By Suzanne LaKamp, OD, FAAO
Nov. 16, 2016
Advanced IOLs can restore youthful vision and improve the lives of cataract patients. Co-managing these patients can be a prime revenue-generator for ODs.
RECOMMEND BEST SOLUTIONS. Let patients know we now have the ability to essentially restore youthful vision–eliminating the need for readers or PALs.
INVEST IN NEEDED INSTRUMENTATION. Additional instrumentation that may be used in selecting IOLs include the pentacam, IOL Master, and during surgery, the ORA System.
CREATE EDUCATIONAL MATERIALS. Have brochures made up by the practice that discuss IOL technology broadly. Brochures should be kept in patient exam rooms, and no one lens technology should be advertised.
Premium IOLs, such as those that are multifocal, present advanced technology to your patients, and the chance for you to give them a “wow” experience, restoring youthful vision. In the process, you also have the potential for a great revenue source for your practice. Prepare your staff, and craft communications to turn IOL recipients into eye health patients, so that even with their likely reduced need for eyewear, they still know they should visit your practice each year for comprehensive exams.
Your cataract patients–a growing segment of many practices in our aging population–deserve the best vision solutions. For most cataract patients that means premium IOLs that sometimes make it possible for patients to see near and far, with no eyewear needed, after surgery. My mostly cash-pay OD-MD practice routinely recommends premium IOLs, providing the patient superior vision, and creating a revenue-generator for the practice.
In an OD-only practice, the opportunity to co-manage a premium IOL patient also offers a significant increase in profit, relative to a standard lens, without much difference in difficulty managing these patients.
Brochures Dr. LaKamp’s practice created to educate cataract patients. Insurance does not cover premium IOL options, so educating patients about the significant benefits of these more advanced IOLs is essential.
Lens technology continues to evolve, with more options available to the patient. A premium IOL is a lens that offers advanced technology beyond that of a standard single focus, or monofocal lens. Premium IOLs are not covered by insurance. There are many premium IOL types, which may be accommodating, multifocal, toric, or a combination. Each lens type has a variety of options.
For instance, there is a AcrySof ReSTOR multifocal, a family of 3 Tecnis Multifocals, and a newly offered Tecnis Symfony Multifocal. The Symfony lens also comes available with a toric option. This new lens technology is already showing very promising results as compared to previous multifocals.
ODs and MDs who co-manage patients between practices will have to set up their own arrangements for reimbursement. Reimbursement is also limited by insurance.
ODs who work in refractive surgery practices may get a certain fee for each post-operative patient encounter. Lens type typically does not change reimbursement as the post-operative care is no different between these patients. Salaried employees who work in refractive surgery clinics will not see any difference in revenue per patient encounter.
However, it is safe to say that for conventional cataract surgery, the co-managing doctor can expect to receive about $90 per eye. For premium IOLs, torics and multifocals, the doctor may receive between $400-$600 per eye. Most co-managing surgeons will pay the OD a fee based on the level of difficulty in the follow-up care demanded by premium IOLs.
Offering premium IOL options is an absolute necessity to achieving the best possible vision for a variety of patients and visual needs. Insurance does not pay for the premium IOL options. The practice must appropriately charge a patient for providing this technology and service. It is important, however, to not let price and revenue for a premium IOL bias lens selection. Ultimately, the best lens choice for the patient is most important. It is key to discuss lens technologies prior to surgery referrals.
Often, the optometrist who has worked with a patient for years will have better insight about which lenses are best for a patient. For instance, a very particular patient may not succeed with multifocal IOL optics. The optometrist should also not hesitate to recommend a lens choice to a referring surgeon. For patients who self-refer to a refractive surgery practice, extra time must be given to patient eye health, lifestyle and visual demands.
Assess Patient Base & Recommend What Works Best
For patients who live in the same zip code area as the practice, the average income is $95,000. About 60 percent hold a Bachelor’s degree, or higher, and about 25 percent hold a graduate or professional degree. The median age is about 52.
My practice sees two groups of IOL patients. The typical age for patients who undergo IOL surgery is early fifties for my current practice. Our patients are younger, and more active than traditional cataract patients. These patients are too young to qualify for standard cataract surgery, and desire freedom from glasses. The younger patients can choose refractive lens replacement to achieve better vision through our Refractive Lens Exchange (RLE) surgery. The patients who could qualify for cataract surgery, but choose our premium surgical options, are our refractive cataract patients.
RLE patients represent the biggest portion of our IOL surgeries. RLE is refractive surgery. Vision correction is achieved through lens replacement prior to the natural lens turning into a mature cataract. RLE patients experience some degree of lens dysfunction, and seek accompanying presbyopia correction, in addition to the correction of other visual complaints.
Patients with significant levels of astigmatism perform much better with premium toric IOLs, for instance. Premium IOLs, such as multifocals, should only be used in healthy eyes, without optical barriers such as keratoconus or maculopathy.
Invest in Needed Instrumentation
All IOL patients at my practice get comprehensive examinations. Additional instrumentation that may be used in selecting all IOLs can include the pentacam, IOL Master, and during surgery, the ORA System.
Pentacams can cost $25,000-$50,000. There are a variety of IOL Masters, which may range from $7,000 – $19,000. The ORA may cost about $40,000, with ongoing subscription fees. Practices may charge patients for biometry to offset the cost. Our practice does not charge patients for measurements, as these fees are built into a surgery package. The cost to break even on the investment for instrumentation largely depends on fee structure, and if the practice is primarily insurance driven versus cash-pay.
Educate the Patient About the Surgery & IOL Options
Since my practice is primarily cash-pay, the patient is informed well ahead of their visit about what types of services we provide. The first recommendation is simply to get a comprehensive exam. The doctor may then recommend surgery, the lens type and vision plan. The vision plan is communicated to the counselor, who will then discuss cost, payment options, and possibly, financing. Our model charges the patient by surgery, rather than lens type. It is important to choose the best IOL for the patient, and that might not be a premium IOL.
Our fees for a lens replacement surgery include measurements, facility fees, surgeon’s fees, the cost of the IOL, anesthesia, two years of post-operative care and two years of no-charge enhancements. Everything is rolled into one for the patient. Each package costs the same, regardless of lens type.
While our care covers a two-year period, most patients are happy to return to former optometrists once the desired refractive outcome is achieved. Our practice encourages a patient to seek regular care with their optometrist if there is a long-standing relationship. It is also beneficial for patients to return to those practices for glasses if necessary. I may recommend driving glasses for patients who have blended vision (also referred to as mono-vision with typically no more than 1.5 D between between the eyes). While we market directly business-to-consumer, and do not co-manage, we still get referrals from area optometrists.
It is important to discuss the different advantages of each lens type. Equally important is to address the limitations of each. Whereas a premium IOL can provide a superior visual result to one patient, it may be a poor choice for another. Each patient, and each eye, has a different visual need. The variety of lens choices means better lens selection, improved refractive outcomes and happy patients.
For instance, we may tell a truck driver that “a single-focus IOL in the distance dominant eye may be a more appropriate choice for crisp night-time vision.” While a multifocal lens provides a range of vision, the single-focus lens offers superior image clarity. The patient may opt for two distance lenses, select monovision with monofocal IOLs, or consider a premium multifocal in the non-dominant eye.
For patients desiring greater flexibility from lenses, multifocal lenses provide a large range of vision. Multifocals also provide for better balanced distance vision as compared to monovision with monofocal lenses. There is also the concern about depth perception with monovision. A dancer may prefer to have a multifocal lens, rather than sacrifice depth perception with monovision.
It is important to educate the patient on the surgery, post-operative recovery and healing process. The lens capsule plays an important role for IOL surgery. I may tell patients during the post-operative visits that “the capsule is very dynamic. It seals to the IOL, contracts, and later becomes fibrotic. The changing capsule after any IOL surgery means visual recovery takes months to stabilize.”
I also discuss that while the lens takes months to stabilize, that the neuroadaptation process to the lens also takes months. Multifocal lenses may take a longer adjustment period than a monofocal lens. I may say that “the brain needs time to adjust to the new lens, and new optics.” While improvement to multifocal lenses takes a few months, I often see patients improve even up to a year. Due to more complicated multifocal optics, it is important to do YAG capsulotomies earlier than most patients with monofocal lenses. Patients with multifocal IOLs are very symptomatic of capsular fibrosis, and even more affected by glare.
Create Patient Educational Materials
We have brochures made up by the practice that discuss IOL technology broadly. Brochures are kept in patient exam rooms. No one lens technology is advertised. One brochure is directed at younger patients for Refractive Lens Exchange (RLE), who do not qualify for traditional cataract surgery that is reimbursed by insurance. These patients, if they do not have the RFE surgery, will still experience lens dysfunction which will later progress to mature cataracts without intervention.
RLE surgery aims to correct refractive error and vision quality long before a patient must suffer the years of declining, impaired vision seen with advanced cataracts. The other brochure is for refractive cataract surgery, which includes traditional cataract patients. The cataract patients receive the same services offered to the RLE patients, which include premium lenses. These patients can opt for surgery elsewhere and use their insurance, but insurance does not include premium lenses. Patients often choose to have surgery for the best possible vision, rather than for the best deal.
Educate Staff to Serve Premium IOL Patients
Support staff have a basic knowledge regarding IOL surgery. Monthly meetings can be a great way to discuss clinical topics with the staff. For more detailed IOL discussions, the staff can direct the patient to the surgical counselor and the doctor.