Premium IOLs: Pointing Patients in the Right Direction

How to guide your patients toward the best option without giving the dreaded sales pitch.

By Samantha Stahl, Assistant Editor

Ophthalmologists have never been all that comfortable “selling” premium IOLs. Even the most successful surgeons can struggle to make the case to patients, as they (rightly) fear that a “hard-sell” approach would jeopardize the physician-patient relationship that is based on trust and candor. And after surviving an economic downturn, consumers have grown more resistant to sales pitches, meaning an aggressive surgeon-turned-salesman approach will ultimately do more harm than good.

Here, successful cataract surgeons from across the country share the strategies they employ to keep conversion rates high. By educating the patient and keeping the overall consensus on the premium channel positive, it's possible—and, in fact, necessary—to keep patients happy with their investment.

Patient Education

“The most important thing is educating the patient and letting them know their options, then staying quiet and letting them decide. That's what we've found to work for us,” says Kiper Nelson, MD, of the Southern Eye Center in Hattiesburg, Miss.

The practice presents information on the various IOL options no fewer than three times before the patient speaks with the doctor. Upon scheduling an appointment, each patient receives a DVD about cataract surgery and lens options, as well as a lens “menu”—a paper that offers three choices: (1) the basic lens that Medicare pays for, (2) a high-definition package that would include an aspheric monofocal lens or a toric lens, depending on the patient's needs, and (3) the multifocal lens.

“By putting everything on one page, it's easier for patients to understand the material rather than being overwhelmed by every single lens option available,” Dr. Nelson says. After the patient has had an opportunity to soak up some of the information on their own, a refractive counselor will call a day or two before the patient's scheduled appointment to go over the options and pricing, and certification for credit if price is an issue. On the day of the appointment, a technician will review the options again. Dr. Nelson finds that, in most cases, patients have already made up their minds by the time he meets with them.

“There's a certain percentage of people who can't decide between chocolate or vanilla, so I have to spend a few minutes discussing the options with them. But the coordinated education effort is really important—the doctor can't do it all by himself. He'd spend about two hours with each patient.”

Southern Eye has spent a lot of man-hours tweaking their education process (the DVD and “menu” were both made by the practice) and ensuring that everyone on staff can speak intelligently about any lens option. Hattiesburg isn't a particularly affluent area, which might make Dr. Nelson's high conversion rate baffling to some. He insists that their numbers are a testament to their patient education system that stresses how important the investment is for future eyesight.

“The average person is willing to spend $5,000 a year on a car they know won't last more than 10 years. When you explain to them that this decision will affect their eyesight for the rest of their life, then the upgrade rate is going to naturally follow. ”

Sidestepping the Sales Pitch

At the other end of the community spectrum comes A. James Khodabakhsh, MD, of the Beverly Hills Vision Institute. While there are indisputably more patients in that setting who can afford premium lenses, he says that geography has very little bearing on patient conversion. While his conversions are around 70% in his Beverly Hills office, he still gets 65% at the large HMO practice where he does surgery one day a week.

He attributes the high rate to the quality time he spends with every cataract consultation, where he details the different options and offers a realistic summation of each lens's real-world performance. If the patient expectations are out of the realm of reality, they aren't a good candidate for premium lenses, he says.

“We review all the risks and benefits. I tell them outright that there is a chance they will still need reading glasses. I speak to them about the potential for post-surgery laser vision correction.” He finds that patients prefer to hear about the options straight from a doctor, but will leave the price discussion up to a coordinator.

Most importantly, he avoids ever making his patients feel like they are being “convinced” to buy any one lens and leaves the final say up to them.

“No one ever wants a sales pitch at their doctor's office. It's a huge turn off and, frankly, bad for business. If the patient feels like they are being sold something, that is a deal killer,” he says.

Instead, he aims to convey exactly what the lenses are capable of—a wider range of vision, similar to the way they saw at a younger age, but with limitations or shortcomings to accept. Confidence is another crucial factor in the conversion rate conundrum. If a surgeon isn't convinced of the technology's merits, how is a patient expected to be? Dr. Khodabakhsh worries that many surgeons aren't exuding enough confidence toward premium lenses.

“I had a patient for whom I was giving a second opinion tell me that they felt the other surgeon just wanted them to get this lens because he wanted to charge extra, but really did not care about the lens. If the patient feels the slightest bit of doubt from their surgeon, then the deal is off.”

Picking the Right Lens

“There is no 100% perfect lens and patients understand that. Artificial lens, hip and heart implants are all great, but nothing is as good as young, healthy human body parts,” says Uday Devgan, MD, of Beverly Hills. “I can give patients really great vision, but I can't give them the eyes of a teenager. Once they understand that, they can get over the psychological roadblock of unrealistic expectations.”

Dr. Devgan stresses the importance of being proficient with a wide variety of IOLs so that he can precisely select the right choice for each patient based on their lifestyle. Though the choice is ultimately up to the patient, he makes strong recommendations to guide them towards the best option.

“My patients aren't ophthalmologists and they will never have the knowledge base that we have as surgeons. It's our duty to provide guidance and recommendations for our patients. I may know a lot about ocular surgery, but if I had to have hip replacement surgery, even though I'm an MD I wouldn't know what to pick if the surgeon asked which hip implant I wanted. I would tell the orthopedic surgeon, ‘Well, this is my hip, this is my anatomy and these are my needs for my lifestyle. What do you think is best for my surgery?’”

Determining the patient's desired near focal point is crucial, he says. While a 6' tall man may hold reading materials farther away, a small woman who's only 4'11” and has shorter arms will need a closer focal point. By doing some simple math, it's easy to find the focal point of each lens, which he then matches to the patient's lifestyle needs. For example, Alcon's ReStor SN6AD1 lens has an average +2.25 add at the spectacle plane, which equates to a 0.44 meter focal point, or 18 inches away. AMO's Technis ZMB00 multifocal, on the other hand, has a +3.00 spectacle plane equivalent add, giving a 0.33 meter focal point, or 13 inches. The surgeon needs to be well-versed in the details of each lens option to make the best assessment possible.

By going over a patient's daily activities and their vision needs—Do they spend a lot of time sitting in front of a computer? Do they frequently drive at night?—the proper lens choice can be made, ultimately resulting in a happier patient.

Cynthia Matossian, MD, who practices in Doylestown, Pa. and Ewing, NJ, also stresses the importance of lifestyle considerations by having each patient complete a questionnaire. She educates each candidate on the full range of IOL options with handouts, Eyemaginations cataract surgery videos and in-depth discussions with technicians and surgical coordinators before she makes two lens recommendations—the basic and premium option that makes the most sense for that patient's ocular condition and needs.

“Each one of us explains the same two options a little differently to help the patient make the most informed and educated decision. I discuss the two options with every patient, never making any assumptions based on their age or appearance.”

For example, those who want better near vision for reading without relying on “cheater readers,” she steers toward multifocal IOLs. However, if distance and night vision are more a priority, she feels that Bausch + Lomb's accommodative IOL Crystalens is a better option.

Dr. Matossian also recommends Crystalens for patients interested in presbyopia correction who are not ideal candidates for multifocal IOLs because of a positive angle Kappa, previous LASIK surgery or a mild epiretinal membrane, which may pose a problem with a multifocal lens.

“If a patient with positive angle Kappa gets a multifocal IOL, it is probable that he or she may end up looking through the first ring of the IOL, even if the lens is perfectly centered within the pupil. This causes visual symptoms and unhappy patients.” To avoid this situation, Dr. Matossian advises that patients be evaluated for a positive angle Kappa prior to surgery.

All for One and One for All

Many surgeons reported that they offer complimentary refractive touch-ups if the initial outcomes aren't spot on, saying that it makes the patient more comfortable with the cost knowing they'll be well taken care of after the procedure. An oft-ignored benefit of a happy patient? Satisfaction is contagious—the more happy people wandering around buzzing about their newly restored vision, the greater the number of new patients interested in acquiring these new technology IOLs for themselves.

Alan Aker, of Boca Raton, Fla., lives by the “rising tide lifts all boats” mentality—so much so that he has no qualms about sharing his techniques and experiences with nearby competing surgeons, believing that it is better to share pearls so the overall provision of care in the local area is improved. Dr. Aker also frequently communicates with other surgeons in his community about the importance of “finishing your work.” He expresses concern that doctors who cannot routinely achieve emmetropia or don't address post-op refractive needs could cause the premium channel to suffer.

“All of us in the community have an obligation to each other to ensure that our premium IOL patients have achieved premium outcomes. If we miss the mark, we must address it or we tarnish the image of premium IOLs. Those surgeons unwilling to go through hoops to get patients a good outcome should be discouraged from entering the premium marketplace.”

In order to keep patient perception of premium IOLs positive, he also stresses that no one lens should be harshly criticized, regardless of a doctor's partiality towards one technology over another. When discussing lens options with a patient, it is important to focus on the positive aspects rather than relaying problems that some lenses can cause.

“If you're a strong proponent of accommodating technology over multifocals, don't tell patients that you've seen all kinds of patients with problems relating to multifocals. This simply throws all premium IOLs under the bus.”

Talking negatively about premium IOLs, says Dr. Aker, is much like the way early naysaysers opposed the first IOLs and phaco. Discouraging patients from investing in the lenses will only hurt the patients themselves, other eye surgeons and progress in the ophthalmic industry, he advises.

“Amidst the ongoing reductions in reimbursements and onerous regulatory constraints, the one bright light for us as we move down the road is the widening array of premium products. It is absolutely imperative that we as surgeons protect the premium channel.” OM