamer, but I hope for a day when patients’ outcomes and satisfaction are the main drivers of the financial success of all health care providers. That includes glaucoma surgeons.

James D. Dawes is the president of the J. Dawes Group in Sarasota, Florida, and he serves as the chief development officer of Vold Vision in Northwest Arkansas. Mr. Dawes may be reached at (941) 928-2589;


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