Jump-starting Your Refractive Surgery Practice

Twenty marketing tips on keeping this life-enhancing procedure alive during the downturn.

By René Luthe, Senior Associate Editor

Like many other Americans, refractive surgeons may find it difficult to believe that the “great recession” ended in June 2009. They've heard the official pronouncement from the economists, of course, but the fact remains that laser vision correction volumes have continued to decline. According to David Harmon of Market Scope, the number of US procedures in 2007 was 1,370,200 eyes. For 2011, the projection is 743,500 eyes. And with wages still stagnant, unemployment hovering at just over 9% and consumer confidence low, a case of bad nerves on the part of the industry is understandable.

It's an ironic state of affairs for a surgery that delivers results that are better than ever. For the optimists, however, that is the very reason laser vision correction fortunes have to turn around sometime. So while warnings about a “new normal” in American life may turn out to be greatly exaggerated, how can a refractive surgeon survive the current hanging-in-there state of the market? Those in the laser vision correction trenches tell what has worked for them.

Don't decrease price — add value and convenience

William Wiley, MD, a cataract and refractive surgeon from Cleveland, offers these pearls:

1. Make them an offer they can't refuse. Stagnant salaries and high unemployment make patients reluctant to pay laser vision correction's price tag, but slashing fees, of course, means a reduced profit margin and/or cutting corners. Dr. Wiley's practice has devised a win-win alternative: increasing patients' perception of value. They do this by packaging the surgery with other services the patient will find desirable. One of their most successful packages is a five-year vision plan with the surgery. The deal ensures that patients will get the annual exam they need, especially after LASIK, at a lower cost than the exams would run individually. He says that the practice has seen an increase in laser vision correction surgery volumes in response.

The practice also offers non-ophthalmic items to enhance the value of their surgery: teeth-whitening and massage are two, as well as the lash-lengthening drug Latisse.

2. For your convenience… Additionally, Dr. Wiley's practice has sought to hook LASIK patients by making the surgery more convenient. They offer transportation services so that patients don't have to arrange a ride to and from surgery. “I've got two kids and my wife is busy taking them back and forth to school,” he says. “If I had surgery, she would also have to drive me to the office to get my surgery and drive me back home. It's hard to coordinate all that, especially if you've got two working spouses, and you don't want to miss a day of work.”

To further reduce the need for patients to miss a day of work in order to have surgery, the practice now offers evening hours one night a week. Patients can have LASIK on Wednesday night and return on Thursday evening for the postop exam. Evening hours also allow patients to save up their valuable PTO for the northern midwest's relatively short summers.

“Cleveland winters are tough, and we are always busy then, but in the summers it gets really slow, because people don't want to lose a weekend recovering from refractive surgery, and they don't want to miss work,” Dr. Wiley explains. Adding evenings allowed them to save their precious PTO for fun in the sun.

3. Go to them. The economic downturn had made the practice rethink their marketing efforts as well. “We've stopped almost all traditional marketing,” Dr. Wiley says. “We've spent so much money on radio or billboards or TV, and you're still not maybe reaching your target audience.” Their new-and-improved approach is to have a presence at popular regional events. The size of that effort depends on the size of the event. Their RV acts as a sort of mobile billboard to attract attention and is sent to larger events — for example, something that draws an audience from neighboring counties and states. The practice's sprinter van is dispatched to smaller events such as county fairs, or the practice sets up a tent. At these venues, the practice may present, or simply have staff available for questions. “We've found that in each little town, there is one big event for that year, so we'll go to that,” he says.

4. Open your doors. Another way to bring in revenue, Dr. Wiley notes, is to open your center to other LASIK surgeons. Those who don't perform enough surgeries to justify their own laser or obtain the latest technology can keep their hand in by renting another center's equipment and space. The center decreases its overhead costs. “It can be a win-win for both the surgeon who has the technology and the surgeon struggling to stay afloat in this market.”

Smart Marketing — And Its Limitations

John Potter, OD, FAAO, has gained his insights as vice president of patient services at TLC Laser Eye Centers of Dallas. The economy and consumer confidence may be out of the refractive surgeon's control, Dr. Potter concedes, but smart marketing and realistic expectations for growth can go a long way toward maintaining a successful laser vision correction practice. Here are his take-away lessons.

5. Personalize the message. “If the physician wants to have social influence over how people behave, and that includes both consumers and patients, it's really useful to have the message be personalized,” he says. That means that marketing messages should feature someone who looks like the patient whose attention you want to get, or someone who has the sort of refractive error you can successfully fix. Often, he notes, ads for refractive surgery are the same in every community, regardless of region or audience.

Avoid high-level medical jargon, he recommends. Including such language turns “a message that should be about improvement in vision and quality of life into a number — 20/20, 20/15, etc. Most people have no idea what that means.” Stick to concepts that patients understand.

6. Take a multi-pronged approach. Dr. Potter finds that just as it is critical to diversify your stock holdings for your investment portfolio, so you should diversify your marketing plan. Relying on just one marketing approach would be a great mistake. In the new era of social media, forums such as Facebook and LinkedIn are ignored at the surgeon's peril. Have a presence there, but don't neglect the old-school health fair or brochure. “I think a successful refractive surgeon is able to do a little bit of everything to get his message to consumers so that they will become patients,” he says.

7. Marketing has its limits. Even the best-laid marketing plans will only go so far, Dr. Potter warns. Refractive surgery is simply not a commodity. “I'm not aware of any surgical procedure that has ever been able to be marketed to consumers that has been sustainable as a marketing effort,” he says. While a well-thought out, glossy ad can get people's attention, when it comes to healthcare, it would be a mistake to think that was enough. “At the end of the day, if you are going to become a patient, it's a different kind of relationship than a customer/vendor relationship.”

The refractive surgery market, Dr. Potter maintains, is substantially tilted in the individual practitioner's favor. Most people sign up for surgery because of a belief in the surgeon as a physician. But building that kind of patient awareness takes time and marketing will not provide a shortcut. “Consumers are uncomfortable becoming patients because of an advertisement,” he says.

8. Beware machismo. Dr. Potter warns against falling into thinking that if you do one more surgery than Dr. X this month, you're a better doctor. Given the state of the economy and patients' high expectations, he believes a more modest approach will help surgeons to both enjoy refractive surgery and ride out the current downturn in volume. “The right thinking is, ‘I'm pretty good at this, I get great results, patients enjoy their vision, so I'm going to keep trying to grow this and make it an important part of my medical practice.’” Often the doctors most impatient to boost their numbers are those who have been in practice for only five to 15 years. “Yet they've still got 20 years of practice ahead of them, and they want to climb Mt. Everest tomorrow,” Dr. Potter says. “I'm not sure that's a good approach.”

Don't Overlook These Marketing Basics

Emil Chynn, MD, MBA, practices at Park Avenue LASEK in New York City, where he has found that remembering some marketing basics has helped his practice grow year after year.

9. Educate, educate, educate. The number of eligible patients who haven't yet had refractive surgery is so great, Dr. Chynn points out, that even given a bad economy, surgeons ought to be busier. According to Desmond Fonn in 2002, two to three million people drop of out contact lens wear each year. Dr. Chynn says that refractive surgeons have done a very poor job of tapping into this candidate pool, a group of people who almost have “no choice.”

“Clearly these people would rather not wear glasses, or they wouldn't have gotten contacts,” he notes. “Forget the millions of new myopes, hyperopes and presbyopes every year. We're not even lasering as many people who drop out of contacts every year.”

This discrepancy indicates that refractive surgeons need to do a better job of educating the public. “They need to know that this surgery is safer than contacts in the long run, because of the continued risk of infection from contacts year after year.” If surgeons can succeed in communicating that message, Dr. Chynn believes the economy becomes much less of an obstacle. In New York City, Dr. Chynn reports, it is not unusual for people to spend $1,000 on a pair of glasses. “They get designer frames, anti-reflective coating, they don't buy a cheap pair of glasses. So you can't tell me that patients won't pay $5,000 to stay out of glasses.”

10. Brand yourself. “There are only two prominent refractive surgeons in the greater New York tri-state area who perform exclusively advanced surface ablations — myself and Marguerite McDonald. In contrast, three LASIK centers have gone bankrupt in the past four years in New York City alone. That tells you that the more unique you are, better you will be able to withstand any downturns in the economy.” Partly because of the “fortuitous” circumstance of being located in an area where three LASIK centers have gone bankrupt in the past four years, Dr. Chynn finds himself in the position of being unique. “I'm the only purely surface procedure center, and surgeon, in New York City — all five boroughs.”

By performing only LASEK or epi-LASEK, he believes he appeals to those who are afraid of having their eyes “cut.”

“If they were the types who would just get LASIK, they would have gotten it 10-15 years ago,” he says.

Though the longer recovery times required for LASEK and the lack of “wow factor” can be marketing disadvantages, Dr. Chynn points out that the procedure offers advantages he can trumpet to the public: The final results are just as good as those from LASIK and complications, he finds, are fewer.

Dr. Chynn seems to have succeeded in persuading his market. “We are the only center in New York City that has grown every year, year over year, through the recession.” His experience confirms how critical it is that the surgeon clearly position and brand himself, Dr. Chynn believes. Being just another laser center will not only fail to catch a potential patient's attention — it will fail to overcome the lack of consumer confidence that has been plaguing the economy.

His own case of branding has been more successful than he realized. At the ESCRS meeting in Vienna in September, he gave his card to a surgeon from South America. The card bore only his name and his practice's name and address. But the other surgeon knew of him.

“He asked if I was that guy in New York City who has the laser in the window so people can watch it from the sidewalk? I couldn't believe he'd heard that in South America. He said that doctors there looked at what I did so that I could be on the bleeding edge and they could be on the leading edge,” Dr. Chynn jokes. “We've got speakers so I could talk to the crowd on the sidewalk, we just got walkie-talkies so that they can talk back to us, so a premed intern can ask us questions.” While it may sound dramatic, Dr. Chynn says it is the kind of thing a surgeon has to do in New York to stand out from the crowd.

11. Don't overlook internal marketing. Dr. Chynn finds that many ophthalmologists don't bother with this comparatively inexpensive outreach. When he visits the practices of open-access surgeons who use his laser, “nowhere in the entire office is there a single promotional material to the patients that they are doing laser vision correction.”

One of those surgeons typically does about 100 cataract procedures a month. Some signage with a message along the lines of, ‘If you trust me with your cataracts, you should ask me about laser vision correction for your children,’ should generate at least one patient a month, Dr. Chynn says. “I don' know if internal marketing is the best way to reach patients, but it is the cheapest way.”

Consider These Readjustments

Kay Coulson is president of the consulting firm, Elective Marketing. She cautions that the problem with the refractive surgery market isn't just the economy. Surgeons should seriously rethink who their audience is — and even the price point at which they can deliver great outcomes.

12. Deal with the “new normal.” Ms. Coulson finds that many refractive surgeons believe the economy is the only factor that's been pushing down LASIK volumes in recent years. She does not agree. The more significant trend, she points out, is that the group who signed up for LASIK in the late '90s and early '00s have “aged out” of the procedure. These were the baby boomers, many of whom needed the distance-vision correction refractive surgery offered, believed in technology and were willing to spend the money (or obtain credit) on themselves. The recession kicked in at about the same time that this demographic shift was increasingly making itself felt, masking the fundamental cause of the problem, Ms. Coulson believes. Some signs were there before, though, she notes.

“About the time that femto came along and custom LASIK, that group was aging a little bit and we were starting to have to talk about presbyopia more,” Ms. Coulson says. “And we tried: We kept making all kinds of adjustments that would suit that aging LASIK patient.”

Among many in the refractive surgery industry, there has been an expectation that new and improved technology would lead to another boom, but new technology didn't improve outcomes, and its expense burdened practices.

13. Think younger. Ms. Coulson says that a look at US demographics indicates that surgeons should be appealing to the 20-to-35-year-old cohort. However, this group is not just like the boomers, only younger — there are critical distinctions.

Boomers often paid for laser vision correction with low- (often very low-) interest financing. That kind of easy credit isn't as available today, of course, and moreover, Ms. Coulson says that this generation is credit-shy. “They will not finance; they are debit-card oriented.”

Additionally, and crucially, no one has convinced this group of the value of LASIK. If surgery costs approximately $5,000, when they can purchase contacts and/or glasses right now for $500 — is LASIK really 10 times more valuable? The “lifetime value of LASIK” meme rings hollow with this audience, according to Ms. Coulson.

“Forget it! This audience isn't thinking lifetime value; no one in this economy is thinking lifetime value,” she maintains. “They are thinking, what can I do this year?”

14. Rethink your fee. Given a new target audience and a new economic reality, Ms. Coulson encourages surgeons who want to stay in the refractive game to consider re-evaluating what it takes to deliver excellent distance vision. Research shows, she says, that people believe LASIK is worth about $1,000 per eye. While that figure may seem painful and unrealistic, a hard look at the books will probably reveal that that is close to what practices are actually capturing for the procedure.

“Most surgeons believe that they charge $2,000+ per eye. But if you look in-depth at what they really capture, it's $1,200 to $1,400 per eye,” Ms. Coulson says. “Discounts, specials, comanagement, financing and marketing steeply discount the true revenue capture of LASIK.” Because of the easy credit available in the past, “we've never seen the real value the market places on LASIK.” The choice for practices that care about LASIK, she maintains, is between offering a demand-based fee for LASIK or “letting it go away.”

15. What do you really need? To facilitate a realistic cost, Ms. Coulson urges ophthalmologists to take a hard look at the technology they really need to deliver 20/20 vision. A femtosecond laser, she suspects, is probably not necessary. While the femto may make surgeons feel more confident about performing LASIK, the fact is that it has not grown the market or improved outcomes. “It made the surgeon feel better about step 1, but the patient didn't even realize there was a step 1, and when you started talking about step 1, you shut conversions down,” she says. Surgeons should ask themselves what has delivered a measurable improvement in their outcomes, and stick with whatever those things are. “The reality is that we can deliver great LASIK with excimer lasers and manual microkeratomes, and we can do it profitably within our practices.” As in so many other areas of life these days, it is about doing more with less.

Other experts disagree, pointing out that a femto laser allows for greater precision in flap creation and thus should be considered the standard of care, especially for an elective procedure. Patients who pay entirely out-of-pocket will want the best technology used in their surgery. Whichever way you go, make sure you genuinely believe it best serves patients — and communicate that to them.

Adapt to the Market As It Is — Then Work It

Given that demand for laser vision correction has gone soft while the market for cataract procedures is thriving, Jay Pepose, MD, of St. Louis, notes that it is natural for practices to devote their resources to what sells and to throttle back on what doesn't. However, he warns, less effort almost certainly translates to less patients. To keep your refractive surgery practice profitable, he advises to keep doing what it takes to make it so — and learn the ways of a new species of patient.

16. Dedicate resources. Doctors who want a growing refractive surgery practice should have a laser vision coordinator — someone in charge of creating and implementing a plan to educate and attract more patients, to make internal and external marketing decisions and to follow up on leads. Otherwise, decisions may be made piecemeal, without an overarching strategy, and leads may fall through the cracks as staffers with plenty of other responsibilities go about their “day jobs.”

17. They don't know if you don't tell them. Dr. Pepose finds that many potential patients are not aware of all that refractive surgery can do at this point. They don't know that the new technology and improved techniques mean that surgeons can now correct astigmatism and higher levels of myopia than before; they've never heard of monovision. It is the practice's job to educate patients about the wonders that modern ophthalmology can achieve for them.

And don't underestimate the need to educate them out of fear. “That's the biggest obstacle,” Dr. Pepose notes. “I hear it all the time.” If you can listen to patients to learn what it is exactly that they are afraid of, and give them evidence-based information that may help to dispel those fears, “you are 90% of the way home.”

18. Enough with the negativity. Dr. Pepose suspects that part of the reason market penetration remains so low is the negative advertising that industry, as well as other ophthalmogists have engaged in as part of their efforts to get patients. Ads along the lines of “my laser is better than Dr. X's laser,” or “the laser or the razor” tend to create fear in potential patients as they worry that picking the wrong device means they will end up with impaired vision. Price wars also send the wrong message to patients, creating confusion about what the surgery is worth.

“You don't see price wars in plastic surgery,” Dr. Pepose points out. “You don't open the newspaper and see an ad claiming, ‘I offer the cheapest breast augmentation’.”

Industry could help, he believes, by running direct-to-consumer ads promoting the benefits of refractive surgery, period. “Create consumer confidence and let the tide rise for everyone.”

19. Alas, social media may not be a passing fad. It's not a stereotype — the Millennial generation likes to operate through social media, and that includes investigating refractive procedures and surgeons. Dr. Pepose says it's as if they would rather remain anonymous, at least in the early phases; they don't want the face-to-face encounter that would be required by coming to a surgeon's office to speak with a laser vision counselor, or even attending a seminar.

But there is an inexpensive way to turn this to your advantage and get your message out in a way that this demographic likes. Dr. Pepose suggests online seminars posted on the practice Web site, or live online question-and-answer sessions. “You can have people call in or write in,” he says. “It's a much less expensive way of getting the message out.”

The prevalence of social media is another reason that creating good word of mouth is critical, Dr. Pepose notes. People will post on Facebook that they are having LASIK that day, and their friends will ask how it went. Make sure they have good things to report.

E-mail blasts, not so long ago considered cutting-edge marketing, may have already gone the way of the buggy whip — or rather, the local newspaper ad. “My three 16-year-old teenagers laugh at me because I still use e-mail,” Dr. Pepose says “They think it's old-school. Everything now is more social media.”

20. Do unto others… As to ensuring the word making the rounds on social media (and other media) is good, Dr. Pepose recommends providing extraordinary service. “That is really what people are looking for. It's why they go to the Ritz-Carlton.” In this case, it means doing things right, doing things other practices may be skipping, treating patients the way you yourself would want to be treated, even if it costs you a little more. “We hear it all the time — patients come in and say that they've been to two or three places, and never had this thorough an exam, our whole staff seems friendly, and notice that everything is checked two or three times,” Dr. Pepose says. “They say they went to other places where they weren't even told that they needed to be out of contact lenses prior to surgery.”

An extraordinary level of service also means that the patient has many points of contact with the doctor — not just with a LASIK counselor or a technician. Patients who had shopped around before coming to Dr. Pepose said that other refractive practices told them they would meet the doctor only on the day of surgery. “I'm not sure I'd like to first see the doctor only when I've just been handed some Valium and I'm about to have the surgery,” he says. “I'd rather see the doctor before, so I can express my concerns and find out what the risks are, really have a discussion; I don't want to meet the doctor when I'm stressed on the day of surgery or about to be laying on the table.”

He would also want to know that the surgeon would be there the next day for the postop exam. There should be continuity of care, he maintains, and attention to the doctor-patient relationship, and patients will respond to doctors who offer these things. “How about calling the patient after the procedure and asking how they are? Things like that make a big impression. People are putting their confidence in you.”

Listen to the patient, provide good outcomes, follow up on leads — these strategies may not deliver another refractive surgery boom for you next week, but Dr. Pepose believes that when the economy finally turns around, you will be well positioned to take advantage of it. OM