The Pursuit of Happiness: Patient Expectations for Premium IOLs

BY LESLIE GOLDBERG, ASSOCIATE EDITOR

A gentleman in his mid-60s — a long-time, loyal patient — sits in your exam chair, looking glum. “Doc,” he says, “I paid extra for these lens implants that were supposed to make me see like I did when I was young, and they don't. Sure, I can drive at night, but I get headaches from reading and it's hard to focus on the ball when I play tennis.”

It's a scenario every cataract surgeon dreads — unhappy patient in your chair, with you on the hot seat — and one of the chief deterrents to wider adoption of premium IOLs. Fortunately, those ophthalmologists who've learned how to succeed with this promising new category say that careful patient education and screening can make this a rarity.

We asked several experts for their best suggestions and insights on how to do just that.

All Aboard

“The most important thing to do when introducing premium IOLs into your practice is to spend the time to educate your staff,” says Richard Tipperman, MD, a private practitioner from Bala Cynwyd, Pa. “This includes the front desk, the surgical scheduler and the technicians. You want them to know what premium lenses you are offering, the type of patients who are going to be selected for these lenses and the way the fees and the financing are going to work.”

Robert Weinstock, MD, a private practitioner from west Florida, also emphasizes the team approach, especially since patients interact with your staff as much or more than with you. “You need a consistent message — in brochures, on the phones, what is said in your exam rooms, what the scribes write and what counselors say to patients in your office and in the surgery center,” he says.

Patient Dealings

Dr. Tipperman says it's equally important to consider how you are going to educate patients. The message has to be forthright and the presentation effective. He highly recommends a module on premium IOLs created by Eyemaginations and developed with prominent cataract surgeon David Chang, MD, which can be run in the office waiting room, in the lane or linked to a practice's Web site.

“When I have asked colleagues why they haven't adopted premium IOLs, their response is that they encounter difficulty with conversions,” says Dr. Tipperman. “They don't want to get involved with additional chair time and the cost issue.”

He believes that the Eyemaginations module provides a clear assessment of the benefits associated with premium lenses without over-promising. “Cost becomes less of an issue once patients understand the value associated with the lenses,” he says.

In Dr. Tipperman's practice, the choice of whether or not a patient is even offered a premium IOL comes down to biometry and other clinical factors. “If a patient has more than a diopter and a half of cylinder, we counsel them about toric IOLs. Those with less than a diopter of astigmatism are good candidates for a presbyopic lens. With these recommendations, we should be able to satisfy their expectations and make them happy.”

He says the problem of presenting and advocating the presbyopic lens option first is that if the patient doesn't want it, it is difficult to back-pedal into a toric lens and make them as happy. It feels like a consolation prize and won't be greeted with enthusiasm. He tells his patients that since they are only going to have cataract surgery once in their lifetime, they should take the time to thoroughly consider all options. “I tend to say to my patients that if you have a monofocal implant, you will be reaching for glasses to view anything at arm's length or less. If this is not acceptable to you, we have a better option. This way, the patient is deciding what they want.”

His practice takes the following steps to educate patients:

(1) When booking a new patient appointment, a letter is sent out stating that the practice offers the best technologies available, including a lens that corrects astigmatism and a lens that minimizes the need for reading glasses. “We provide them with information on their additional options and let them know there are out-of-pocket expenses tied into these options” as well as risks of suboptimal outcomes, says Dr. Tipperman. Because the letter is only one half page, this increases the chance that it will be read, he says.
(2) In the waiting room, brochures and information are available for perusal.
(3) The patient is then evaluated and, after the work-up, is provided with the doctor's recommendation.
(4) Patients are then shown the animation of the lens that has been recommended.
(5) He says that if patients have additional questions, he has a surgical counselor who can answer 90% of the questions comfortably.

Dr. Weinstock prefers to take a few minutes to speak with his patients about their lifestyle rather than use a questionnaire. “We set very realistic expectations for our patients. I need to give them their options and provide my top recommendation,” he says.

There is a very controlled process of communication from the moment his patients walk in the door to the time they leave. His scribe documents the entire interaction between the doctor and the patient and his counselors deliver options based on his recommendations, talk about financial burden and have patients sign a document saying they agree to the cataract package presented. “It is important that they understand the process and that the surgery does not guarantee glasses independence,” says Dr. Weinstock.

To potentially improve patient screening efforts, Steven Berger, MD, of Springfield, Mass., and colleagues have created a psychological test aimed at identifying the most suitable premium IOL candidates. “We've been trying to bring some science into the measurement of predictive personality factors to improve patient selection,” says Dr. Berger of the collaborative effort he's undertaking with Shane Owens, PhD, and Andrew L. Berger, PhD.

The goal of the test, he says, is to differentiate adaptive patients from those that are less flexible. The online questionnaire, called the Berger-Owens Surgical Screen version II (BOSS II), uses a series of statements that patients mark as either true or false. This research may help the investigators to understand better the factors that affect outcomes of — and satisfaction with — certain medical procedures. All elective surgery patients are invited to participate, and patients can take the test via the Web site. Once a critical number of patient responses are analyzed, their goal is to hone the BOSS II into a streamlined screening test for patient satisfaction that doctor's offices can incorporate into their preoperative patient selection pro cess. Visit mdpsy.com for more information.

Investing in Outcomes

“Eyecare has nothing to do with the economy and everything to do with a patient's vision. Money should be taken out of the equation,” says Dr. Weinstock. “I look at all the technologies available and help the patient make the best decision based on their life style and vision. I think decision-making is up to the doctor.”

He believes that if it weren't a question of finances, 90% of patients would want to see without glasses. “We explain that we charge extra to deliver premium vision. We want to empower patients to strive for spectacle-independent vision.”

The practice has also invested in the ORange intraoperative abberometer from WaveTec Vision, which enables Dr. Weinstock to perform refractions during cataract surgery and adjust toric lens positioning or identify the need for LRIs while the patient is on the table. He explains to his patients that if they want “refractive cataract surgery” that includes astigmatism correction, a sophisticated piece of equipment will allow him to fine-tune the results during surgery. His practice is seeing a reduced enhancement rate and patients are experiencing better vision one-day postop, so their experiences are more positive. Although ORange requires additional capital investment, Dr. Weinstock reports that his practice has seen “a great ROI” from it.

The “E” Word

“The management of expectations is critical in any type of business,” says Johnny Gayton, MD, of Warner Robins, Ga. “Note that I did not say ‘patient expectations,’ I did not say ‘premium lens' or even ‘ophthalmic practice.’ Expectations are held by customers, patients, family members, staff and vendors.”

Dr. Gayton says that premium lens patients expecting “improved” uncorrected vision are happy, but those expecting something the lens cannot deliver are not. “All of the lens companies tell us to under-promise and over-deliver with premium lenses.” Making their educational materials consistent with this philosophy, he says, would help avoid confusion among surgeons who might be inclined to overstate the results. He strongly encourages manufacturers to help set realistic expectations — for surgeons as well as patients. “Our use of premium lenses is a very important part of our practice, but it was a constant source of frustration until we started properly managing patient expectations. Be realistic; even understate what you expect the patient to achieve with the lens that you recommend. Your patients and your staff will thank you for it,” concludes Dr. Gayton.

Others concur. “Personally, I think company testimonials are way too strong,” says Dr. Tipperman. “When these lenses first came out, we talked about percent of people spectacle free. Most doctors in the lane no longer talk about that — they now talk about better quality of life and more convenience,” says Dr. Tipperman.

“Companies are in the business of sales,” adds Dr. Weinstock. “But they are doing a disservice if they oversell. This puts doctors in a bad position. We must go above and beyond to set realistic expectations with their patients.”

“It is essential to receive your staff's feedback on a patient,” says Kevin Waltz, MD, of Indiana. “I encourage my staff to tell me their impressions and how they were treated by a patient because they will be more readily abused by the patient.” He suggests that patients may be more “eager to please” when the surgeon asks about their willingness to tolerate imperfect results; with your staff, however, they'll be more forthcoming about what they are, and are not, willing to tolerate.

Dr. Waltz says 10% to 20% of patients will need a second surgery to fine-tune results — and that's if he doesn't anticipate any problems. “Tweaking is included in the initial price quoted to the patient. We will do whatever we need to do to get them fine-tuned,” he says. Surgeons looking to add premium lenses to their practice need to accept and account for retreatments, both in terms of pricing and scheduling.

According to Dr. Waltz, “the old mind-set of enhancements as a negative reflection on your surgical ability doesn't work with this surgery. Successful cataract surgery is no complications and not too bad of a refractive outcome. Most times, pristine spot-on refractive results are not possible the first time through.” He says patients are fine with a second surgery as long as they are made aware of it in advance.

To provide surgeons with real-world outcomes data, Guy Kezirian, MD, has created a database called the SurgiVision DataLink IOL Edition that tracks comprehensive premium IOL outcomes in a collaborative data registry. Data-Link, which is sponsored by Bausch & Lomb, compares IOL outcomes from all manufacturers in an easy-to-use online interface. Outcomes measures include spherical equivalent, and monocular and binocular visual acuity at distance, intermediate and near vision. Users receive customized reports that compare their practices outcomes to the global pool of users (see Figure 1). Over 70,000 IOLs have been entered into the database; participation is voluntary.

Figure 1. A customized report created using the SurgiVision DataLink IOL Edition database.

Listen Up and Follow Through

Incorporating premium IOLs into a practice should be done gradually and selectively, but the surgeons must be committed to careful patient selection, surgical excellence and completing their work. Should you begin with accommodating, multifocals or toric IOLs? Some surgeons feel that toric IOLs tend to have greater likelihood of patient satisfaction than presbyopia-correcting IOLs. Regarding multifocals, “a prominent ophthalmologist once told me ‘patients would never be happy with multifocality because of quality of vision issues,’” says Alan Aker, MD, of Boca Raton, Fla. Multifocality is a compromise that must be discussed and demonstrated thoroughly before patients can make an informed decision — and that kind of education is often lacking or inadequate, according to Dr. Aker.

“My practice at times feels like a referral center for unhappy patients with problems relating to premium IOLs,” says Dr. Aker. He says that most of his referrals originate not from poor surgical technique, but rather poor doctor to patient communication. “In the face of good postop visual acuity, many doctors seem to downplay or ignore patients’ complaints — complaints of glare and halos or poor quality vision. They tell their patient to give it time and they will get used to their new optical system,” says Dr. Aker. “The truth is — and this applies to all premium IOLs — in many cases when a patient is unhappy, that patient is unhappy simply because the doctor and his team have missed the mark and not achieved postop emmetropia.”

Dr. Aker says that when patients have paid for a premium IOL, they expect and deserve a premium outcome. He tells patients, “if we don't achieve the vision we've described, we will 'tweak you — at our expense.” For a premium IOL to work, he feels it is imperative to get patients within 0.5 D of emmetropia and leave them with less than 0.5 D of astigmatism. If a patient is more than half a diopter off, he recommends a LASIK procedure to fix the residual refractive error.

“It is imperative that we finish our work,” says Dr. Aker. “If a surgeon is unable or unwilling to address astigmatism or postop residual refractive error, that surgeon is really hurting the premium channel. Unhappy premium IOL patients discourage others from having premium lenses. Their unhappiness impacts the entire sector of premium IOLs. Any surgeon unwilling to finish the work — to do what is necessary to ensure their patients are happy with their surgical outcome — should not be implanting premium IOLs.”

Dr. Aker emphasized that companies need to protect the premium channel lenses as well. “Each company needs to continue to stress the importance of proper patient selection, the importance of being within half a diopter of emmetropia, and the importance of reducing astigmatism to 0.5 D. Multifocals are less forgiving of astigmatism than accommodating IOLs. If astigmatism is not eliminated, there will be unhappy patients — and unhappy patients will poison the pool.”

“Perfecting a person's vision is a wonderful, precious privilege and, as surgeons, we need to do the job right and finish the work. It is incumbent upon us to make the patient happy. We have to listen so we can understand their complaints. We can't be defensive. When the patient knows we're on their side, the battle is half won. We must address their issues quickly and ensure that we don't leave them unhappy because of unmet expectations,“ he concludes.

Educating the Masses

“Patients come to us knowing they can't see and they may even recognize that they have a cataract,” says Paul Koch, MD, of Warwick, RI. “Our job then is to evaluate why they can't see, make the appropriate diagnosis, explain what a cataract is, the operation needed and how we are going to fix them. We are meeting their expectations.”

Dr. Koch says it is then his job to tell them that there are other products available on the market that may provide additional benefits and will entail additional costs.

“It is my opinion that the companies have been remiss in their public relations in their introduction of premium IOLs to patients. There has not been a whole-hearted effort to have patients come in and ask for premium IOLs,” says Dr. Koch.

Dr. Koch believes it is the premium lens company's job to get the initial word out to patients — not the doctor's job. “Our job is to make the right diagnosis and therapy decisions. Our job is to not become sales people for a product that costs a large sum of money.”

He believes there is an overt financial conflict of interest when a practice can make one to two times the profit than it would make on a “regular” cataract surgery. He says if patients were already aware of the premium lens option in advance, it would not be such a conflict.

“In a suffering economy, where people are worried about buying food next week, it's difficult to recommend significant additional expense to people on fixed incomes. Cataract surgery alone is a miraculous and wonderful procedure — most patients don't care about wearing glasses if they are told about the need in advance.”

“We need to keep in mind that the primary reason the patient comes to us is to have their vision evaluated, receive a good diagnosis and to come up with a therapeutic plan. No matter what the lens, the primary issue is to improve a patient's sight. The focus should be on doing excellent cataract surgery.” OM