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Cover Stories | Nov/Dec 2009

Nobody Wants Eye Surgery

Surgeons struggle with patients' desires when promoting presbyopia-correcting IOLs.

In this relatively new era, when cataract surgeons can act as direct providers and charge patients for certain uncovered services, I offer one essential truth: no one wants to undergo eye surgery. Most people desire a nice vacation, new furniture, or a new wardrobe. I don't know anyone who says he or she wants eye surgery. This is precisely the challenge facing refractive cataract surgeons today. You are competing with patients' wishes when promoting premium IOLs and the benefits the lenses provide.

Current estimates show that approximately seven out of every 100 cataract procedures utilizes one of the available presbyopia-correcting IOLs.1 Can you imagine how much healthier ophthalmic practices and manufacturers would be if they could achieve a 15% or 20% adoption rate among consumers? This is an achievable goal, as evidenced by two data points. First, I am aware of several dozen surgeons who routinely see 30% to 50% (or more) of their cataract surgery patients choose premium IOLs. In my opinion, this is proof that the supply side of the equation can be built in an ophthalmic setting. Second, a survey of nearly 300 patients in the process of scheduling cataract surgery showed a strong desire to explore premium IOL options (80% expressing interest), a low level of awareness (20% knew about the ability to see at all distances without glasses), and a willingness to pay out of pocket (27% would pay at least $2,000 per eye).2 Therefore, the demand side of the equation also exists.

The new question is, how do refractive cataract surgeons advance from the current 7% to the more desirable 15% to 20%? I refuse to accept that better technology is the answer, despite the fact that IOLs will undoubtedly improve over the years. Furthermore, new enabling technologies are being launched to improve outcomes with today's available IOLs. These include intraoperative wavefront refractions as well as ultrafast lasers for capsulorhexis and dissection of the crystalline lens. Early LASIK patients were happy with their results, even though today's laser technology is far better. The same is true with today's premium IOL patients. Remember that technological improvements, although necessary, are not in themselves sufficient to increase demand for refractive surgery. Indeed, widespread commercial success requires something more.

Successful refractive cataract surgeons have recognized that the doctor-patient transaction is different and requires a break from the traditional model(s) of a flourishing cataract practice. Although stating these differences is far easier than putting them to work, I want to highlight three significant changes that form the core of the "something more" necessary for success with premium IOLs.

Refractive surgery melded two distinct worlds: medicine and retail. This new combined realm for serving customers takes on as much significance as treating patients. In fact, the mind shift begins by thinking of those who patronize your practice as both patients and customers. Customers have a broader set of expectations than patients, and those expectations are in line with strong customer service levels that are routinely delivered in retail settings such as hotels, restaurants, and clothing boutiques. Surgeons who think their customer service is already good should understand that, while 80% of CEOs surveyed on customer service rate their companies as excellent in this regard, only 8% of those companies' customers rate that same service as excellent.3 In other words, surgeons tend to think they are much better in this regard than they truly are as defined by their customers.

Since the advent of Medicare and third-party coverage plans, ophthalmologists have been forced to define a cataract to the satisfaction of regulatory bodies to justify reimbursement. With declining surgeon fee reimbursement and the ability to charge patients directly, the future livelihood of the surgeon is in the hands of the paying customer rather than an intermediary. It is time for the language surrounding refractive cataract surgery to become more accurate. Innovators such as Trevor Woodhams, MD, and Harvey Carter, MD, first exposed me to their use of phrases such as the dysfunctional lens and the progressive series of changes in the quality of vision, beginning with presbyopia. They use wording that is much more likely to resonate with patients, especially those who want to see better without glasses. As consumers, patients need surgeons and staff to make the connection between personal wants and the need to pay for a premium IOL. Indeed, the entire conversation needs to shift from a discussion of reimbursement to how the procedure will benefit their lifestyle.

The words surgeons use, their tone, and their entire approach toward a customer seeking the best technology for unaided vision matter if surgeons want to have a successful premium IOL practice.

Patients form their impressions of a surgeon and his or her practice long before they meet. I have yet to enter a practice that did not suffer from a host of negative cues, the signals to a patient that go against the presentation of a premium offering. Whether in the environment (eg, the term waiting room is automatically a negative cue) or in the staff's behavior (eg, two employees discussing personal issues in the presence of a patient), negative cues abound and must be eliminated. These signals prevent patients from gaining the confidence and trust they need to invest their hard-earned savings in what surgeons are offering with presbyopia-correcting IOLs.

Eliminating negative cues while also creating a positive customer experience is no longer optional given the emergence of consumer-driven rating systems on the Internet. Consumers can rate every product and service in every industry, and doctors are not exempt. In elective areas such as refractive surgery, these sites serve as a gateway to evaluating a medical practice's level (or lack) of customer service. Poor ratings and negative comments may drive potential premium IOL patients away, not just from the offending practice, but from consideration of the offering. These Web sites allow patients to tell the world about their encounter with an ophthalmic practice. Patients, now empowered consumers, may not be able to critique a surgeon's clinical diagnosis, but they are able to discern if his or her staff is rude, the facility is dirty, and their waiting time is excessive. These Web sites are not going away, and surgeons and staff should focus on making environment and their behavior consistent with the high levels of service expected by individuals paying thousands of dollars out of pocket.

Being a premium provider is a lifetime commitment, not a one-time declaration. Surgeons need to continuously improve the levels of service provided to customers. Physicians who heed the call will do very well, especially given the recent announcement by the US government that Medicare becomes insolvent in 2017, 2 years ahead of schedule. The premium IOL channel and technologies commercialized by manufacturers are the proverbial gift horse being offered to ophthalmologists. Although success in this arena is neither guaranteed nor promised, a small segment of surgeons is already proving that it can be achieved.

Shareef Mahdavi is the president of SM2 Strategic. Mr. Mahdavi may be reached at (925) 425-9900; shareef@sm2strategic.com.

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