Meeting the Premium IOL Challenge

How to succeed despite the increasing demands of cataract surgery.

By Sean McKinney, Contributing Editor

If you're a cataract surgeon, your world is about to be rocked by the demands of a tidal wave of aging baby boomers and tighter surgical economics. What will your strategy be?

Many experts say your success will hinge on your ability to offer premium intraocular lenses (IOLs) while refocusing your staff, improving surgical efficiency, reorganizing patient flow, tracking outcomes and launching integrated care teams that link you to the front desk through the coordination of optometrists, nurses, technicians and surgical counselors.

Here are some important steps to take.

Get bullish on premium IOLs

"With premium IOLs, everyone wins," says Daniel Durrie, MD, of Durrie Vision, Overland Park, Kan. "These lenses help provide more of the services patients want and also benefit our bottom line."

Premium IOL options include:

■ Presbyopia-correcting IOLs: AcrySof IQ ReSTOR IOL (Alcon Laboratories, Fort Worth, Texas), Tecnis (Abbott Medical Optics, Santa Ana, Calif.), ReZoom Multifocal Refractive IOL (Abbott) and Crystalens (Bausch + Lomb, Rochester, N.Y.)

■ Astigmatism-correcting IOLs: AcrySof IQ Toric IOL (Alcon) and Staar Toric IOL (Staar Surgical, Monrovia, Calif.)

Surveys by Elective Medical Marketing of Boulder, Colo., last August showed that 207 of its clients charged $1,037 to $1,180 for a toric IOL and $2,200 to $2,312 for a multifocal IOL (not including lens or ASC fees), according to Kay Coulson, president of Elective Marketing. These patient-paid fees for professional services didn't include standard Medicare reimbursements for extracting a cataract and replacing it with an IOL implant.

"If you offer all lens options, plano to premium, you'll get the most patients," adds Stephen Lane, MD, managing partner at Associated Eye Care in St. Paul, Minn., and clinical professor of ophthalmology at the University of Minnesota. "You can't offer only a certain type of lens. Patient choice will determine which surgeries will be performed."

He says you have to develop your skills and make a commitment to premium lenses. Some ophthalmologists are reluctant to implant them because of the need to achieve optimal refractive outcomes. But Dr. Durrie says improved lens technology and instructional classes that teach how to implant IOLs can help overcome hesitation.

"Once you become competent, you can deliver this level of care," he says.

Mastering premium IOL implantation skills pays off significantly for you, your patients and your practice if you commit yourself fully to the procedure.

Reorganize your staff

A key strategy is to hire employees with retail sales personalities and provide performance-based compensation when your practice achieves premium IOL targets, Ms. Coulson says. Skilled counseling up front is time-consuming but critical because choice needs to be individualized for what she calls "patient-preferred vision."

Edward Holland, MD, director of cornea services at the Cincinnati Eye Institute and professor of ophthalmology at the University of Cincinnati, sends patients information on surgical options before they come into the office. At the office, they complete a visual needs assessment that might reveal a predisposition to solutions. For example, a monovision contact lens wearer may do well with multifocal or monovision IOLs.

All staff members deliver a consistent message. "By the time patients meet the surgeon, they should be reasonably educated and able to make good decisions," he says.

Dr. Lane recommends making a verbal commitment to patients. "You should do everything possible under one bundled fee to meet the desires of each patient," he says. "These patients may be more demanding but for good reason. It's incumbent on us to create realistic expectations, then fulfill those expectations."

For example, presbyopic IOLs may be recommended for a patient who desires independence from spectacles. However, the patient needs to know he may experience visual disturbances under some circumstances.

Create an integrated care team

To make room for premium IOLs, Dr. Holland recommends partnering with optometry. The Cincinnati Eye Institute, where 45 ophthalmologists practice, employs 15 optometrists. One of them works side by side with Dr. Holland.

"Practicing with MD-employed ODs is an important model that will be critical to assist with the increasing manpower issues facing ophthalmology," he says. "I can have my patients follow-up with my OD partner when I am in the OR. The optometrist who works with me understands my approach to patients and my clinical care."

Dr. Holland delegates much of the post-operative care and follow-up he managed alone in the past. "This has allowed me to be more efficient in the clinic and has increased my surgical time," he says.

He also co-manages cataract patients with private optometrists in the community, making sure that the patients are returned to the care of their optometrists 30 days after surgery.

Dr. Lane, whose practice includes an ambulatory surgery center, nine ophthalmologists and three optometrists, also recommends co-managing with optometrists, as long as the surgeon determines the need for surgery. Ms. Coulson suggests training staff to channel patients to ophthalmologists and optometrists to maximize practice efficiency.

Extra steps can maximize efficiency when preparing the patient for premium IOL surgery. Here, the staff perfectly positions the patient's head, using a special pillow as a final adjustment.

Alan B. Aker, MD, who operates the Aker Kasten Eye Care Center with his wife, Ann Kasten, MD, in Boca Raton, Fla., co-manages 1,000 of his 2,500 cases per year with optometrists and other ophthalmologists. Referring ophthalmologists and optometrists benefit from the comanagement fee, good surgical results and the ability to retain patients. Referring ophthalmologists can perform Ng:YAG capsulotomies, and patients benefit from surgeon accountability.

Dr. Aker believes success will come to those who can develop proficiency with all lens options, including premium IOLs, in a team-oriented ASC, where he says surgeons will need to perform 25 cost-conscious cases a day. To meet the increasing demand presented by the baby boomers, he plans to add a fourth morning of surgery each week.

"If the 21% Medicare cut goes into effect, we could drop down to a global reimbursement of $600 and a co-management fee of $480," he points out. "I believe $500 is a psychological and fiscal level that, once broken, will push many surgeons out of cataract surgery. Premium lenses will be one of our few remaining opportunities."

Track your outcomes

Post-operative refractions and visual acuity tests are essential to inform future decisions about lens technology, lens power or technique, according to Dr. Holland, who along with his partners looks at outcomes frequently to determine if they need to adjust their A-constants.

"There's a great parallel to what patients expected from refractive surgery in the 1990s," says Dr. Holland. "We'll see refractive and cataract surgeries continuing to merge."

Be prepared to manage surgically induced-astigmatism, the leading cause of uncorrected visual loss in post-IOL patients, he says. "The better the IOL calculations, the fewer enhancements you'll have to perform after premium IOL surgery," adds Dr. Holland. "But in some cases, no matter what you do, you'll have to handle these patients post-operatively."

"We used to just do biometry and then see how we did after surgery," says Dr. Durrie. "For premium IOLs, we have to do better biometry, and use technology such as the ORange intraoperative wavefront aberrometer (WaveTec Vision, Aliso Viejo, Calif.), so we can achieve vision that is as perfect as possible."

A stretcher is measured to ensure proper height.

What is Your Premium IOL Profile? A survey late last year of 207 practices on our client list indicated that premium IOL enthusiasts were only doing 65 procedures per month but earning an average physician fee of $1,062 per lens implant (not including lens or ASC fees). Premium IOL dabblers were doing an average of 88 cases per month, 84% of them monofocal lenses, and were averaging physician fees of $805 per lens implantation. In my consulting experience, the enthusiasts enjoy their surgical practice more because they get to spend more time with the patient, achieve positive outcomes and earn more revenue. — Kay Coulson, president Elective Medical Marketing kay@electivemed.com

Consider supporting technology

Dr. Durrie says several new technologies support new surgical practices, which will emphasize precision and efficiency to justify additional fees. Here's how two emerging technologies can help:

■ Femtosecond laser: At least three companies — OptiMedica (Santa Clara, Calif.), LensAR (Winter Park, Fla.) and LenSx (Aliso Viejo, Calif.) — are developing femtosecond lasers for cataract surgery.

"The laser provides a perfectly centered capsulorrhexis that you need for premium IOLs," says Dr. Aker. "For premium lenses to work, the surgery must be built on a series of near-perfect steps. You'll find yourself spending a lot of chair time, as well as needing to do a lot of enhancements, if you don't do these surgeries right the first time."

The femtosecond laser, when guided by real-time OCT, also can facilitate precise limbal relaxing incisions, enhancing both prebyopia-correcting and toric IOL implantation. The cost of technology acquisition will need to be absorbed by operating revenue at a time of decreasing fees. However, Dr. Aker says the laser can improve efficiency by allowing for exquisite sideport and main incisions and a perfect capsulorrhexis in a third OR.

After these three cuts have been made, the patient can be wheeled into a separate OR, saving the surgeon the time it takes to perform these important steps. Besides increasing surgical precision, this innovation can save 90 seconds per procedure, resulting in a gain of five cases per morning of surgery.

The scopes are centered over the patient's eye by the nurses. Staff headsets decrease OR chatter and increase efficiency by keeping the surgical team connected.

■ Intraoperative wavefront aberrometry: The ORange intraoperative wavefront aberrometer, attached to the operating microscope, captures refractions in 2 to 5 seconds during surgery, measuring sphere, cylinder and axis. The information can improve the accuracy of toric lens positioning or limbal relaxing incisions and may allow the surgeon to choose a different IOL than originally selected.

"It eliminates possible IOL formula and human error, which in turn can help reduce the need to fine-tune patients with enhancements," says Dr. Aker. "For example, I might have filled the eye with viscoelastic and planned to implant a 22D lens. The ORange technology might indicate that I should put in a 22.5D lens. This last-minute adjustment reduces post-op enhancements. Or if I'm doing relaxing incisions for astigmatism, it tells me exactly where to make my incision. After a toric IOL is inserted, ORange will tell me to rotate it a few degrees to be exactly on-axis."

Streamline technology and approach

Dr. Holland notes that a small practice can thrive if it adopts premium IOL surgery and follows these steps. Meanwhile, Dr. Aker believes that all surgeons, from small and large practices, will need to become efficient when implanting premium IOLs and other IOLs.

"We all have to change and do things smarter and better," he says. "Premium IOLs provide one important part of this overall strategy." OM