How Many Refractive Procedures Should You Offer?
High-volume surgeons see benefits in providing a wide range of options. But what's the answer for smaller, lower-volume practices?
BY ROBERT D. WATSON

In the past year, advances in refractive surgery technology have prompted both cataract and refractive surgeons to rethink their practice business models.

During the laser vision correction boom days, many refractive surgeons made the decision to abandon general ophthalmology and cataract surgery. Concurrently, many cataract surgeons chose to stick with just doing cataracts and ignore refractive.

Although each of these business models has proven successful when executed well, a growing portfolio of techniques and technologies may mean refractive surgeons will need to return to the operating room to hone their phaco skills, while cataract surgeons catch up with tools of the refractive surgeon's trade.

For those who succeed in making the transition, the benefits could be great, including increased procedure volume, better outcomes and increased incomes. In this article, I'll show how some ophthalmologists are adjusting to the variety of vision correction options they can now offer to patients.

For a few years after the introduction of LASIK, there seemed to be no end to how many patients would pony up for laser vision correction. Patients enthusiastically paid cold, hard cash in advance while telling the world that their vision was worth more than they were charged.

Given the surging marketplace for LASIK, many refractive surgeons opted out of general ophthalmology with all of its headaches. They envisioned an end to nightmares caused by fear of overcoding, or frustrations with being underpaid because of undercoding. They looked forward to no more 12-hour days, trying to see as many patients as possible to cover the ever-increasing overhead, while making less and less for themselves with each Medicare cutback.

However, other ophthalmologists with successful cataract practices didn't particularly subscribe to the notion of operating on perfectly good corneas. Rather than make expensive investments in lasers, consumer marketing and refractive coordinators, they opted for the steady stream of elderly patients with cataracts and other diseases of the aging eye. Reimbursements, while down from previous levels, were still adequate for a reasonably efficient cataract surgeon.

Technology Creates New Options

But times are changing once again due to the tremendous advances in refractive technology, and patients' ever-increasing demands for quality visual outcomes.

With the advent of custom ablation, "20/happy" probably needs to be redefined. As baby boomers develop dysfunctional lenses or their first refractive procedure expires, new IOL technologies now offer them tremendous advantages, many of which do a better job at addressing presbyopia, hyperopia and high myopia than surface procedures.

All this new technology suggests that a portion of patients who would have had laser vision correction will likely shift to a lenticular procedure, but the overall number of all refractive procedures should continue to grow as more and more patient expectations are met.

"Now, we are not pushing any technology," says Michael Woodcock, M.D. "We can select the sweet spot of each technology, so our patients will benefit and our practices will benefit. Everyone will be happier with their results and the service we provide, and we will be doing more procedures on more patients."

Barrie Soloway, M.D., has been asked by prospective patients why they should choose him over Dr. X, who does nothing but LASIK. Their argument is that if all a doctor does is LASIK, then he or she is probably really good at it.

But Dr. Soloway and other refractive surgeons who offer multiple options for refractive candidates feel they are the better choice precisely because they don't just do LASIK.

"I can talk to you about LASEK, lenticular, and a number of other options that may be better for you in the long run. And, if there is a problem with your procedure, I will be better able to handle it," says Dr. Soloway.

"What's amazing is that we used to sit around and say we don't really have anything for hyperopia and presbyopia," says Stephen Slade, M.D. "Now, I have three or four choices for them. I think you do better when you can address everything that comes through the door and to do what you need to have access to all the technologies."

Keeping Up with Change

Dr. Woodcock also believes that you have to have an excimer laser to be a successful refractive lenticular surgeon.

"It's like a carpenter who doesn't have a full set of tools," notes Dr. Woodcock. "They can get the job done but maybe not as efficiently. You really need back-up technology to make minor changes to give the patient the expected quality outcome that he came to you for in the first place."

All these new technologies and procedures can be difficult for patients, patient counselors, and doctors to navigate through. How does a patient who could benefit from CK or Crystalens or multifocal IOLs or LASIK or custom LASIK or LASEK make such an important decision, and how does the cost of each procedure weigh into his or her decision? Does the availability of a higher-cost lenticular procedure such as Crystalens make the lower-cost surface procedures more popular?

"I can't remember a situation where I told a patient it really didn't matter, other than cost, if he had CK or Crystalens," says Dr. Slade. "I can tell a +5 hyperope that CK is not for him, or a plano presbyope that she can have just one eye done with CK. I've also never had a patient say, 'Gee, how come this procedure is so much more than that procedure?' If we think they will do better with lenticular, they understand that lenticular involves a surgical facility fee, going inside the eye and that it is much more involved and therefore expensive, than doing one of the other procedures right here in my office."

Pricing the Procedures

One of the most important decisions facing the doctor offering the full range of procedures is how to price them. The first real test came with the approval of custom ablation in the fall of 2002. Most of the initial providers of custom priced it at a premium of $300 to $500 over conventional LASIK. This not only recovered the cost of their investment but also generated new profits for their practices, reversing the trend of declining refractive income in preceding years.

Others opted for a variation on this approach.

"We decided, when custom ablation became available, to raise our LASIK fee in general," says Dr. Soloway. "But we charge the same for custom and conventional. If I feel the patient would benefit from custom, I tell them about it. If they ask if it costs more, I tell them it's the same price. I couldn't sleep well if cost caused me to do conventional LASIK on someone I knew would benefit from custom."

The introduction of new IOLs for refractive lens exchange has taken the pricing discussion to a new level. According to Dan Durrie, M.D.: "There are lots of people charging $2,995 for laser vision correction who are waiting for the $3,000 barrier to be broken. The refractive lensectomy has done it for them."

Faced with new cost elements to perform the procedure, including an ASC facility fee, anesthesia and the cost of the lens, many of the early adopters of eyeonics' Crystalens are charging between $4,500 and $5,000 per eye. But, with higher-priced procedures come higher patient expectations. Some doctors are deciding to include any enhancement treatment in the price, such as an LRI, YAG or even a LASIK procedure if needed to get the patient's vision to a high satisfaction level.

"Those practices that have access to both an ASC and excimer technology are going to be strategically positioned to offer the whole package," adds Dr. Durrie.

Smaller Practices Can Compete

Large group practices are the norm in many specialties such as OB/GYN and orthopedics. But, ophthalmologists tend to be more independent and prefer solo practices or at the most, one or two partners. While large-volume practices can afford all the new technologies and are usually early adopters, most ophthalmologists don't have the volume to support the overhead required to offer it all. So, how can they participate and be competitive in this rapidly advancing technology boom?

Clearly, one way is to merge with other practices in the market, but forming or joining a group practice is probably not in the cards for most lower-volume surgeons. Nor does this approach necessarily generate the capital needed to invest in the full range of procedures. However, there is another way to find capital for and gain access to technology that may make sense, especially in light of the fact that much of this newer technology is pointing towards lenticular.

And that answer is to participate in joint ownership of an ASC.

Steve Winjum, CEO of NovaMed, Inc., a Chicago-based ASC management company predicts: "The future of the refractive centers of excellence is going to move out of the laser centers and into the ASCs."

Winjum explains that when five to seven lower-volume ophthalmologists have a capital partner in an ASC and each of them owns a piece of it, the economic case is good for everybody. The capital partner can provide the money to purchase multiple technologies for the ASC, while each doctor's risks are minimized because they all benefit from the other doctors using the ASC. With more technology available to each doctor, they can provide a wider range of procedures to a larger patient base and charge more per case.

It's interesting to me that the many technologies now becoming available are as potent a force in bringing refractive and cataract surgery together as LASIK was in pushing them apart. And, the change in ophthalmologists' attitudes is every bit as remarkable.

Over 22 years of providing patient education materials to ophthalmology, I've heard dozens of ophthalmologists say they wouldn't encourage their kids to be ophthalmologists. However, I can't recall another time that I've seen ophthalmologists more excited about their field than they are now.

Robert D. Watson is the president and founder of Patient Education Concepts, Inc., one of the ophthalmic industry's leading providers of patient education and practice marketing materials. He can be reached by phone at (800) 436-9126 or via e-mail at robertw@patientedconcepts.com.