Comment by bityard | Hacker News Reader

Comment by bityard | Hacker News Reader

Same reason medical care is so expensive in the US: Insurance and the art of the upsell. The provider gets to charge high prices because the bulk of the cost is covered by insurance and thus "hidden" from consumers. The insurance company gets a non-trivial cut of the pie, which pads the bill further. And in my experience, when you go in with something wrong with you, most doctors will recommend (or perform without asking) tests that aren't covered by insurance and you don't find that out until the bill arrives in the mail.

I have a pretty standard vision insurance plan and need glasses roughly every two years. (Two pairs: one for indoors, and sunglasses for outdoors and driving.) I go into an optometrist office and get my vision checked. $10 copay or whatever for the exam. Then the pain starts. The frame selection is terrible and it turns out that the only decent-looking frames and lenses cost 3-4x what insurance will cover. And insurance doesn't cover more-or-less "required" add-ons to lenses like anti-glare coatings. And the person selling you the glasses is _very_ good at convincing you that you need all the extras.

I did the math one time and I paid $200 per year for vision insurance to save $190 (including the cost of the exam) on one pair of glasses.

The last time I bought glasses, I took my (recent) prescription to an online eyelasses e-tailer website and purchased a pair that included all the fancy extras for $60 out the door. I don't _love_ them, but I can certainly live with them for the price.

It's healthcare monopolies, from supply to distribution, it's all wrapped up pretty tightly. There's also one large payer that covers most of the market already.

Zero people have effective choices in this system. So.. prices go up.

I would suggest checking out other optometrists, most have a much better insurance wall than they had a couple of decades ago. Or go online (to order, not suggesting an eye exam over webcam :D ).

That said, I'm currently getting cataracts removed and IOL implants and insurance is like "correcting your astigmatism isn't needed so we won't cover the IOL that does that, just your distance vision". If correcting my vision isn't necessary then why cover any IOL at all??? :-/

This gets into the weeds a little but the reason boils down to money and tradition, and “what is needed” is a shifting goalpost for society.

Just thirty years ago you may have never even gotten an IOL due to tradition or cost. After adoption in the developed world there was a huge push to prevent lower income countries from accessing the technology because they “didn’t need” that technology and could benefit from lower cost interventions such as glasses.

So as companies started to innovate and lower cost, single vision non toric IOLs became cheap enough for insurance to cover. Then to make some money on premium lenses companies (and ophthalmologists, sadly) really started to push torics and multifocal lenses.

The fact of the matter is that few patients benefit all that much from toric lenses that fix astigmatism. Most people have less than 1 diopter of astigmatic error, which they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics), and surgical modifications can nullify that to some extent. Veterans get it free at most VA hospitals though, so they probably get more implanted than the average population.

In the next fifteen years though I bet Medicare will begin to cover toric lenses, and the rest of the insurance industry will follow. The surgery doesn’t change much between toric and non toric. The Multifocal IOLs will remain “premium” for a while to come I expect.

> The fact of the matter is that few patients benefit all that much from toric lenses that fix astigmatism. Most people have less than 1 diopter of astigmatic error, which they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics), and surgical modifications can nullify that to some extent.

I do think the cheapness of astigmatism correction in lenses for glasses means that more people get full correction than in the past, but if you're like me and apparently descended from mole people then correcting distance vision alone does squat. My distance vision is far from the worst at 7-8 diopters, so can be mostly corrected with normal lenses, but my astigmatism is bad enough that I wouldn't be able to legally drive without correction. Despite that, instead of getting insurance covered IOLs, I'm paying 3k each for the IOL for each eye.

Only real problem with the one I have so far is that the existing "accommodating" IOLs simply aren't particularly good, and the varying types of multi-focal IOL do cause halos, so if you're like me and already get halos they're off the table. So on the one hand my right eye now has 20/20 vision, on the other: instant presbyopia.

My unpopular opinion is that Multifocal and extended depth of field IOLs are all attempting to cheat physics unsuccessfully and are a cash grab by ophthalmologists and manufacturers.

The other option you have is some form of refractive surgery. Also the wholesale cost of a toric IOL is somewhere around $700 so unless the surgeon fee is thru the roof it shouldn’t be costing you $3k each eye.

multifocal ones work for some people, but also fairly often creates halos etc because as you say they're trying to cheat physics and rely on the brain learning what to filter out.

I cannot find any place that is offering $300 toric IOLs, patient cost of tonic IOLs is generally 1100-1500 (with insurance covering the remainder, however it does make me realize that I should get the receipt so I can submit that particular bit to my insurance company directly which I realize they may not have done)

> [...] they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics)

I tried a quick google search but couldn't immediately verify. That seems horrible. Really production/specification tolerance, or just eye-correction tolerance to determine the need for a change?

I feel tempted to replace the lenses when eyes have changed by 0.25 (though delaying until 0.5 off). I have returned glasses which were mis-manufactured with the cylindrical axis for one eye off by 10 degrees.

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