Thirty-five years ago, as an emerging 4th grade myope, I put on my first pair of glasses. Fifteen years ago, I put spectacle correction down for the last time when Dr. Michael Gordon of San Diego performed radial keratotomy (RK) on me, leading to my still-perfect monovision. At that same time, I picked up the pace of an uninterrupted career advising surgeons on the business intricacies of this marvelous subspecialty.

Since then, lasers have eclipsed diamond blades. The new refractive surgeon’s barrier to entry has risen several fold. Corporate-sponsored centers may be poised to permanently enjoy a dominant share of the market. And while the last train still hasn’t pulled out of town, many non-refractive surgeons believe that they’re about to miss the last great opportunity of their careers.

But before you decide to leave refractive surgery to others, consider these 20 recommendations for succeeding in this subspecialty learned in my years as a consultant. Although the emphasis and reference in most cases is on laser-assisted in situ keratomileusis (LASIK), many of these pearls were as germane to RK as they’ll be to the next generation of procedures.

Refractive surgery isn’t a product you put on the shelf of your largely anterior segment/geriatric eye care/disease management practice. It’s a separate business that happens to share space with your existing practice.

This separate business needs serious capital and time resources, which can only be fairly allocated after the surgeons decide on their goals. Do you simply want to keep your hands in co-management, leaving the procedures to local specialists? Do you want a few cases a month, done in a co-op laser center, as a hedge against falling third-party payments? Or are you morphing your cataract practice into a LASIK practice?

At every level of commitment and volume goals, you and your management team must apply proportionate resources.

In the typical setting, this must include, at the least, a full- or part-time refractive surgery coordinator/counselor, and a surgeon with not only clinical and surgical time, but 5 or more hours a week of management time. Even in practices deeply committed to refractive surgery, with staff assigned to the job, the most critical resource gap can be marketing capital.

For a newer LASIK practice in a service area with 500,000 people, your practice must spend a minimum of $7,500 per month (more is better), quarter after quarter, on consumer advertising to build brand awareness and develop traffic. And this cost is before creative assistance, advertising production or even staff payroll to answer the phones.

As with cataract surgery, every metropolitan market will support one or two major LASIK surgery practices and perhaps as many as five secondary players. These providers typically control 70% or more of the total case volume. Absent significant dislocations, such as a major advertising offensive or the purchase of referral sources, each surgeon’s relative market share in percentile terms remains relatively stable just a few years after refractive surgery is introduced in a market. The doctor who performed 27% of the cases in 1994 is probably doing about the same share of cases in 1999.

Because practices are so reliant on alumni referral, it either requires a significant "breakaway" campaign on your part, or a lot of errors on the part of your competitors to change these market share figures. Your total case volume increasingly depends on growth in the entire market volume as much as on your individual efforts.

LASIK surgery is a luxury for most Americans. I did extensive man-in-the-street interviews some years back to find out, among other things, what average people thought an affordable price was for vision correction surgery. The average answer was $500 or less per eye.

This is hard for the average ophthalmologist to fathom. It’s not unusual for the typical working family’s disposable income to be a few hundred dollars a year. That’s not a lot, even to cover financed LASIK payments, and it’s competing with other luxuries. At present, in markets with significant advertising exposure, LASIK is still only purchased by about 1% to 2% of the patients each year who would benefit from surgery. I believe this penetration rate will remain until fees fall.

The recent ramp-up in cases, allowing some ophthalmology practices to double their volume every 12 to 18 months, is due to several factors.

Patients who had been holding back on surgery realized that LASIK was the "real deal." Significant numbers of patients are now out in your community talking up the benefits of surgery. O.D.s are now more likely to encourage their patients to have surgery. They realize that their patients will have surgery anyway, and they now have incentive to co-manage. Multiple advertising practices have cross-validated this whole class of surgical care — patients are no longer wondering if they should have surgery, but with whom and when.

Where will it all end? Permanent vision correction will eventually become the eyecare equivalent of braces for teeth, with conscientious parents of sufficient means paying for their young adult children to have their genetically faulty eyesight corrected. This will especially be the case if fees fall.

Ophthalmology has been immune to consumer price resistance since the Medicare program was enacted. Until just a year or two ago, these same surgeons (and their managers) looked at the sustained high prices for LASIK and felt immune to the prime economic law, that of supply and demand. They’ve been shocked in the last 12 months to see fees falling to as low as $750 per eye. A trip to England several years ago, when laser surgery prices plunged, would have blunted their surprise today.

LASIK is heading inevitably toward commodity pricing. This will be accelerated in the future as savvy patients bid out their elective surgery just as savvy travelers bid out their plane flights today.

I’ll go out on a limb and call the average price-point for LASIK at $1,250 per eye or less within 5 years in America. Patients willing to travel to Canada will pay half this.

It’s important to remember that we have a historically remarkable wealth and income disparity in this country. The most prosperous 1% (which happily includes a lot of eye surgeons) control some 85% of America’s wealth.

For more than a decade, our nation’s large middle class has been cleaved down the center, with a significant portion losing spending power and disposable income. Most product and service pricing is similarly bifurcating today. Consider, for example, Wal-Mart and Neiman Marcus; drop-in gyms at $5 a visit and the Golden Door Spa; Day’s Inn at $59 a night and The Plaza Hotel for $359. There will always be a market for the best, including the best LASIK surgeon. Such surgeons should preserve their high price-points (or even raise fees) package their product lavishly, provide concierge-level service, and market accordingly. The rest should plan to deliver an acceptable enough level of quality at an affordable enough price.

I don’t believe there will be a place at the table, at least in competitive markets, for middle-ground, middle-price practices. It may be intelligent for some surgeons to build two differently branded LASIK practices in the same market, one for their affluent patients, and one for patients of average means.

The core surgical outcome may be identical but the packaging, service and value-added amenities will vary drastically. A good example of this is airline travel. First class and coach passengers flying from Los Angeles to New York safely reach their destinations. But while the first class passengers enjoy champagne and attentive service, the coach passengers snack on peanuts.

Realize that it’s impossible to simultaneously optimize market share, profitability per case and quality (not just surgical outcome but patient satisfaction). One and sometimes two out of the three must be sacrificed. Decide on what you’re unwilling to relinquish, and you’ll have a very good start at positioning your refractive surgery practice. Most cases done today are in practices sacrificing market share for quality and profit. Most cases in the future will be done in centers sacrificing per-case profit for higher market share.

In group practices, it’s typical for one surgeon to lead the charge and focus his or her talents on refractive surgery. Increasingly today, this surgeon’s partners are looking on enviously as case volumes and cash flow increase.

When I help clients through the resulting conflicts, we have two levels at which we often make corrections. We first establish ground rules about who does what in the practice. In most settings, I favor an approach of letting any ophthalmologist provide any services he or she is qualified to perform.

The second level is an adjustment to the compensation model. In your practice, you need to make sure that the group’s refractive surgeon is paying a fair share — not too much or too little — of the practice’s overhead. Numerous other governance and housekeeping rules eventually emerge, such as fair approaches to new patient assignments, call coverage and marketing budget allocations. If your practice is undergoing a LASIK-driven shift, it’s essential that you set aside sufficient incremental time for partner and management meetings to work through the inevitable problems.

Patients repeatedly report their desire for three core attributes from their LASIK providers. Deliver these, and you’ll be more likely to succeed, even if the competition gets rough.

• Surgeon experience.
This is ideally expressed in terms of number of refractive surgery cases. For those doctors with abundant eye surgery experience but scant LASIK experience, years in practice and "total eye microsurgery cases" can be an acceptable substitute for less-sophisticated patients.
• Staff skill, polish and experience.
Patients can immediately sense if your staff members are skilled or rookies. The relative sophistication and high demands of this patient base require that you staff accordingly.
• A long-term relationship.
People are starting to understand that some practices have a traditional, longitudinal relationship with their patients, while other eye surgeons are creating extremely high-volume clinics, with little residual attention after the immediate post-op period. Most patients want the former and are willing to pay more to get it.

In addition, ongoing care through annual checkups (provided by the surgeon or an optometrist-extender) provides at least three benefits. It can be a post-surgical annuity for the practice, through the ability to sell sunglasses and spectacles for any needed residual correction. It maintains a relationship with patients in a position to refer friends to the practice. And it catches any (thankfully rare) complications in-house, rather than in your competitor’s office.

As successful LASIK practices swell, staff training and infrastructure rarely keep up. In practices with strong refractive surgery programs, having a profit center manager to handle operations separate from the practice administrator is essential.

Serial re-engineering of patient flow is important. Higher-volume practices are now clustering patient visits to make communication and flow more efficient.

In these same growing practices, surgical capacity becomes the critical resource gap. You’ll need to index your personal fitness, diet and stress management programs to the demands of your LASIK practice.

Three out of five new LASIK surgeon clients I serve could benefit from a personal trainer and a nutritionist. Those who take this advice excel in their practices.

"Alumni," or patient-to-patient, referral remains the best source of new patients in almost every mature LASIK practice. Staying in touch with past patients is thus the most important marketing job.

Tight database management, regular bulletins, periodic survey calls and various forms of referral acknowledgement are basic and critical. Newer practices must spend significant sums on advertising to build a base of patients.

Once they’re successful, they can step down their paid advertising efforts somewhat — just how much depends on local competition, growth goals and the efforts applied to alumni referral development.

Optometry referrals have a large and growing influence on the LASIK case mix in many practices. Unlike cataract co-management arrangements, in which protocols are nationally mandated and uniformly followed, we’re still in a "Wild West" phase with LASIK.

Avoid the competitive escalation of co-management fees, which in some markets results in payments that exceed the actual value of services O.D.s provide patients. Consult with competent legal counsel to make sure that your protocols comply with state or federal regulations.

Realize, too, that patients are getting more sophisticated in their understanding of these matters. You must respect the wishes of patients who resist seeing optometrists for post-operative care. At the same time, you must break this news to your referral source as gently as possible.

Consumer advertising remains a crucial part of the overall marketing mix, but its role is over-emphasized in most settings. Practices should have the marketing basics (staff sales training, brochures and videos, facility upgrades, lead-tracking software, etc.) well in hand before launching a media campaign.

Paid advertising works best when you use testimonials and the doctor’s image. Radio and daily circulation newspaper print ads and TV infomercials out-pull billboards, prime-time TV spots and monthly magazines.

At $100 and more per lead, you must match your ad traffic with internal telemarketing capacity to avoid wasting your marketing investment. It’s also a waste of money to bring prospective patients to the practice and not have them meet the surgeon. He or she is the "product" and should be available for at least one brief inspection by the patient, without charge.

Smart practices provide free full consultations because they know their surgeon’s closing rate will be better than that of the best lay representative. It’s of paramount importance to align the price, terms and other details of the service offering with the practice’s advertised positioning. Practices that keep patients waiting excessively, or that give a surgical candidate 60 harried seconds of a surgeon’s time can’t overcome these service deficits with even the most brilliant advertising campaign.

Public RK seminars were started in the early ‘80s as a cornerstone of refractive surgery promotion. They still work well for LASIK in markets where relatively little advertising has been placed, but poorly in markets with multiple competitors and longstanding promotion.

In my experience, every community has different responsiveness, but all eventually yield diminishing returns over time. If you haven’t tried seminar-oriented marketing, and if others haven’t dominated this niche, you should give it a try.

Make sure that every presentation includes the following success factors: Sunday-Tuesday promotion, Tuesday or Wednesday evening seminar (scheduled at a time that encourages attendees to come straight from work), great audio-visual materials, live surgery if possible, a surgeon (or a surrogate staff member) with adroit speaking skills and one or two past refractive surgery patients.

As a former publicist for the likes of Dr. Jonas Salk, Dr. Francis Crick and diet guru Nathan Pritikin, I know that publicity — news and feature stories placed in various general consumer outlets — can have a significant promotional benefit in some settings. However, publicity has only a modest potential impact on case volumes in the typical LASIK practice.

If you have a practice with more than 100 cases per month, consider hiring a freelance publicist to get the word out about interesting patients (with their permission, obviously). In smaller markets, with more accessible reporters, you can follow the guidelines of any publicity manual.

Short of these specific situations, a formal public relations campaign is probably a misallocation of external marketing resources, which should mainly be spent on paid advertising.

The Internet is fast becoming an essential part of your practice’s marketing mix, especially if your practice is the largest, most experienced or the least expensive provider. Keep in mind, however, that this tool is double-edged. It won’t be many years before patients routinely shop the Web and select the lowest bidder. Some of my LASIK clients now report that 5% to 15% of new patient leads are coming from their Web sites. This ratio could grow steeply in the years ahead.

Even the most successful LASIK practice has a significant base of "fence sitters," patients who put off making a decision to have surgery. Routine points of patient resistance include fears about potential outcomes, fear of pain, or — most commonly — price resistance.

All practices, large and small, need to develop some variation on "second harvest" programs to convert clinically appropriate candidates into patients. Examples include step-down price negotiation for price-resistant patients, an abundance of past patients for fearful patients to meet, and customized in-house finance programs.

Diversifying the sources of your patients is essential. Don’t be the surgeon getting 80% of your cases from a few key optometrists, only to find these referring practices bought up, one by one, by your competition. Don’t rely on one spokesman in your ads if you have a closed-end contract with the person.

You may now enjoy being the sole provider of LASIK for your local fire and police departments, at very little marketing cost to your practice, but what happens when everyone has been served? And for that matter, you shouldn’t depend on refractive surgery as your sole source of income.

It’s not too late to take advantage of this great practice-building opportunity. With the right marketing, staff and expertise, you’ll be ready to handle the latest refractive surgery boom.