Overcoming Psychological Barriers to Refractive Surgery

Better patient selection and a simpler approach to counseling helps weed out poor candidates.

By Adrianne Resek, Contributing Editor

When LASIK debuted nearly two decades ago, early enthusiasm and pent-up demand for a permanent means of refractive correction made it an overnight success—despite some lingering questions about safety and long-term durability that simply couldn't be answered at the time. Although both the safety profile and visual outcomes have improved substantially in the intervening years, patient reluctance persists in some quarters. Qualms about refractive surgery involve a mix of questions on safety, price and outcomes.

One practice, Crystal Clear Vision (CCV) in Homewood, Ala., is helping patients overcome these psychological barriers with a novel concept: one custom procedure, at an affordable price, for every eligible patient. CCV provides ophthalmic practice management services and works with surgeons who offer each patient the same procedure—wavefront-guided CustomVue with the iLASIK Suite (Abbott Medical Optics), including laser flap creation with the IntraLase iFS femtosecond laser. Here, we'll look at a few of the secrets of their success.

Fewer Options, Better Information

The practice believes that its move to an almost entirely paperless workflow, including the medical histories and informed consent process, has enhanced both the safety profile of their services and their operating efficiencies, while lowering costs. All new patients are assigned to a LASIK advisor that counsels them on the process and sets them up on an online “patient portal.” Patients use the portal to schedule their procedures, manage their payments and apply for credit if they so desire. It also contains a proprietary educational video version of the written informed consent. As part of this educational process, the patient actually sees an animation of the procedure and is shown such complications as epithelial in-growth and night glare. They are required to answer questions throughout the video to ensure their understanding; all of their answers are documented and reviewed. All FDA booklets are also online for patients to review.

When patients arrive on their surgery day, once the Pentacam and Wavescan are done, the patient is ready for surgery. “We schedule patients one at a time every half hour, and they get our undivided attention. After their testing, they meet their surgeon, and then they go in for surgery all by themselves,” explains Sondra Black, OD, Vice President of Clinical Operations at CCV.

Jeffery Machat, MD, founder and CEO of CCV and original co-founder of TLC Vision centers, believes one of the problems with the current vision correction market is that there are too many options given and not enough clear information. Patients often go to a consultation for LASIK and are offered a variety of options based on how much they want to pay. They may be offered standard LASIK or custom LASIK, wavefront optimized or wavefront guided, mechanical microkeratome or femtosecond flaps. And the decisions usually determine the price they pay.

“We were asking patients to determine the level of technology they wanted to have used on their eyes, and that isn't done in any other segment of medicine,” explains Dr. Machat. “Normally you go to a doctor that is recommended, they tell you the best procedure and the price, and that's it. I always tell physicians to recommend the procedure they would perform on themselves, if it were their own eyes.” In Dr. Machat's case, he recommends a custom all-laser procedure, which he feels clinically gives the best results, and he finds most patients agree that any extra cost is worth the assurances that come from having the best procedure possible.

CCV also feels it's important to tell potential patients exactly what technology and what equipment they use. In an industry where technological advances are integral to the outcomes of the procedure, it has been very difficult for patients to get information on the actual technology used by individual doctors and clinics. Dr. Black states, “If a patient tries to do research on the internet and they search ‘LASIK centers’ or ‘laser centers’, it is not easy to get information on what laser that center is using, what technology they're using and what the actual price is.” The CCV Web site provides visitors with all such information.

Select for Success

Upon analyzing his clinical output, Dr. Machat discovered that, “I spent 90% of my time on a mere 20% of my patients.” Eighty percent of patients are straightforward cases with few or no problems, while those 20% of complicated cases that take up the majority of his clinical time were still paying the same as the straightforward cases. Thus, Dr. Machat determined that CCV should work with surgeons who offer a custom all-laser procedure in hopes of achieving the best possible outcome, and who would limit the offering to patients with the highest probability of success.

When patients come to Crystal Clear Vision, they are not given a confusing menu of LVC options to choose from. Instead, custom, all-laser wavefront LASIK technology is available for as low as $1188/eye with a promotion or discount, compared to the average price of $2170, according to the 2010 MarketScope report. “When you start to analyze it, there are enormous ways to gain efficiency that allow you to offer the most technologically advanced procedure at an excellent price for your patients,” says Dr. Machat. Therefore, CCV only works with surgeons who treat patients with up to −7 D of myopia, up to 3 D of astigmatism and up to 2 D of hyperopia. Patients also must have at least 500 microns of corneal tissue, and the surgeon will leave at least 300 microns postoperatively in the bed. Patients who have questionable topography are also eliminated from the patient pool. Thus, the treatment and postoperative care is extremely streamlined. “There is very little chance of a patient that fits into this profile needing a postoperative enhancement or excessive chair time,” states Dr. Machat.

“After a patient has gone through the education and evaluation process, if they don't fit these criteria, the potential complications of their case are explained to them,” says Dr. Machat. “By this time, they generally feel very informed and enthusiastic about the procedure, understand the additional risks of their individual case and the resulting need for a cost increase. These patients have no problem seeing another physician to whom they are referred to have the surgery anyway. In that way, we are educating and increasing the entire pool of LASIK candidates.”

Another aspect of creating cost efficiencies: CCV doesn't offer the lifetime guarantee that many LASIK centers advertise. With the limited parameters for their patients, around 98% will achieve 20/20 vision and won't need any kind of enhancement. For the 2% that don't reach 20/20 with one procedure and request an enhancement, they must pay an additional fee.

CCV is having great success with their pioneer location and looks forward to expanding when the time is right. Dr. Machat credits his choice of procedure with the excellent results and safety profile that allows them to offer the procedure at a reasonable price. “I do believe that the custom all-laser LASIK is the absolute best procedure today and what I would do on my own eyes or a member of my family's eyes,” he says. “While different procedures can and have been done with great success, the incidence of side effects or not achieving 20/20 vision is higher. For me, it's simply not worth it.” OM