Premium IOLs & O.D. Comanagement

Allowing optometrists to match patients to premium IOLs improves both patient care and practice growth.

BY STEPHEN V. SCOPER, M.D.

I belong to a busy ophthalmic practice that performs more than 1,800 cataract surgeries a year, and we have developed a large optometric network to help us comanage these cases. This network worked well for us for years — and then premium IOLs entered the U.S. ophthalmic scene. Suddenly, our smoothly running network came close to disaster because optometrists had not been trained in how these premium IOLs were different. They did not understand the nuances of patient care that were different from a routine, standard IOL.

I knew that for the good of our patients, we needed to address the situation, so I immediately stopped comanaging the premium IOLs and developed a program to teach optometrists what I felt they needed to know. The result was patients who were much happier with their cataract surgery and the quality of life it gave them.

Over time, this presentation evolved into a 3-hour, comprehensive course with a 200-page notebook that I give to optometrists around the country: "Comanagement of Premium IOLs: Training Opportunity for Comanagement of Multifocal and Toric IOLs." And while I am well aware that the ophthalmic community does not have uniformly warm feelings on the topic of comanagement, I do believe that it enables you to run your cataract practice more smoothly and to deliver a superior quality of vision to your patients. Following is a summary of how my course works to educate optometrists; you may want to consider this model for your own practice.

Finding Ready Students

As I said, this course began with my own personal situation and my own network of optometrists. I discovered the need was there, so I now conduct the course in other towns for Alcon Labs. I approach busy ophthalmologists who already comanage and have an optometric network. I tell them about my course and encourage their networks to attend. Any comanaging optometrist from a given area can attend; I tell ophthalmologists, "You send your optometrist, because your competition is sending theirs!"

However, I also make sure there is no territorial fighting — in fact, I don't even permit my attendees to utter an ophthalmologist's name; this course is designed to let O.D.s learn about premium IOLs in a "nondenominational" setting, not to promote any particular ophthalmologist. But ophthalmologists encourage their optometrists to attend my course because they see it as a "win" for all concerned — for themselves, for the O.D.s and for their patients.

I have three goals for my course to make this happen. Number 1 is to give the optometrists the knowledge base they need for premium IOLs. Number 2 is to motivate them and generate some enthusiasm about offering this to patients so that they really believe they can give their patients a better quality of life. Finally, number 3 is to challenge the O.D.s to go out the next day and recommend premium IOLs to their patients — to actually put the information they learned in the course into practice.

Help Them Help You

Please understand that having optometrists put into practice what they have learned about premium IOLs will greatly benefit your patients. The reason is that optometrists frequently know the patients much better than we do, having followed them for years versus the maybe 6 to 10 minutes the surgeon spends with them during an initial examination.

For instance, a standard, monofocal IOL focused at near is an option we can provide our cataract surgery patients — some people are nearsighted and they like to have their glasses off to read at near, while they continue wearing distance glasses. I had such a patient, and not being familiar with her habits, I made a mistake. She was in her mid 70s with a refractive error of -2.50 near. She has read in bed at night all of her life.

So the patient is sent to me and I take away her nearsightedness and give her 20/20 vision at distance with no glasses for the first time, and I think I've done a great job. But guess what? She's distraught, because she can't see at near and doesn't understand that she does see well at near, she just needs to wear glasses. But I changed her whole life, because I didn't really understand what she wanted — she loves to read with her glasses off.

The optometrist who sent her to me should have told me that. He knows her better than I do. He should have said, "Dr. Scoper, leave her -2.50, that's her life, and she'll be happy." I use that example in my course to tell optometrists that they have a huge responsibility to make a recommendation like that when they know the patient.

What They Need to Know

In order to help optometrists play their part in making the patient's cataract surgery as successful as possible, I take great pains to educate them on the latest IOL technologies and options for patients. The latter I present as monofocal for distance/glasses for near; monofocal for near/glasses for distance; monovision (stipulating that this patient must be successful with monovision contact lenses); toric IOLs/monovision for distance/glasses for near; and multifocal IOLs.

Then, within these options, I explain the differences between lens materials, such as acrylic and PMMA. I also cover key concepts like blue light, diffraction and apodization. Presbyopic IOLs, of course, are what all the buzz is about in cataract surgery, so I give optometrists a thorough education in the relevant IOLs on the U.S. market: the ReSTOR (+3.0 and +4.0 Aspheric, Alcon Labs), the ReZoom (AMO), the Tecnis multifocal (AMO), the Crystalens 5-0 and HD (Bausch & Lomb). I detail the mechanism of action for each IOL, provide an overview of U.S. clinical trial results for each and also explain the contraindications for each lens.

Instead of the O.D. just telling the patient, "You have cataracts, so I'm going to send you to Dr. Scoper for surgery," I want them to think about which IOL option is going to be best for the patient. After all, optics and refraction are the core strengths of an optometrist's training and expertise, plus the O.D. has likely known the patient for years and is able to assess their needs with greater perspective. The O.D. should educate the patient about IOL options and make a recommendation to the surgeon.

In my patient-selection segment, I detail who are good candidates for each lens, and who are not — such as patients with unrealistic expectations or ocular pathology.

I also use my course to educate optometrists about comanaging the patient postoperatively. This section includes postoperative complications the optometrists need to know about and four "pearls" of postoperative care that I learned from Eric Donnenfeld, M.D. They are: Treat residual refractive errors; do YAG capsulotomies early; aggressively treat ocular surface disease; and look for cystoid macular edema.

While this course doesn't do everything to prepare O.D.s for comanagement, I think it is the most thorough first step in training currently available. Ultimately, of course, if an ophthalmologist comanages with a group of optometrists, that ophthalmologist has a responsibility to train them and make sure they are capable of comanaging.

The Business Model

Now for the delicate issue of billing in comanagement. I offer the standard 20% comanagement fee that has been used with cataract surgery, as well as with Medicare and other carriers for years, and that has also been used with LASIK. For instance, in most eye care centers that offer LASIK, the ophthalmologist gets 80% and the optometrist gets 20%. I do the same thing with premium IOLs.

Let's say the average charge in the United States is somewhere between $2,200 an $2,500 per eye over and beyond what insurance covers. The patient writes out a check for $2,500. The lens costs about $900 and that needs to go to the ambulatory surgery center. So you take off, say, $1,000 for that. Then there's a $1,500 profit generated; out of that, 20%, or $300, would go to the optometrist and the other $1,200 would go to the ophthalmologist.

Now, it's very important to understand that this is not a kickback. The optometrist is working for that 20%. They know more about the patient's lifestyle and they've got a good knowledge base and they spend time making a recommendation before surgery; then they do a lot in the postoperative care of that patient. So they are providing value for that comanagement fee, and that work translates to less time the patient spends in the ophthalmologist's office. It is a true pay-for-service arrangement.

It is very important, in my practice, that the patient makes three different payments. They buy the lens and pay the ASC for the lens; they pay me 80%; and they write a separate check to the optometrist for the 20%. It is crucial for me not to collect everything and then to write a check from my practice to the optometrist for that 20% comanagement fee. Otherwise, it looks like a kickback. The patients are paying for their care, and the patient has two doctors in this situation. While the idea of allowing optometrists to take a portion of our hard-earned cataract surgery money may seem painful, consider the growth your practice will enjoy from comanagement with optometrists educated about cutting-edge IOL technology. Probably more than 60% of the cataract cases I do are comanagment and I've been able to double my surgical volume because of it. Currently, I do about 1,800 cases a year.

Additionally, my premium lens conversion rate is about 25% of all cataracts I do, and approximately 10% of that is from optometrists taking the course and being able to present the benefits of premium IOLs before they get to the surgeon. The educational process that the patient goes through before meeting the surgeon is so important, so that all this information is not dumped on them suddenly. They can make a really informed decision when their optometrist educates them. And when all components of an eye care practice are on board regarding a new technology and are enthusiastic about it, patients are more receptive to it. In the case of premium IOLs especially, that results is a win for both the practice and patients. OM

Dr. Scoper is an associate professor of ophthalmology at Eastern Virginia Medical School and in private practice at Virginia Eye Consultants in Norfolk, Va.