What Your LASIK Enhancement Rate Says About You
Your percentage affects profitability and patient satisfaction. These strategies can lower it.
By Daniel S. Durrie, M.d., and Michael J. Collins, Jr., M.D., Overland Park, Kan.

In the early 1990s, the enhancement rate for refractive surgery typically was 35% to 40%. These rates were acceptable for radial keratotomy. We were worried about overcorrecting patients so we sometimes titrated the surgery to achieve the desired effect.

When we moved into the "laser phase" in the late 1990s, and photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) became the primary procedures, the acceptable rate was 12% to 15%. With the recent advances in laser technology, it's dropped to below 10%.

It's possible to reduce your enhancement rate to 5% or lower, as we have at Hunkeler Eye Centers, if you standardize operating procedures, use better technology and structure your practice so that patients have realistic expectations about their surgery. Here, I'll discuss each of these strategies in more detail.

Standardizing procedures

One of our standardized protocols is performing most of our enhancements when the first surgery stabilizes. This is around the 3-month visit for myopes and the 6-month visit for hyperopes. We've found that results of the first surgery can't be predicted well before these intervals.

Having a policy in place for doing enhancements is also beneficial because we don't have patients coming to us and requesting an enhancement 1 month after surgery. We tell our patients that we know the natural history of their healing from doing studies where we couldn't do any enhancements for 1 or 2 years. By letting them know they're more likely to be a "moving target" during the typical healing time, they understand it would not be in their best interests to have an early enhancement.

We've also standardized our operating suites for temperature and humidity, and have broken down the LASIK procedure into 68 steps so that each of our 11 refractive surgeons does surgery the same way. This uniformity improves efficiency and makes it easier to detect and correct problems.

We do a full eye exam 1 hour after surgery to make sure we find any problems that may be easily correctable at 1 hour, but harder to correct the next day. We then use our 1-hour data to help refine the procedure.

If one of our surgeons has an idea for improvement, we talk about it and if it seems reasonable, we do a randomized prospective study on it. If the idea is shown to improve our technique and results, we change the way everybody does surgery. For example, one of our surgeons suggested we start using oxygen to help seal the flap and check edge alignment. After it was shown to give us more consistent outcomes (as well as more efficient surgery), we made using oxygen part of the procedure for everybody.

We've also found it beneficial to always recheck the patient's manifest refraction on the day of surgery. This is especially important when working with co-managing doctors. We have picked up substantial differences at times and have found it to be more accurate to go by the numbers we get at our own center. Anything that decreases variability will increase your accuracy and decrease your enhancement rates.

Better technology

Better technology is essential as well. For us, this meant the Bausch & Lomb Technolas 217 and the LADARVision from Alcon Summit Autonomous. This equipment helped us lower our enhancement rate to 2.3% for patients with myopia up to 7D and astigmatism up to 3D. Before we used this new technology our enhancement rate was 8.5% to 9%.

We're fortunate to have five different lasers to choose from when we do a refractive procedure. Of course, not every surgeon can have five different lasers, but you can use the best laser you have access to for each type of refractive error. It may not make you the cheapest guy in town, but it says that you care about patient satisfaction and that you're on the cutting edge of technology.

Keep in mind, too, that although investing in a new laser is expensive, doing too many enhancements can be more expensive. Because most surgeons incorporate free enhancements for a year in the initial LASIK fee, doing a lot of these can rapidly increase your overhead. Also, fewer enhancements means happier patients and more referrals. Patients who've had more than one surgery are less likely to refer.

Setting realistic expectations

The third strategy that helps us to keep our enhancement rate low is structuring our practice so that patients don't think enhancements are free for a lifetime. Unfortunately, some doctors have used this as a marketing inducement for LASIK. This creates a perception among patients that as long as they complain enough they'll get an enhancement. The problem with this kind of thinking is that we have the potential technology to improve vision to 20/10. If we're not careful, patients will come to expect that when a new technology comes along, such as wavefront, they'll get the procedure for free.

Another large potential problem is presbyopia. Patients in their early 40s will sometimes come in 5 years after surgery and expect an enhancement because they can no longer see well enough up-close to read. We tell these patients that what they're requesting is similar to buying a new car and expecting a new one after 5 years.

Our patients sign an informed consent form that is specific about our enhancement policy. They know up front that our free enhancement policy lasts 1 year. We make exceptions if we're waiting for stabilization or if we're working on a specific problem and the 1-year time limit elapses. However, once the patient is happy and we're happy, and the 1-year mark passes, we "graduate" the patient. This way, it's clear that if anything new comes along, the patient will receive a new evaluation for a new procedure that will not be covered by the first payment.

We base fees for enhancements after the first year on what sort of enhancement is done. For example, we're planning on charging more for a wavefront enhancement than a simple monovision enhancement.

We're willing to lose a few patients to a center in our area that advertises free lifetime enhancements because we believe that our enhancement policy will be more beneficial for us economically in the long run. When patients come to us and ask "why are they doing it and you're not," we tell them that we'll make sure they're happy with the results of their surgery and we expect to be able to do this within a year's time. We also explain to them that only a small percentage of patients need any sort of enhancement.

Offering lifetime enhancements is similar to discount pricing -- it's not a good business plan long-term. We have to stop looking at the short term of having to make a rent payment and start setting the stage now for technologies that are 2 to 5 years away.

Continuous improvement process

Investing in better lasers and standardizing policies and procedures will help you lower your enhancement rate, but you won't have any idea what your enhancement rate is unless you follow your patients closely and record your data. We use an outcome analysis system to record every enhancement. We keep track of when the patient had the original surgery and when they had the enhancement. We then know how many procedures were done in a specific month and how many of those patients had enhancements. We use this data to find out such things as which lasers are better for which corrections. We recently started to recommend to our surgeons that they use a specific laser to correct low and moderate levels of myopia because we saw how much lower our enhancement rate was for those corrections with this particular laser.

We add data every day we do enhancements. It's a continuous process so we can improve our quality of care. The key is to have systems in place to get it done. 

Dr. Durrie is the director of refractive surgery at the Hunkeler Eye Centers in Overland Park, Kan. Dr. Collins is a cornea and refractive surgery fellow at the Hunkeler Eye Centers.