Eric D. Donnenfeld, MD: There’s a never-ending cycle right now in all of medicine and certainly in ophthalmology, where reimbursement continues to spiral down while patients continue to look for their best possible outcomes. In ophthalmology, we’re given the privilege of giving patients superior outcomes and making a patient-shared billing opportunity where the patient can receive refractive outcomes, that are not covered by insurance, that improve their quality of life.

The first procedure that I performed at a significant volume that was not covered by insurance was PRK and LASIK. Patients obtained great visual results and it was markedly better than the previous generation of RK. Patients were willing to pay out-of-pocket for a procedure that could improve their quality of life, and that’s the bottom line when we do these types of procedures.

We’re looking to improve patients’ quality of life, and there’s nothing that’s really better for patients than to give them better quality of vision.

In our practice, we’ve embraced the patient-shared billing opportunities which include LASIK, refractive IOLs, oculoplastics, femtosecond laser, cataract surgery, intraoperative aberrometry and presbyopic inlays.

The most important thing about these refractive opportunities is always to do what’s best for the patient. They give patients their best possible options, and if that’s not covered by insurance, that’s a decision we can make together. I always give the patients the alternative.

Cynthia Matossian, MD: We are very fortunate in ophthalmology to have the opportunity to do patient-shared billing. Whether it’s multifocal implants, extended depth of focus IOLs, the toric implants, we can make the patients’ vision so much better. So refractive cataract surgery is here to stay, and it’s only growing.

We also do oculoplastics because patients are having these procedures done whether we offer them or not. A certain percentage of our patients are going to be going elsewhere to stay looking “refreshed” or looking more youthful. So why not offer them the periocular types of treatment, whether they’re Botox or fillers?

And we make available at check-out the over-the-counter products we recommend to our patients, like omega-3 supplements, instead of having the patient go to a pharmacy. This helps our bottom line, but it also helps the patient.

Steven Dell, MD: When we started in ophthalmology, we knew it was among the most desirable specialties in medicine that had probably one of the highest levels of practitioner satisfaction. The most recent data suggests that ophthalmology is now in the bottom half of surgical specialties in terms of practitioner satisfaction. I think that a lot of that has to do with the weariness that many doctors feel having fought the reimbursement wars over the years and watching their services be valued less by the insurance world, while outcomes were getting better and better. I think that disconnect is the source of a lot of frustration.

In the early 2000s, we started providing ancillary services for our cataract patients in terms of presbyopia-correcting IOLs, but even years before that we were correcting and charging for astigmatic correction, essentially performing refractive surgery concurrent with cataract surgery in the form of limbal-relaxing incisions. That was the first baby step in a process that has evolved into treating a generation of patients, that cataract surgery is not free. That’s been a big uphill battle over the last 15 years or so to educate patients that Medicare is only going to cover the medically necessary cataract component of what they may be having done and that, if they want refractive extras, there will be a substantial additional charge.

We have come to rely heavily upon that additional source of revenue; it’s become a big focus of ours. It’s not just in the cataract world. Other components of patient-shared billing extend to a whole host of things that [other specialists] have gotten really good at doing over the years.

Ophthalmology Management: When you realized this potential, did you start marketing?

Dr. Dell: We were also developing a LASIK practice beginning in the mid-‘90s, and laser vision correction inherently lends itself to marketing in ways perhaps that cataract surgery does not. But for surgeons who are thinking about transitioning to more patient-shared billing procedures, the patients are in their practice already. They just need to provide the option to the patient and communicate it effectively.

Dr. Matossian: The easiest place to start is with astigmatism correction, because a very substantial percentage of our patients have enough astigmatism that warrants correction at the time of cataract surgery. So, whether it is a femto-AI, or a manual LRI or a toric implant, right there you have your built-in population at the time of cataract surgery.

Shachar Tauber, MD: Patients are maturing, and we’re seeing this maturation of the refractive services starting to come into the cataract world. These patients who are now early cataract patients or the parents of LASIK patients are now demanding the same results. They already understand the lingo, and that has helped us dramatically get into this game. The lens technologies that we use for premium services, whether they be toric, multifocal, accommodative, pseudo-accommodative or now the extended range lenses, have given us an armamentarium that let us reach out to each patient.

We feel very strongly that these premium lenses are part of the discussion with our patients. They expect it from us, from the idea of, “I came to you because you are considered the best in your community. You guys have all the accolades. You’re part of this big health system. What do you have for me?” And we have to speak to them and be fluent in that because otherwise we become mediocre. Patients can smell mediocrity fast, and they will go elsewhere if we don’t offer them this technology.

Dr. Donnenfeld: Premium services really are not premium services for the patients. It’s really all about patient expectations. If a patient has an expectation of what would make them happy, it’s not only something that we can do, but it’s our obligation to provide the patients with the best outcome that they’re looking for to improve their quality of life, and there’s very little that we do that doesn’t improve patient quality of life.

Our goal for every patient is, “What can we do to make them optimally happy?” If the solution is an insurance procedure that’s reimbursed fully by their underlying insurance program, that’s great. But if it’s something that is not reimbursed by their insurance, and we believe that it’s in the patient’s best interest, from my perspective it’s our obligation to discuss this with patients, because it’s not our role to decide what is in the patient’s budget and what’s not in the patient’s budget.

Our obligation is to do what’s best for the patient and then give them the alternatives that they can have to meet their goals.

OM: Do you consider the terminology faulty, calling these services “premium?”

Dr. Donnenfeld: Yeah, I think it is. A premium service may not be the right way of looking at this, because what we’re really doing is giving each patient their best possible visual solution, and whether it’s a patient-shared billing procedure, or a nonpatient-shared billing procedure, they’re all premium services because at the end of the day we’re doing what’s best for patients. So every patient is a premium patient.

Dr. Matossian: And as a result, we don’t call it “premium” at Matossian Eye. We say “advanced technology,” but even more than that, we say, “We’re customizing the best option for each of your eyes so you can get the best result.”

We make sure the patient understands why it is that we’re recommending this, what their money goes towards, that now they’re going to see intermediate vision in addition to far, or intermediate and near in addition to far. They now know with the basic implant, I’ll only see far, maybe not so clearly if I have astigmatism, but now I understand that by paying $X I’m also going to get intermediate and near and astigmatism fixed, or whatever it might be. Then they’re willing to pay for it, but they have to understand what it is that they’re buying with that out-of-pocket money.

Dr. Dell: We only talk in terms of results and outcomes. We don’t market technologies, a particular technology. We ask a patient whether they would be interested in seeing well without glasses, first of all. And whether that would be at a distance, near, both or whether that would include intermediate. We tailor whatever technology is required to achieve that.

In some cases it might require the use of a femtosecond laser, astigmatic incisions, toric lenses or all of the above, including an excimer laser enhancement afterward. But whatever it takes, we deliver a result, not a technology. That has been the most effective way to communicate what the value to the patient really is. Nobody asks for femtosecond laser surgery. They ask for a vision-correcting result.

Dr. Tauber: The questionnaire that Steve developed, the Dell Questionnaire, in its early period was the first tool we had that we’d put it in front of the patient and say, “Tell us what you want. And we will offer you the tools that will get you to that point.” Back then, we just had a small collection of different options for the patient that are being dwarfed by the options we have now across all different platforms.

And to Steve’s point, we can’t keep up with inventory of lenses and developments and expect that to be digested by the patient to say, “Okay, it was a multifocal.”

Now it’s an extended range, and we’re talking chromatic aberration or not. Their expectation is, “What is the best for my needs?” and I’m willing to have that conversation. But some will say, “No, I’m happy with glasses and that’s what I need.”

OM: Are more cataract patients opting for customized services? Has it affected growth?

Dr. Matossian: In our practice, the percentage of patients selecting something that is out-of-pocket is growing. That’s for multiple reasons. There’s more awareness among people of these options. Some of it has been direct-to-consumer advertising, or just that friends and neighbors have started discussing it. Technically, we have more options. Therefore, it’s a broader range of patients who are potential candidates to benefit from this.

Dr. Donnenfeld: In our practice, we’re doing more and more of these types of procedures. Obviously, you’re going to do more as the options get better, but I think it’s more than just that.

I think it’s a societal change that we’ve noted over the last several years. Cataract surgery has moved from the greatest generation where patients were stoic and were very happy with whatever you offered them. They had different mind sets, and their penetration of premium products was markedly diminished compared to the baby boomers who have come in with a different expectation. They used to view cataract surgery as an aging process, and now they view it as an opportunity to restore their vision and see it as a way to restore their youth. And in many ways it is.

These patients have very high expectations and they’re more demanding, but that’s a good thing. We want more demanding patients, because these are the patients who have high expectations, who are coming to us because we can meet their expectations, and they’re the ones that are really driving the patient-shared billing market.

Dr. Dell: Our practice has had a really high percentage of patients opting for refractive services in conjunction with cataract surgery, because we’ve embraced this for a long time.

But, we’ve trained a generation of patients that these options are available and that they cost money. And it was very tough initially to convince people who were the first among their cohort to pay anything substantially extra for cataract surgery, but now that’s considered routine.

OM: Have you met physicians who were nervous about inserting these IOLs? What advice would you give them?

Dr. Dell: It’s not the physical insertion of the device, because that is somewhat comparable to every other type of cataract implant that they put in. It’s everything else that goes along with it. It’s managing astigmatism. It’s getting the refractive predictability improved through better biometry, or intraoperative aberrometry, whatever it takes doing refractive surgery. Those are the necessary ancillary skills to be a comprehensive refractive and cataract surgeon lacking in those I see who are intimidated by these technologies.

There’s a course on astigmatism treatments I teach with other doctors every year at ASCRS and at the Academy meeting. You would be shocked at how surgeons out there are very uncomfortable treating even small amounts of astigmatism, because it wasn’t part of their training and they’ve never embraced it. But without those skills, you can’t be successful as a refractive cataract surgeon.

My advice would be to load up on astigmatic management: learn about proper biometry, learn about intraoperative aberrometry, and have a solution for closing the refractive loop afterward with even rudimentary PRK. They could learn how to do small corrective refractive errors to make their patients whole again if they miss their refractive target.

Dr. Donnenfeld: You have to believe in the technology and realize that the value that you’re giving patients is much greater than the financial request that you’re making, that this is something that patients will value every single day for the rest of their lives. You have to be able to do excellent surgery, and be able to do the necessary refractive enhancements. My advice for those interested in entering premium markets is to spend a day not only in the operating room with a refractive cataract surgeon, but in the office and see how they talk to patients. See how a good refractive cataract surgeon talks to patients and handles problems.

Finally, start off with technologies that have a high reward and low risk. And the low hanging fruit of refractive surgery is toric IOLs. If you’re not doing toric IOLs, you’re not really trying, because there’s never the increased risk that you have with other procedures.

Once you get comfortable with toric IOLs, then you can branch off into LASIK, or multifocal, or depth of focus intraocular lenses. I don’t see a downside to toric IOLs for most patients, so it’s something that I think is a great starting point for cataract surgeons who are saying, “It’s time for me to get involved.”

Dr. Matossian: Many colleagues would be more than happy to spend time mentoring. So for the hesitant surgeon, make sure you believe in yourself and have a plan. If there’s no plan, you’re not going to have the result. And call colleagues, like Eric said. Go visit them in the operating room, spend a day in their office.

And you must get to know the diagnostic tools. If you don’t even have a topographer, you can’t calculate what toric IOL to use. It must be a calculated goal in order to achieve and get into the refractive cataract surgery market.

Dr. Tauber: I have learned to go to our referral source, our optometrists, and watch them talk about the premium services they offer. They are amazing. They can go from multifocal contact lenses onto another [service] they feel is critical for the patients’ needs; they’ve done this for years. They probably learn it on the second day of school. I’ve learned from one optometrist who refers to me. I watched him for half a day, and he pushed us. And we eventually knew that when he sends us a patient who has multifocal contact lenses, it’s the easiest discussion you’ll ever have. OM

ROUNDTABLE CONTRIBUTORS

Eric Donnenfeld, MD is a board certified ophthalmologist and experienced corneal surgeon. A professor of ophthalmology at NYU and a trustee of Dartmouth Medical School, he is a consultant for numerous ophthalmic companies. He may be reached at: ericdonnenfeld@gmail.com.

Cynthia Matossian MD, FACS is the founder of Matossian Eye Associates. Her e-mail is cmatossian@matossianeye.com.

Steven J. Dell, MD is medical director, Dell Laser Consultants, Austin, Texas.

SHACHAR TAUBER, M.D. is the section chair of Ophthalmology and Optometry at Mercy Clinic Springfield, where he practices cornea, cataract and refractive surgery. He most recently built the Mercy Eye Center Femtosecond Laser Assisted Cataract Surgery Program. In 1997, he built the Yale New Haven Eye Laser Center.