September 2019


Patient out-of-pocket expenses for premium cataract surgery
Today’s best practices and lessons learned

Dr. Thompson leads a
discussion with members of the ASCRS Refractive Surgery Clinical Committee, starting with the topic of patient out-of-pocket expenses for premium cataract surgery.
Source: ASCRS

The Refractive Surgery Clinical Committee hosted a roundtable at the 2019 ASCRS ASOA Annual Meeting. The roundtable was chaired by John Vukich, MD, and Vance Thompson, MD. They were joined by Daniel Chang, MD, Eric Donnenfeld, MD, Kerry Solomon, MD, Robert Maloney, MD, George Waring IV, MD, and William Wiley, MD. The following is the first part of the discussion. The transcript has been edited for length. The next three parts of the discussion will be shared in upcoming issues of EyeWorld.
Dr. Thompson: The first question is about preparing your practice for working with patient pay. Does anyone want to take a stab at the refractive cataract consult in their practice? Think of it in three phases: preop/diagnostics, intraop, and postop.

Dr. Maloney: I think it’s important to get the options in writing in front of the patient in a clear and simple way. You’re asking the patient to pay a lot of money, often for services that are confusing. Anything you can do to clarify that makes it easier for the patient to make a decision and move on. In our practice we have grid-like forms that show the offerings: standard lens with standard cataract surgery, standard lens with femto surgery, femto surgery with advanced lens. It’s all laid out—what’s included and what it costs—and it makes it easier for a patient to make a decision.

Dr. Wiley: I think education is a key portion. Often it takes what we call “five points of touch,” and we want that with the patient as many times as possible prior to the doctor seeing them. We set up an education phone call coupled with a survey to see what the patient might be interested in, followed by another phone call, followed by literature to help explain things, followed by an email with videos. The day of the consult they meet with a refractive surgery counselor to discuss different possibilities. I think it’s important so that they understand the options. We tend to simplify those options by boiling it down to what the patient’s visual goal is. We break it down to three things: Do you mind wearing glasses? Are you going to be wearing glasses for distance and near, or do you want to get out of your distance glasses but still wear them for reading? Or are you looking to get out of glasses for both distance and near? Depending on what the patient chooses, we’ll choose the technology to fit what their goals are.

Dr. Vukich: When do you provide patients with information about premium IOL options? If you send information prior to their appointment, do you find that this helps them with their decision making?

Dr. Wiley: A lot of patients zero in on that because I think many patients think all cataract surgery is the same and if they learn that it’s different the day of the consult—the day they see the doc—they seem to be overwhelmed. But if you can start that education process sooner, they tend to absorb it more and can make a better decision. We also offer monthly seminars where we can inform patients. We find some patients want to really understand what those options are before they make a decision.

Dr. Thompson: They say that 50–80% of the information that we tell a patient is instantly forgotten. Of the balance of what is remembered, half of it is remembered incorrectly. That first round is so important. I think the way you do it, Bill, is wonderful because getting all this information to make this life-changing decision can be sensory overload.

Dr. Waring: It is important to be effective and efficient on this part of the conversation as patients are trying to make a lifetime decision during a consultation. Ironically, the preoperative consultation for refractive cataract surgery may take more time than the actual surgery itself. One of the things we learned is the importance of creating an experience around their perioperative and operative care. We try to do things like minimize wait time, and that takes a lot of discipline to do. We all want to see more patients, but there is a tipping point where you can start to lose some experience when trying to see an extra patient, or we don’t stick with the schedule. Essentially, we’re trying to eliminate a waiting room and taking our patients on a digital tour of their eye. It’s a high-tech, high-touch experience. With advanced diagnostics, we’re educating them on their anatomy and helping them understand the decisions and recommendations that we make. It’s been shown that if we make a recommendation, they’re twice as likely to follow through with the recommendation relative to if we don’t. At the end of the day, they’re coming to us for a recommendation, not a bunch of options, which leads to confusion. We have fantastic tools to deliver fantastic outcomes, and it makes the consultative process very genuine and organic, and patients appreciate that.

Dr. Vukich: What have you found to be the most effective way to provide education prior to seeing the patient?

Dr. Chang: Ideally, this starts at the time of cataract diagnosis. We educate referring optometrists about the surgical options and encourage them to share that information with the patient. Nevertheless, what referring doctors tell patients is highly variable. Reaching out to the patient prior to the visit is also helpful, but the challenge is to have the right specificity of information before knowing the actual diagnosis. A patient may not even be a candidate for a premium procedure. When we send letters and brochures to patients, we keep it and simple and promote the experience and expertise of our practice and doctors more than any particular technology. When patients come to the office, they see an educational animation video playing in the reception area, so the education starts there, if not before. Our technicians continue the discussion with a lifestyle questionnaire, and if patients see one of my optometrists before seeing me, presbyopia- or astigmatism-correcting options are discussed, if appropriate.

Dr. Donnenfeld: I agree completely that there needs to be multiple touchpoints. That is a fundamental concept here, but I don’t think it matters that much whether or not those multiple touchpoints occur before or after the consultation. There are many different ways to skin this cat. We don’t have touchpoints before the patient sees me—there is some marketing material in the office—but I feel very strongly that I want to make the recommendation to the patient of what I think is best for them before they have any preconceived concepts. We do a thorough preoperative exam, as all of us do, then speaking with the patient, looking at the data that I have, which includes topography, OCT, ocular surface evaluation, I make a recommendation to the patient of what I think is in their best interest. I talk to them in simple terms. I don’t talk about technology, I talk about visual results and what they want, and if they’re a good candidate, I go through a description of how we can give great vision with glasses all the time, great vision with glasses for reading, or great vision all the time with no glasses. I go through the risks and benefits. After I do the consultation and leave the room, the patient talks to my technician who goes over it a second time. Then they go to the surgical counselor and they get the options a third time. So we do it a little differently than what I’ve heard here, but it’s the same effect. It’s multiple touchpoints. At the end of the day, it’s about keeping the concept simple, not overloading with information, and allowing the patient to make a good decision that they understand. The final aspect is to bring family members into the room, if possible, because patients don’t remember. Having that extra family member there is sometimes incredibly beneficial in helping the patient make a good decision.

Dr. Vukich: Often patients won’t make a decision at the time of their initial visit. They’ll want to talk to family members or take some time to think about it. Do you change your preoperative testing for a premium channel patient vs. a patient who may be undecided?

Dr. Donnenfeld: No, all my patients get the identical workup regardless of what lens they choose. Everyone in my practice gets a dry eye workup, a topography, a biometry, and an OCT of the macula. Even if they don’t choose a premium channel, I want them to have a premium result.

Dr. Thompson: I’m the same way. Everyone gets the same workup because a lot of them don’t know what they want by the time they get to the doctor, so the only way we can go through all their different options is to know the status of their whole eye. We do the same workup on everyone. It’s labor intensive when you want to offer both a refractive component and a therapeutic component.

Dr. Chang: When the patient first comes in, we don’t know what they want. Due to compliance concerns, we do not perform the same workup on all patients. We do perform biometry before any drops go into the eye, thus preserving the ocular surface for best keratometry measurements. Our biometer has a swept-source OCT, and the resultant images provide invaluable information to determine the options reasonably available to the patient. If they decide to move forward with a premium option, we bring them back for repeated and additional testing on a separate day. This saves on the upfront time and effort.

Dr. Thompson: When are you doing a cataract workup? Do they get charged a refractive consult or are you using that technology mainly as a screening tool?

Dr. Solomon: In my practice, we do a biometry when they come in. If they are going to have basic therapeutic, that’s all that they get, and for those that want to enter into a refractive package, we bring them back and they have several touchpoints along the way, then there is a fee as part of the package for all of the testing.

About the doctors

Daniel H. Chang, MD
Empire Eye and Laser Center
Bakersfield, California

Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Garden City, New York

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles

Kerry Solomon, MD
Carolina EyeCare Physicians
Charleston, South Carolina

Vance Thompson, MD
Vance Thompson Vision
Sioux Falls, South Dakota

John Vukich, MD
SSM Dean Clinic
Madison, Wisconsin

George Waring IV, MD
Waring Vision Institute
Mt. Pleasant, South Carolina

William Wiley, MD
Cleveland Eye Clinic
Brecksville, Ohio

Relevant financial interests

Chang: Johnson & Johnson Vision, Carl Zeiss Meditec
Donnenfeld: Alcon, Allergan, Johnson & Johnson Vision, Novartis, Carl Zeiss Meditec
Maloney: None
Solomon: Alcon, Allergan, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec
Thompson: Alcon, Johnson & Johnson Vision, Bausch + Lomb, Mynosys
Vukich: Johnson & Johnson Vision, Carl Zeiss Meditec
Waring: None
Wiley: RxSight, Alcon, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec

Contact information


Patient out-of-pocket expenses for premium cataract surgery Today’s best practices and lessons learned Patient out-of-pocket expenses for premium cataract surgery Today’s best practices and lessons learned
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