Rivalry Between Canadian, U.S. Eye Doctors Heats Up Into Laser Fight

A cross-border battle between U.S. and Canadian eye surgeons has all the high-sticking civility of a hockey brawl.

Canadian clinics accuse their American competitors of price gouging. U.S. doctors warn patients they risk blindness at foreign laser mills. Some even refuse to treat those who venture north for bargain surgery.

The war of words is getting nasty, and it’s easy to see why: People spent about $2.1 billion in the United States for laser eye surgery last year in hopes of throwing away their glasses. U.S. doctors want more business this year.

Americans have been going to Canada for corrective eye surgery for years--first because the procedure was unavailable in the United States and now because it’s much cheaper there, especially with current exchange rates.

The “flap and zap”--so called for the two-step process required to cut a corneal flap and remove tissue beneath it--usually takes less than 15 minutes.

American doctors typically charge $4,000 to $5,000 for both eyes, though prices in the $2,000-$3,000 range can be found in competitive markets.

Lasik Vision Canada, which operates 15 clinics north of the border, charges $999 U.S. for laser in-situ keratomileusis, or LASIK surgery, to correct nearsightedness, farsightedness and astigmatism. That fee covers both eyes, as well as all pre- and postoperative visits.

For doctors, there is an added bonus: Fees come directly from patients. The procedure is considered cosmetic, and most U.S. insurance carriers won’t pay for it. Neither does Canada’s national health insurance.

Some U.S. doctors won’t treat patients who have had laser surgery in Canada. They cite liability concerns.

“I think that’s the excuse they give,” says Michael Henderson of Lasik Vision Canada, which opened its first U.S. clinic last year in suburban Bellevue and plans to open six more in the American West this year.

“It’s a way to try to say you ought to stay in the States and pay more.”

Henderson scoffs at the U.S. rates as “gouging” and notes his company “did over 46,000 eyes” last year.

“You don’t become the No. 1 player if you’re not good,” he says.

U.S. doctors fret that price isn’t the best reason for choosing a health care provider.

“The public too often considers this like buying a new pair of shoes, a new set of tires,” says Dr. John Sonntag in Boise, Idaho.

“Would you go to a foreign nation for a thyroid operation? Probably not,” he said. “More people fear blindness than fear death, so it’s interesting so many people would be willing to risk it.”

Henderson dismisses the liability issue, saying malpractice claims are based on “a surgeon making a mistake--rarely from seeing someone on a post-op visit.”

Stateside doctors and health administrators say it’s not that simple.

“Our court system is funny that way. You typically inherit some liability” by providing follow-up care for a procedure that has a bad result, says Ken Taylor, vice president and health care industry consultant with Arthur D. Little in Cambridge, Mass.

Suing for malpractice in Canada--where judges generally decide damages--is not as lucrative.

A patient unhappy with Canadian clinic results may go after the U.S. doctor who provided follow-up and has relatively deep pockets through malpractice insurance, said administrator John S. Bell of Maine Eye Care Associates in Waterville, Maine.

Some doctors are willing to do follow-up if they know the surgeon or clinic involved. But they prefer advance arrangements.

“When I tell them the fee is about $1,000, they usually disappear,” says Sonntag, who recommends a year of post-op care.

Follow-up “enhancement” procedures about three months after surgery, to fine-tune the patient’s vision, are required in about 10% of LASIK patients, said spokeswoman Jan Beiting at the American Society of Cataract and Refractive Surgery/American Society of Ophthalmic Administrators in Fairfax, Va.

Post-op care is part of the deal, but you have to go to Canada to get it, Bell said. For patients who live far from the border, air fare costs could quickly eat up any savings.

Distance also can mean delay, which can cause small problems to turn into big ones.

Serious complications are “pretty rare,” says Dr. Lawrence Spivack in Englewood, Colo. “But if you get to it quicker, you’re much more likely to have a great result than if you wait.”

In Seattle, Dr. Steven Wilson cited the case of a young man who had surgery in Canada and follow-up care with an optometrist. A fungal infection was not treated appropriately, and he underwent two corneal transplants.

“He’ll probably never have the vision restored to one eye. . . . He’s basically blind in that eye,” said Wilson, director of the Refractive Surgery Center at the University of Washington’s Ophthalmology Department since 1998.

Optometrists--who test vision and prescribe corrective lenses--are not surgeons or even doctors, though they can be certified to provide post-operative care. Ophthalmologists, doctors who specialize in diseases of the eye, are generally a more appropriate choice, Taylor said.

Another factor in the lower Canadian prices is patent-royalty fees imposed on U.S. doctors by the American makers of excimer lasers. The standard fee was $250 per eye until early this year, when most were dropped to about $100.

But spokeswoman Lola Wood at industry leader Visx is not sure the fees are at issue. When Canadian doctors first began offering the procedure in the early 1990s, the price for two eyes was $4,000 to $5,000.

“We never charged a royalty fee in Canada, and the price was the same,” she said from company headquarters in Santa Clara, Calif.

Prices dropped as competition increased--as is happening now in the U.S. market, Wood said.

Lasik Vision Canada charges twice as much for surgery at its U.S. clinic, $999 per eye, but is still priced far below most American competitors.

Doctors’ salaries also are a factor. Some clinics in both countries hire doctors with very limited LASIK experience, practitioners complain.

Typically, such clinics “find someone young who spends a couple weekends in training and then starts doing surgery,” Wilson said. “That cannot compare to someone like myself who does a one- or two-year fellowship” in refractive surgery and has 12 years’ experience.

Some doctors opening new practices claim to have done 5,000 eye procedures, when in fact they have done 4,900 cataract surgeries and 100 LASIK procedures, rivals say.

And quantity isn’t everything, Wilson said:

“You can go to a military barber who’s done 10,000 haircuts, but you probably don’t want to go to him when you’re having dinner at the White House.”

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On the Net: American Society of Refractive and Cataract Surgery site:

www.ascrs.org

American Academy of Ophthalmology site: www.aao.org

U.S. Food and Drug Administration site: www.fda.gov

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Eye Surgery Basics

Some basics about the three primary types of corrective eye surgery, and related actions by Health Canada and the U.S. Food and Drug Administration. All three procedures modify the curvature of the eye, which determines near- and farsightedness, to make it refract light the way it is supposed to and thus correct vision. As many as 800,000 Americans will undergo laser eye surgery in the United States this year, up from about 500,000 in 1999, said analyst Christopher Douglas of Crowell Weedon & Co. in Los Angeles.

RK, radial keratotomy: Involves cuts with a scalpel to the radial spokes in the cornea, to correct nearsightedness. A procedure used in the United States since the 1970s. Little interest reported in Canada.

PRK, photorefractive keratotomy: A laser excimer, a device adapted from industrial use in the 1980s, is used to vaporize corneal tissue. FDA approved use of certain excimer lasers for this purpose in 1996; Health Canada approved their investigational use for this purpose in 1989.

LASIK, laser in-situ keratomileusis: The cornea is cut with a blade in a circular pattern leaving a hinge so it can be lifted and laid back to expose the tissue underneath. A tiny bit of corneal tissue is removed with an excimer laser, using calculations based on the individual’s eye or eyes. FDA approved use of certain excimer lasers for this purpose in 1999; Health Canada began issuing investigational-use authorizations in 1995.

Intacs: Tiny plastic ring segments implanted in the cornea to change the shape of the front surface of the eye. FDA approved their use to treat slight nearsightedness in 1999. Health Canada approved their sale in 1998.

Other Options Undergoing Clinical Trial in U.S.

Laser thermal keratoplasty: Using lasers to heat the cornea to correct farsightedness; and radio frequency keratoplasty, a similar procedure using radio waves.

Phakic intraocular lenses: Artificial lenses similar to those used for cataract patients, which are implanted in the eye to improve focus of the natural lens.