Premium IOLs: Are We There Yet?

How top surgeons are managing and meeting patient expectations.

BY JERRY HELZNER, SENIOR EDITOR

The life of a cataract surgeon was much simpler prior to the 2005 advent of patient-shared billed for premium IOLs.

In those somewhat fondly remembered days, the vast majority of cataract surgery patients underwent a rather routine, Medicare-covered procedure. They typically received a rather forgiving monofocal IOL that provided significant improvement in vision even when it was not implanted with precise accuracy. Patients were usually surprised and delighted with their reduced dependence on eyeglasses. Despite declining reimbursement for the surgery, doctors were almost always happy with the outcomes they were achieving.

Then, in the spring of 2005, everything changed. With the approval of patient-shared billing for three presbyopia-correcting lenses — the ReSTOR (Alcon, Fort Worth, Texas), the ReZoom (Advanced Medical Optics, Santa Ana, Calif.), and the crystalens (Bausch & Lomb, Rochester, N.Y.) — cataract surgeons suddenly found themselves with an opportunity to both benefit patients by providing them with improved vision at both distance and near while boosting their own bottom lines with the creation of a new profit center.

New Technology; New Questions

However, the advent of patient-shared billing also made the lives of traditional cataract surgeons infinitely more complicated than ever before. The addition of this option to their armamentarium meant that they now had to weigh the level of patient satisfaction that they could consistently deliver through this technically demanding elective procedure against a much higher level of expectations from patients paying thousands of dollars out of their own pockets. They also had to plan for more extensive patient education programs, take into account the possible need for enhancements after the initial procedure and even consider the possibility of marketing presbyopia-correcting IOLs to potential candidates outside of their practice.

Worst of all, cataract surgeons had to begin thinking about the unpleasant prospect of having to deal with patients who would complain about being unhappy with their outcomes.

Now that 3 years have passed since the advent of patient-shared billing for presbyopia-correcting lenses, Ophthalmology Management wanted to know how some of the country's premier cataract surgeons are handling this new and more complicated environment. We posed a series of key questions about incorporating premium IOLs into practice to six experienced and highly respected surgeons: John A. Vukich, M.D., the Davis Duehr Dean Center, Madison, Wisc., David F. Chang, M.D., Los Altos, Calif., Johnny Gayton, M.D., Eyesight Associates, Warner-Robins, Ga., R. Bruce Wallace, M.D., F.A.C.S., Wallace Eye Surgery, Alexandria, La., David R. Hardten, M.D., Minnesota Eye Consultants, Minneapolis, and Michael Korenfeld, M.D., Comprehensive Eye Care, Washington, Mo.

The Surgeon's Dilemma

Interestingly, all six of these top surgeons share most of the same general views on patient-shared billing and presbyopia-correcting lenses. They also include toric IOLs in the so-called "premium" category.

They all offer the premium option to every cataract surgery patient who is a potential candidate. They all have thoughtful and well-planned patient education programs. And they all are reluctant to market premium IOLs outside of their own practice. Though they all embrace the new technologies, they believe that one of the most difficult aspects of offering these lenses is the amount of effort required to provide each patient with realistic expectations as to what constitutes a successful outcome.

"If we could give each patient three diopters of dynamic accommodation, then I think every cataract surgeon in the country would be a strong advocate of premium IOLs," says Dr. Vukich. "But the technology hasn't advanced to that point yet. The presbyopia-correcting lenses we have today can provide patients with greatly improved vision, but we do have to make sure that we don't promise more than we can deliver."

"Cataract surgeons are spoiled in the sense that we have historically exceeded the expectations of the vast majority of our patients," adds Dr. Chang. "Facing an unhappy refractive IOL patient despite flawless surgery with a 20/20 outcome is therefore a very uneasy and unfamiliar prospect. Patient selection and patient communication are the keys to the success, and therefore the growth of this premium channel.

"I recently completed the most time-consuming project of my career — a 236-chapter, 1000-page textbook on ‘Mastering Refractive IOLs — the Art and Science’ (Slack 2008). There has never been a greater need for physician-to-physician education than on this very subject, and the fact that I enlisted more than 200 international authors speaks to the wide diversity of opinions and practices."

Following are surgeon responses to some of the specific questions that we posed to them:

Q. "What percentage of your cataract surgery patients are currently choosing premium IOLs and is this percentage trending up, down or staying the same?"

Dr. Gayton: "Our percentage varies, but is close to 20%. We have done a large number of premium lenses, especially toric. After steadily increasing, we have noticed a recent negative trend. I think that is due to the current economic downturn."

Dr. Hardten: "About 10% opt for presbyopic IOLs, with a slight upward trend as our patients and surgeons become more comfortable with the education process. Many more than that opt for astigmatic correction. I think income levels play some role, but the main characteristic seems to be age. Younger patients are definitely more motivated for the (premium) IOLs and have less co-existing pathology."

Dr. Chang: "About 15% to 20%. I don't really think in terms of consciously trying to increase the percentage. My role is to educate good candidates about them. Until we have better accommodating IOLs, too much promotion risks creating expectations that won't be met."

Dr. Korenfeld: "About 10% to 15%, with the trend increasing. I would expect it to continue to increase unless the economy cripples the consumer."

Dr. Wallace: "About 15% to 20% and trending upward due to positive word of mouth from happy patients."

Dr. Vukich: "About 15% including toric, with a gradual uptrend in premium procedures."

Q. "What methods do you use to present the premium option to patients?"

Dr. Chang: We mail an informational packet to every patient scheduling a cataract evaluation. In addition to a brochure explaining cataracts and surgery, there is a handout that I personally wrote which explains the option of presbyopia-correcting IOLs for which patients pay extra out-of-pocket. Finally, we send my modification of Dr. Steven Dell's excellent questionnaire.

"By asking patients to prioritize their goals, the clear inference of the questionnaire is that we don't have a way to deliver everything they may want. Interested patients come in for their evaluation ready to hear if they are a good candidate for these IOLs and what the additional cost is. Some may be disappointed to learn that they are not a good candidate, but it is better for them to hear this now, than to first learn about these options after surgery from a friend who is boasting about his or her results. I send qualified candidates home with more detailed FAQ handouts about whichever IOL I feel they are a good candidate for (multifocal and/or accommodating). This essentially provides informed consent that can be reviewed multiple times, shared with family members, and avoids the problem of selective hearing or selective memory. I have placed all of these handouts in the appendix of my book."

Dr. Korenfeld: "We ask every person just before biometery if they would be interested in being able to see up close as well as in the distance without glasses for most things after their cataract surgery. If they say yes, we ask them if they would be willing to pay for it, since that requires a special implant that their insurance doesn't cover. If they say yes, we tell them the price, and if they are still interested, we discuss the lens further. If price is an objection, we tell them they could finance it, and if they are still disinclined, we move on."

Dr. Gayton: "We use brochures, videos, mailings, the IOL Counselor software program (Patient Education Concepts, Houston) and discussions with techs, our own counselors and doctors."

Dr. Wallace: "We mention this option to every cataract surgery patient, even those who are not considered candidates. We inform them that this option is available but is not a good choice for them. I present these options to each patient personally and my staff will then follow up with any further details regarding these technologies."

Dr. Hardten: "Our patients who set up an appointment for a cataract evaluation all receive written and computer educational information before their appointment. We use a very simple three-question sheet to help us understand their goals with cataract surgery. All patients are educated about the option of presbyopic- and astigmatic-correcting options with their IOL surgery. The staff then follows up with more education if I feel that the patient may benefit from a premium IOL."

Dr. Vukich: "In our practice, premium IOLs are presented, but not pushed. Patients who are 65 and younger are really our target because they usually can get more real quality-of-life benefits from the premium lenses. I do not use a lifestyle questionnaire because I have found that some people will say they have a very active lifestyle and forget to mention that they spend 40 hours a week looking at a computer."

Q. "Once you have identified a good candidate, how do you proceed with the patient education process?"

Dr. Wallace: "Patient education starts with my discussion with these patients in the room. Once the patient decides to proceed with a premium IOL, further education is provided by video and one-on-one discussion with trained staff members."

Dr. Korenfeld: "I do all of the presentation. My staff needs to review the materials we have from the IOL company and be familiar with them, otherwise, they defer that discussion to me, where I think it has the greatest credibility, especially when you are asking for many thousands of dollars."

Dr. Vukich: "I tell them that this technology is an improvement over the standard implant and that their vision will be definitely better, though they still might need reading glasses. I tell them that 'I can't make you 25 again — but I can make you 40.'"

Q. "Do you also market premium IOLs outside of the practice to attract new patients?"

Dr. Korenfeld: "We don't market the premium IOLs outside the office currently."

Dr. Gayton: "We did do advertising for premium lenses, but it was not very effective for us. We have done better by talking to our cataract consults."

Dr. Chang: "External marketing runs the risk of creating very lofty expectations that you may have trouble reining in if your practice did the marketing. I do some refractive lens exchange (RLE) procedures, but find that most of these patients have the luxury of and would do better waiting for newer generation accommodating IOLs."

Dr. Vukich: "We don't market specific procedures. We present ourselves as a 'center of excellence.' We do give our premium IOL patients information that they can share with friends. We encourage that. We've found that often leads to word-of-mouth referrals."

Dr. Hardten: "Minimal. It doesn't seem to have helped with specific marketing for this, and marketing of RLE is not really on label. We do include in our general refractive surgery marketing that we have options for near vision, but this would include a multitude of options including monovision techniques as well as presbyopic IOLs."

Q. "What are the most common post-surgical issues and how do you handle them?"

Dr. Korenfeld: "Teaching patients patience. You must set the stage for the likely postop time course and visual expectations before going to surgery, reinforce it the day of surgery after the case while talking to the patient and their family in recovery, and on each postop visit until they are satisfied."

Dr. Gayton: In troubleshooting unhappy premium lens cases I have found four primary problems. 1) Patients with unrealistic expectations or who do not understand what the lens will do and how to use it. 2) Dry eye decreases contrast and thus decreases the quality of vision. Dry eye also affects preoperative surgical measurements. 3) CME and other retinal problems 4) Residual refractive error."

Dr. Chang: "Residual refractive error is the most common problem. Since I do not perform LASIK, I have prearranged with a local refractive surgeon how to manage these patients needing enhancements."

Dr Wallace: "Neuroadaptation is the most frequently not fully understood aspect. Also dry eye and posterior capsular pacification as well as refractive error."

Dr. Hardten: "Endpoint targeting (that requires) laser vision correction after. Dry eye, treated with Restasis (Allergan), artificial tears and education. Glare/halo that usually diminishes with time and neuroadaptation."

A Realistic Approach Works

Though all six surgeons view premium IOLs as an area of future growth, they tend to echo Dr. Gayton's comment that "We do not yet have an A-plus lens that will do everything."

For now, they are being careful in selecting good candidates for premium IOLs and spending a great deal of time managing patients' expectations. By observing these caveats, the surgeons are reporting that the vast majority of their premium IOL patients are satisfied with their outcomes. OM

Disclosure: Dr. Gayton is on the speakers bureau for Alcon. Dr. Hardten is a consultant to Advanced Medical Optics and Allergan and has done research for Alcon, Bausch & Lomb and eyeonics, which is now part of B&L.