Roundtable Discussion: Attracting, Communicating, and Converting Patients to Refractive IOLs

For the countless hours that doctors spend learning the medical techniques and science behind their profession, very little time is dedicated to understanding how business development concepts will make a practice truly successful. In the following roundtable discussion, which took place in September at the 2007 Refractive IOL Symposium held in Las Vegas, leading surgeons and industry experts discuss their pearls for combining good medicine and good business—to create a winning solution for refractive practices.

Dr. Donnenfeld: We have an outstanding group of people here to discuss the idea of converting more patients to premium IOLs in your practice.

Starting out, I would like to ask each panelist what is your preferred method of communicating the value of premium IOLs to your patients?

Dr. Dell: Typically, I will say to my patients, "What are other purchases that will have a lifelong impact? If you go on a cruise or vacation, the money is gone in 6 days; this is something that you can use every waking moment, for the rest of your life."

Dr. Donnenfeld: That is a great pearl. I think it really helps patients to appreciate the value of what they are receiving. Sam, do you have any pearls that you use in your practice?

Dr. Masket: You must communicate the specific value of presbyopic IOLs to the patient. Functioning without glasses is a meaningful concept and that message should be communicated.

Dr. Chang: The ASCRS Eye Surgery Education Council commissioned a Harris poll that revealed how little people know about presbyopia—including people who have already undergone refractive surgery. I think that the concept of value starts with educating patients about a standard IOL's inability to change focus. Once they understand this notion, we can follow up with the idea that premium IOLs can give them vision that no one else their age can otherwise achieve.

Dr. Donnenfeld: It is important to help our patients understand what they have been given in terms of vision. Alcon Laboratories, Inc. (Fort Worth, TX) makes -3.00-D glasses that take patients from a multifocal lens to a distance lens. In the past, I used these on patients who were unhappy and experiencing problems. Now I use them on every patient—especially happy patients. If a happy patient comes in and I say, "Let me show you what your vision would be like if you have a regular monofocal lens," he is very surprised to find that he cannot read anything. I explain to him that this is what his friends who have had regular cataract surgery see. The patient would not have understood the value of his vision, otherwise. One of your technicians should have all your patients try on these -3.00-D lenses.

Dr. White: We start to help the patients internalize their value as soon as they walk through the door. We want to give them the feeling that they are worth doing this for themselves. I steal good ideas from anywhere I can on how to improve my practice. One of the ideas that I have stolen from Shareef Mahdavi is to replace the waiting room with a lobby that looks very much like a high-end hotel. We want to deliver the message that we value our patients, so they should value themselves.

Ms. Coulson: My pearl would be to listen to your patients. I spend a great deal of time shadowing surgeons and have found that they tend to talk a lot and not listen very well. Also, surgeons do not pick up on patients' verbal or physical cues. What is the patient wearing, what kind of shoes does he have on, is he carrying a book, where are their glasses located? These clues tell a lot about the daily vision needs and interests of the patient. Many times, surgeons think and reason aloud. The weighing of options should be done in your head so as to not confuse the patient. When you present a simple either/or option to the patient and solicit their involvement in the solution, the patient believes you are listening to what he wants. This dialogue alone is so unusual in medical care today, that it will immediately set you apart from other medical providers.

Mr. Mahdavi: Building upon what Kay said, I believe that hiring a listening skills coach or taking a course might be the most valuable strategy you can use for you and your staff. This approach will help you to listen more effectively and glean the necessary information from the patient. Secondly, patients have way too much choice. I suggest that as a physician, you guide the decision and make specific recommendations. As a doctor, it is your job to manage the patient's decision. Lastly, just like LASIK in the past 10 years, the next decade will bring more technology and innovation in the area of premium IOLs. More and more patients are going to ask if they should wait for a specific technology. It is important for you to decide how you are going to respond to that question. You need to be careful not to send the cue that if the patient waits, the technology is going to become cheaper and better. That message was delivered with LASIK, and it nearly killed the industry.

Dr. Chang: As Kay also said, we are indeed bad listeners. The reality, however, is that we are often behind schedule and just do not have enough time in our days in the clinic. This is why the practice of sending the Dell Survey out to patients in advance is so powerful. (The Dell Survey is available at www.crstoday.com.) If you send them this survey before the office visit, patients can take as long as they need to think about their answers. It is interesting how people sometimes call back and want to amend their responses because they really feel that you are putting a lot of weight into what they have written down. In the examination lane, it may take 10 minutes of discussion to elicit that same information. If you instead send the questionnaire preoperatively, it gets patients thinking about their goals before they even set foot in the office and saves approximately 95% of the discussion time.

Dr. Donnenfeld: I agree with David that it is so important to send out information to patients who are coming in for surgery. Additionally, if I have a patient coming in for a cataract consultation, I tell him to bring in as many family members as possible. I want everyone to hear what I have to say. I cannot tell you how many times I have explained the price of the procedure, and the patient declined because of how that added cost might have an impact on his family. I have found that when family members are involved in the decision, someone often steps up and encourages the patient to undergo the procedure, despite the cost. Approximately 25% of the time, the family members decide what type of IOL the patient is going to have implanted.

Dr. White: The patient experience is also an important element in your conversion rates. We have begun the practice in our office of measuring what we call "dead air"—the time the patient is not being educated or in communication with office staff. We measure dead air for two reasons: (1) we want less of it and (2) dead air can be converted into an opportunity to provide information to the patient. We use Eyemaginations videos (Eyemaginations Inc., Towson, MD) at every opportunity and also provide patients with written information to make their visit a totally immersive experience. From the moment that the patient walks into the office, he finds himself in the middle of an educational experience.

Dr. Donnenfeld: We have eight Eyemaginations systems in all of our offices. We do not like to run video loops. Instead, we try to make patients feels like our office has customized their experience to their individual needs.

Dr. Bucci: After we have discussed the price of the surgery, I remind my patients that they have been saving money for their entire life. I then ask, "What is more important to spend money on than your eyes?" Remember that most people in this age group have some disposable income. My practice is located in an area consisting of mostly middle-class or lower-middle-class families, and I have implanted more than 700 IOLs in the last 2 years. You need to suggest to your patients how important their eyes are compared with everything else in their life.

Ms. Coulson: I think that Dr. Bucci's practice of introducing the price to the patient is important. Although the surgeon does not need to review all of the financing options, you need to establish the creditability of the price. If you are afraid to do that, and push the responsibility off on your scheduler, you will probably see less success in your conversion rates. Additionally, it is important for surgeons to keep from negotiating surgery prices with their patients. By setting a conversion rate for your practice, you can increase and decrease price objectively, based on where your rates fall compared with that goal.

Dr. Masket: I also think it is a dangerous concept to tailor the price to the patient. The lower you go, the lower you will go in the future. It is important to establish an appropriate price for your patient base and stay within that range. Remember that although we do want to have high conversion rates, we have labeled these lenses as a premium item. It is a mistake to end up with the same problems we experienced a few years ago with the price wars for laser vision correction.

Dr. Donnenfeld: In terms of medically eligible candidates, what percentage of candidates chooses to undergo elective multifocal IOL implantation?

Ms. Coulson: I set targets in our practices at a minimum of 25% conversion. The practices I currently work with are generating 25% to 65% conversions to upgraded IOLs.

Dr. White: I have a 25% to 30% conversion rate.

Dr. Masket: About 30% of my potential candidates convert.

Dr. Dell: I would say about 70% of eligible patients convert at my practice.

Dr. Chang: One out of three patients convert, but this figure includes people who do not necessarily want to be spectacle free.

Dr. Bucci: In total, my conversation rate is about 24%.

Dr. Donnenfeld: Do the panelists have any other pearls on converting patients, communication, complications, price, or other issues?

Dr. Chang: One of my editorials from the February 2007 issue of Cataract & Refractive Surgery Today discussed writing a handout with all the prerequisite information that you want to cover with the refractive IOL patient. For example, if you do not tell people up front that they may need a laser enhancement before they undergo surgery, they are much more unhappy to find out afterward.

I give every candidate a handout that essentially scripts the basics of what I would tell every prospective premium IOL patient. This way, I do not have to cover everything in as much detail in the examination room. Additionally, the patient can take the sheet home, to re-read, and fully absorb the information. Finally, the handout also solves the problem of selective memory. If at a later point, the patient needs laser enhancement, he now has a reference that we told him from the beginning that this was a possibility. If a patient cannot bring family members with him to the exam, they can review the information later by reading the handout.

I have noticed that since implementing this handout, the number of follow-up phone calls and questions has decreased dramatically. Whether you promote, or are more neutral about premium lenses, this is your chance to script an educational tool for your patients with your own personal message and bias.

Dr. Dell: I think that it is beneficial to create a handout that is no more than one page long. Otherwise, patients may view it as homework, and you will start to lose their attention.

Dr. White: Once we choose a lens, we discuss with the patient what he should expect pre-, intra-, and postoperatively.

On a side note, does everyone who implants the STAAR ICL (STAAR Surgical Company, Monrovia, CA) charge about the same amount as they do for presbyopic lens exchange? Say that you have a 49-year-old patient with a -6.00 D, a +2.00-D add, and a residual corneal thickness of around 250 µm (if you performed LASIK). He is right in the watershed zone for every single option. The cost for an Visian ICL (Implantable Collamer Lens; STAAR Surgical Company) is twice the cost of LASIK, and your cost for presbyopic lens exchange is slightly more than that. What do you do? This conversion nightmare comes into my practice every day.

Dr. Slade: We have set up our pricing a little differently than that. Our ICL price is really closer to our LASIK price. You have to decide whether you will perform clear lens extractions at your practice. We have decided not to perform many of these procedures, which means if a patient comes in without a cataract, we immediately know that he is a candidate for the Visian ICL or LASIK.

Dr. Donnenfeld: The only time I perform clear lens extractions is if the patient wants both reading and distance vision. That is the tipping point for me and the only time I will convert a patient to a clear lens extraction.

Ms. Coulson: We did some work in assessing patients' expectations for elective vision fees, including LASIK, phakic lenses, and presbyopia lenses. The starting point for most patients under age 55 is the LASIK fee, because they generally visited the office for a LASIK consult. When a practice shifts the recommendation to a lens, patients pause. We have found patients are willing to pay about $1,000 more than a custom LASIK fee for an upgraded lens procedure, which they view as somewhat risky and more invasive, but offers a single-surgery, permanent solution. Once you go beyond that upcharge, large numbers of patients have difficulty accepting the cost, and conversions drop.

Dr. Slade: Conductive keratoplasty is another good option for patients who do not want a presbyopia-correcting lens implant and are not suitable LASIK candidates; we have had a lot of success with this treatment. It is remarkably safe, and it was the only procedure ever to gain approval for presbyopia. But, I also have two problems with conductive keratoplasty. First, it is temporary, and unlike Botox (Botulinum Toxin Type A; Allergan, Inc., Irvine, CA), I do not think that patients are looking for temporary eye solutions. My second issue is that the company that originally supplied the conductive keratoplasty treatment under the tradename CK, Refractec, Inc. (now distributed by Precision Lens, Minneapolis, MN), went out of business. At some level, I think that could be a problem.

Dr. Donnenfeld: I agree with you, Dr. Slade. I do not like transient refractive solutions, scarring of the cornea, and the fact that you induce a lot of cylinder in these patients when you perform conductive keratoplasty. It can work on occasion; however, it is not my "go to" procedure. I see it as part of a surgeon's surgical armamentarium to be used in rare cases.

Dr. Slade: Conductive keratoplasty is a good procedure in theory, but it did not grow practices on a uniform basis, so I would say that it did not succeed in the real world.

Dr. Donnenfeld: Another pearl I have has to do with how I have changed my approach with patients. When I first started implanting IOLs, I was very positive about the technology. Now, I tell my patients that refractive IOLs are difficult. I tell them that it is a process that we will work through together. I say, "You might need laser surgery or preoperative medicine." Almost all my patients end up being happy postoperatively, however. I will often add that this technology is not something that every refractive surgeon can perform. In that statement, I have positively differentiated myself as a skilled surgeon.

I always assure my patients that I will work with them and am there for them until they achieve a great result. I tell them that the worst-case scenario is that I would have to remove their implant—which I have done in two out of approximately 700 cases—and implant a regular lens. That is how I show my commitment to my patients.

Dr. Dell: I agree with Eric. I routinely try to talk patients out of this procedure. This method can bring patients to the point where they are trying to talk you into letting them have the surgery; at this point, you have converted them.

Dr. Donnenfeld: Can the members of the panel explain how they correct cylinder in patients who have phakic IOLs? Toric phakic IOLs will resolve a lot of these problems in the future, but in the meantime, what do you do?

Dr. Slade: The best answer is to use a toric IOL or a toric phakic IOL. Currently, we perform LASIK on these patients after surgery. They are a good LASIK population because they are the right age. Of course, there is always a hurdle explaining that they are too myopic to be a good LASIK candidate and then telling them that they are going have to have a phakic lens implant and LASIK surgery. If the patient has an irregular cornea, we will perform photorefractive keratectomy. This procedure may be a little different with Verisyse (Advanced Medical Optics, Inc., Santa Ana, CA) because you have to wait a little bit longer as you are inducing some astigmatism.

Dr. Donnenfeld: One difference with phakic IOLs is that these patients are so thrilled to go from -12.00 D to a 1.00 D cylinder. These are not the patients whom you have to worry about being unhappy. I will perform limbal relaxing incisions at the time of surgery to debulk the cylinder and treat about 1.50 D. This process leaves the patient with about 1.00 D left, and more than likely, he will be happy at that point. The most common path for these patients, however, is laser surgery.

Dr. Slade: That is a good point. Surgeons who frequently perform limbal relaxing incisions should probably consider that at the time of the procedure. Personally, I do more laser correction than limbal relaxing incisions. Still, I think it is important to note that there is no threshold in determining how you decide on LASIK versus a phakic IOL. Obviously, we would consider the corneal thickness and whether the patient has dry eye or an irregular cornea. It is important to have some sort of cutoff, so that your staff knows which approach to take when discussing options with the patient. For our staff, we have determined when the patient needs around 6.00 to 7.00 D of correction, we want to start thinking about phakic IOLs; your range can be anywhere from 3.00 to 20.00 D.

Dr. Donnenfeld: I want to thank the panelists for this informative session. I hope that everyone will be able to take something new away from this educational discussion and implement it with great success at his or her practice.

Eric D. Donnenfeld, MD, Moderator, is a partner in Ophthalmic Consultants of Long Island and is a trustee of Dartmouth Medical School in Hanover, New Hampshire. He is a consultant and performs research for Alcon Laboratories, Inc., Advanced Medical Optics, Inc., and Bausch & Lomb, but he acknowledged no financial interest in the products mentioned herein. Dr. Donnenfeld may be reached at (516) 766-2519; eddoph@aol.com.

Frank A. Bucci, Jr, MD, is Medical Director of Bucci Laser Vision Institute in Wilkes Barre, Pennsylvania. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Bucci may be reached at (570) 825-5949; buccivision@aol.com.

David F. Chang, MD, is a Clinical Professor at the University of California, San Francisco, and is in private practice in Los Altos, California. He is a consultant for Advanced Medical Optics, Inc., Alcon Laboratories, Inc., and Visiogen, Inc., but donates these consulting fees to Himalayan Cataract Project. Dr. Chang may be reached at (650) 948-9123; dceye@earthlink.net.

Kay Coulson, MBA, is founder of Elective Medical Marketing and a practice-development consultant for Alcon Laboratories, Inc. She helps surgeons build their elective vision service lines. She may be reached at (303) 994-0014; kay@electivemed.com.

Steven J. Dell, MD, is Medical Director of Dell Laser Consultants and Director of Refractive and Corneal Surgery for Texan Eye in Austin. He is a consultant for Advanced Medical Optics, Inc., Eyeonics, Inc., and Allergan, Inc. Dr. Dell may be reached at (512) 327-7000.

Shareef Mahdavi is President of SM2 Consulting, a Pleasanton, California firm helping medical manufacturers and providers create demand for new technologies. He is a consultant to Advanced Medical Optics, Inc. Mr. Mahdavi may be reached at (925) 425-9900; shareef@sm2consulting.com.

Samuel Masket, MD, is in private practice in Los Angeles, California, and is a Clinical Professor of Ophthalmology at UCLA. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Masket may be reached at (310) 229-1220; avcmasket@aol.com.

Stephen G. Slade, MD, is in private practice in Houston. He is a consultant for Alcon Laboratories, Inc., Advanced Medical Optics, Inc., Bausch & Lomb, STAAR Surgical Company, and Eyeonics, Inc. Dr. Slade may be reached at (713) 626-5544; sgs@visiontexas.com.

Darrell E. White, MD, is founder of Skyvision Center in Westlake, Ohio. He is a consultant to Allergan, Inc. Dr. White may be reached at (440) 892-3931; they@skyvisioncenters.com.