Informed Consent
Episode 18

Growing Premium IOL Volume

Kendall E. Donaldson, MD, MS, and Cynthia Matossian, MD, join Marguerite McDonald, MD, FACS, to discuss premium IOL conversion rates. Listen for tips on communicating effectively with patients.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: Welcome to Informed Consent: Getting to Yes, the podcast about the exact, fair and balanced words that leading eye surgeons say to their patients in order to get them to say “Yes” to premium services or the recommended course of action. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York. Today my guests and I will discuss successful approaches for getting patients to choose premium IOLs.

KENDALL: So I think we have this extra thing to offer patients, and I think it is an exciting opportunity.

MARGUERITE: That’s Dr. Kendall Donaldson, Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute in Miami, Florida. She’s an expert in cornea, external disease, cataracts, and refractive surgery.

KENDALL: So I really try to go over everything with each patient, and then I try to focus in on what I think is best for them.

CYNTHIA: Treating their astigmatism is key to give them the best, clearest vision, so I got into premium IOLs through toric implants.

MARGUERITE: And that’s Dr. Cynthia Matossian, Medical Director of Matossian Eye Associates, with offices in Hamilton and Hopewell, New Jersey, and Doylestown, Pennsylvania.

CYNTHIA: I know presbyopia is such a nuisance for our patients. They hate it. They hate constantly having to reach for their cheater readers or progressive glasses, when they're essentially an emmetrope at distance. It actually is an impairment in their day-to-day activities, whether it's to look at a price tag or see the food on their plate or whatever it may be. So, I always try to give my patients the best possible vision in as broad a visual range as possible.

MARGUERITE: And of course, I would imagine this has gotten easier for you as the premium IOLs have improved.

CYNTHIA: Yes. Now that we are so fortunate, we have such a broad array of presbyopia-correcting implants and toric implants or a combination thereof that I try to customize the implant to each of my patients' eyes. Sometimes they end up with a different implant in each eye, of course, depending on what's going on in that eye.

MARGUERITE: Let's assume that I'm Mrs. Smith and you have decided at the end of our conversation and your exam of me that I am an excellent candidate for a presbyopia-correcting IOL. Would you mind pretending I'm Mrs. Smith and giving me the exact words that you use, Cynthia?

CYNTHIA: I lean in, actually, and I get very close to my patient, eye level. The body language is very important. That's number one. I'm not talking down at them. I'm talking at their level. Secondly, prior to recommending an implant, Marguerite, what I do is I try to find out personally what hobbies they engage in, what tasks they do. So, I include that as an example. I'll say, for example, "To play your Mahjong, or to see your piano music, or to be able to read your Playbill in the theater ...". Whatever it is that they have shared with me as a hobby of theirs. I say, "My recommendation to you is ... and I'm customizing this implant based on all the testing and all the information I have about your eye. My recommendation for you is X." Let's say a Tecnis Symfony or a Crystalens.

KENDALL: So, I do an overview of standard cataract surgery, and I then tell them that we also have some premium upgrades that we can offer them, and then I do make a recommendation after I've done a review of everything. I make a specific recommendation for the patient because I think through the years cataract surgery has become so great in that it's not just for removal of a cataract. It's also a wonderful opportunity for a patient to have increased independence, freedom from glasses, and I think many patients appreciate that in addition to just getting rid of the cataract, which was the case years ago.

They have so many options now. So, they really need and want the doctor to make a recommendation in their specific situation, so I do try to always end with, "Even though we have all these options, in your case, after getting to know you and doing your examination, this is what I would recommend in your case." So, I think patients are looking for guidance from us as well.

MARGUERITE: Do you feel an obligation to sort of just give a huge overview first? There are monofocal IOLs, and then there's this, and then there's that. Or do you just say, "You know what? There are a lot of options out there, but I've picked these two for you: femto and extended depth of focus or whatever.” Do you feel like you need to talk about all the options so they won't feel like you skipped something?

KENDALL: I do feel that I need to at least give them a brief overview of all the options of standard cataract surgery versus some of these premium upgrades because I don't want them to come back after their surgery and say, "Well, you didn't offer me this. Why didn't you present this to me?" So this way, even if I've told them all these things are possible, I might say, "In your case, this is what's best for you."

CYNTHIA: So what I do is, by integrating their hobby, mentioning the word customized, and say, "In order for you to see the golf ball and to, let's say, keep score, my recommendation is …," and I make one strong, confident recommendation. That's how it works with me, and usually the uptake or the acceptance rate is inordinately high.

MARGUERITE: How do you present possible side effects or complications?

CYNTHIA: I am very honest about that. I tell them, "In my experience ...." For example, if we are talking about a Symfony lens or a multifocal, I absolutely look my patients in the eye and confidently say, "You may get glare. You may get some halos. You may get some starbursts, and we don't know who gets them. We will try our best to minimize it, but you may get it. So, is that going to be acceptable for you?"

KENDALL: “Most patients aren't troubled by these things, but I need to advise you that in order to gain more independence and freedom from glasses, you may have some glare or halos, and we have to be willing to make some sacrifices, but this is what we give up to gain this.” I want them to know it's more of a process. It's not something that it is just instantaneous. It's a process that involves two eyes and that there are ways to enhance and alter their final outcome, even after the surgery.

CYNTHIA: I also say, "You may or will need very mild reading glasses. Will that be okay for you, if you need to see really small font?" If they say no, then I may switch my initial thought from a Symfony to a multifocal, maybe in their nondominant eye, and do a Symfony in their dominant eye. I get them very involved in our discussion because we pretrain our patients. We send them videos. We give them brochures. We use everything we know how, because my belief is that, if a patient is informed, he or she or this Mrs. Smith is empowered to make the decision for him or herself.

MARGUERITE: With all of that, it sounds like there should be no surprises. Do you ever get anybody who says, even though you know you told them about it, "I didn't know this would happen? I didn't know that I'd have glare around headlights at night" or some such?

KENDALL: You know, Marguerite, that's why I try to say pretty much the same thing to all my patients so I can remember what I said. And then I'll focus in on certain things but the same overview and even the mention of ocular surface disease and how that has an impact on our cataract surgery. It does seem that, when we're doing cataract evaluations, a lot of times we end up talking about ocular surface disease because we're paying more attention to that these days. And we know that that impacts our final outcomes from our cataract surgery, so you really can't have a conversation about one without the other.

I think we really realize the importance of having that conversation and certainly having that conversation before a cataract surgery helps put that in the patient's mind so, when you mention it after the surgery, you can say, "Remember when we discussed this?" It's such an easier way to approach things than mentioning it for the first time after surgery.

MARGUERITE: How often do you find somebody who has such ocular surface disease that you just cut the exam short? No IOLMaster. No OCT of the macula. You just cut it all short, treat the ocular surface disease, and bring them back.

KENDALL: Well, actually, all of my cataract preops get a questionnaire, so they get the OSDI. Some people use the SPEED, but we do an OSDI, osmolarity, and MMP-9 on all of my cataract preops. So that's lying out on the counter before I even see the patient for the first time when they come in for a cataract evaluation. So if they're very symptomatic and I can see that they're going to need to be pretreated, then that's when I start the discussion and say, "This is the road toward cataract surgery. This is an investment in a lens that's going to be with you for the rest of your life." So, a lot of times, I end up doing that. And it does seem that it's a bit more common in my female patients compared to my male patients, but I do find that I'm having that conversation really several times a day.

MARGUERITE: Oh, yes, and I've found in my practice and a fair number of my cataracts come through the Dry Eye Center of Excellence at OCLI, Ophthalmic Consultants of Long Island. So I have a lot of discussions like that, and the techs do the same thing. They lay out some of the ocular surface tests, the osmolarity, the HD Analyzer, the InflammaDry. And I look at it and walk in, cut it short, and to my knowledge I don't think I've ever lost anybody. I think they appreciate when the doctor is careful.

CYNTHIA: Actually, my patients thank me. Because I say, "If we were to measure you today, we may not end up where we want to be. I want you to be happy. I want, as your surgeon, to do the best I know how. So, we're going to treat this, get you all tuned up as much as possible, and bring you back." And patients actually say, "Thank you, that you are so caring." I get the nicest notes as a result. I have not lost a patient. Instead, I get referrals.

MARGUERITE: I have found the same thing. Do you ever feel uncomfortable because somebody, another MD or an OD, has referred the patient to you, and you find that the ocular surface disease has not yet been addressed? So, you start to talk about it, and they say, "Well, why didn't Dr. X tell me about this?" That's a little difficult.

CYNTHIA: Actually, that happens quite a bit, because not all doctors are as tuned in to meibomian gland dysfunction and ocular surface disease like you are, like I am. So, what I do is, I never, ever say anything negative about a referral source. I say, "Well, you know, we're fortunate to have this equipment ...," whatever it might be. It could be tear osmolarity. It could be InflammaDry testing. It could be the Placido disc images on my OPD III—whatever it might be that is helping me make that diagnosis. And I'll say, "Well, it may not have been there when the doctor looked at you, or maybe the different testing that we have done here has revealed this. So, I would like to treat it first, to get the best outcomes for you." I always include the patient in my solution and help them understand that my emphasis is giving them the best outcome, getting them to achieve what our goals are.

MARGUERITE: Now, on occasion, we all encounter someone who is just the wrong personality and will not accept any visual compromises. Do you have any pearls for how to detect those people and how to talk them out of it when they come in saying they want to see at all distances? They will accept no compromises and no glare and no halos. How do you deal with those people?

KENDALL: Well, we see a lot of those patients actually, Marguerite, because, in a tertiary care center like Bascom Palmer, we sort of are like a magnet for those patients. And so sometimes I'll be doing a fourth or fifth consultation for cataract surgery for a patient, and they're just trying to get the lens that they want. Their friend had a multifocal lens, and they know that that's what they want; they come in with all this information.

I think we have all these tools that we can show them why they may or may not be a good candidate. We can show them their topography. We can really explain to them with the images that we can use why they may or may not be a good candidate. And sometimes I'll send patients away and bring them back every 2 weeks for three or four visits to do additional measurements, additional topography, repeat ocular surface testing. And then I might say, "You know what? You're still not a good candidate for that multifocal lens that you want," but they have to realize.

I think they also have to realize that a lot of ocular surface conditions are a chronic disease, and they do have to understand from the outset that they're always going to need some type of treatment for that. Cataract surgery only treats the cataract, but you have this other condition that you're going to need long-term treatment for. So, again, having that discussion before surgery is just so key in creating that partnership.

MARGUERITE: This has been wonderful. Do you have any extra little final tips for our listeners about what would help them increase their conversion rates for premium IOLs?

CYNTHIA: I would say, number one, educate your patients. They need to be empowered to understand why they need to pay and what is the benefit for them for that out-of-pocket investment. Number two, train your staff, because they are going to be your advocates. Thirdly, really know your implants, because it's not one size fits all. I use every implant out there, depending on the situation I encounter. And lastly, I would say that you really have to have good diagnostic equipment to make the diagnosis of the tear film before you do your measurements. Bring them back after you tune up the tear film and optimize the surface. Then do your measurements, and use obviously good formulas, because patients judge their surgeons by two things: how well they see and how much discomfort they were in during the surgery and in the immediate postoperative period. But they really judge a surgeon by the outcome and the expectations set, so those have to be done very clearly ahead of time. I always say, "Do you understand that, because of your macular disease, you're not going to be 20/20?" I'm very clear about that, and I actually document it in the chart. "Will not be 20/20 due to X, Y, and Z. Discussed with patient."

MARGUERITE: That was great, Cynthia. I’m sure our listeners agree.

CYNTHIA: Thank you so much. It's been so much fun, Marguerite.

MARGUERITE: And thank you Kendall.

KENDALL: Thank you so much, Marguerite. It's always a pleasure talking with you.

MARGUERITE: You’re both welcome. I know that there were plenty of pearls in there from both of you to help our listeners boost their conversion rates for premium IOLs. Please keep listening, because we’ll keep helping you get to yes in the next Informed Consent: Getting to Yes podcast.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

7/25/2018 | 17:10

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