MARGUERITE: Welcome to Informed Consent: Getting to Yes. I’m your host Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York. On this episode we delve into how my guest Cynthia Matossian, founder and medical director of Matossian Eye Associates, customizes her services for each of her cataract patients.
CYNTHIA: Thank you so much, Marguerite, for inviting me to your show.
MARGUERITE: My great pleasure. So, let's talk first about femto because you operate in two places fairly far away from each other. Tell me your thoughts about femto, current practices, plans for the future.
CYNTHIA: We're so fortunate to have access to a femtosecond laser currently in our cataract procedures. I think it's a fantastic tool that allows precise capsulorhexis, especially in some of the white cataracts. It makes great astigmatic incisions to treat all levels of astigmatism up until a toric implant is used.
But unfortunately, because of my location and the way my split is between two states, Pennsylvania and New Jersey, where I do surgery, and my surgical volume is almost exactly 50/50, I struggled finding an economic and financial model that made sense for femtosecond laser. I spoke with a variety of companies. The equipment was either too large to be moved on a weekly basis, or it would have been too expensive to have it moved, or it just did not make sense because of the two, very far locations.
As a result, I don't personally use femtosecond laser, although I see its benefits. I still do a manual incision, and a manual capsulorhexis, and manual LRIs, if there is a small amount of astigmatism between 0.50 and 1.00 or between 0.50 and maybe 0.90 D. After that, I switch to toric IOLs.
MARGUERITE: With… the customized approach, every practice is approaching premium surgery in a bit of a different way. Some people bundle it with femto. Some people have an á la carte sort of thing where each thing they might do for a patient is proposed separately, and a custom package is put together. What is your approach to custom, Cynthia?
CYNTHIA: I feel right now we live in an era where patients want choice. They want the exact thing they want when they want it, pretty much. So, I wanted to analogize and copy Starbucks in that way in that I want to offer all of the different advanced technology implants and premium services including LRI, and ORA, and ReSure, etc., but offer the choice to my patients. So, sometimes I have patients selecting a monofocal implant with an ORA to make sure it's as precise as possible. Sometimes, I have people selecting a multifocal or EDOF toric lens, and, say they don't want ORA, they trust my calculation. So, each person is very unique in that way, and by giving each person a choice, like at Starbucks, there are hundreds of combination options.
MARGUERITE: Do you go through them and then say, "But for you knowing what I know about you now about your job or your hobbies or whatever, so these are all the possibilities, but I suggest XYZ." Are you very kind of firm in your direction, or do you lay it all out and let them really grab the reins and decide?
CYNTHIA: That's a fantastic question. I think patients are coming to me for my expertise, paying me for their office visit or my wisdom and knowledge. As a result, patients want a confident and firm recommendation from their surgeon. It is too complex of a topic for patients to figure out the nuances of different implants, especially if they have coexisting ocular pathology. So, what I do is I take their preexisting conditions into consideration. Do they have prism in their glasses, are they amblyopic, do they have optic neuropathy or AMD, etc.?
I look at the amount of astigmatism they have, the pattern of the astigmatism, their lifestyle activities, and I personally ask them those questions. Then I put all of it together and recommend something very concretely in a very friendly way, and I say, "For you, based on all of these things, I believe this particular lens or this particular procedure will be ideal.” And I'm always upfront with them, and I say there was an out-of-pocket component that is not covered by insurance and it's going to be so much. I state the dollar amount, but I don't go into detail with that. I say, "Our surgical coordinators will go over that aspect of it with you in greater detail."
MARGUERITE: I do something actually very similar. I mention the other options. I don't want them to get home and have the 45-year-old daughters say, "Well didn't the doctor mention this, or didn't she mention that?" So, I'll say, “There's this option. It's not for you because of X, Y, Z. You have keratoconus. You've had keratoconus for 40 years. I don't think you should have a multifocal or extended depth of focus IOL. It's not for you. Your optics will get worse." So, I mention the things that I'm ruling out for the sake of completeness, and I pass through it very quickly and end up with a concrete recommendation, very much like you. Do you find most of the time they go with what you say, what you propose?
CYNTHIA: Sometimes they do. But I want to back up to something you said. I do the exact same thing. So, if somebody has advanced AMD or keratoconus, I, too, say, "There are multifocal or EDOF lenses, and they are not for you because of this and this." I actually document in the chart. I put, "not a Symphony candidate," for example, “due to AMD.” And so, they need to know that. So, if they speak with a friend or a neighbor, then they know why they were not a candidate for a particular lens. Just like they need to understand why they are a good candidate for a particular other type of an implant.
MARGUERITE: Yes, I couldn't agree more. There's a lot of Googling, talking to doctor Google. They compare with their friends, with their spouse, and you have to have at least briefly mentioned the other options and why they are not a candidate. Couldn't agree more. Do you find that most of your patients take advantage of things like Alphaeon or Care Credit? Are there regional differences between your two offices where they do more of that in one office than the other, or is it kind of all the same?
CYNTHIA: Actually, I don't discuss those options with my patients. I leave that up to our surgical coordinators, but they do say we accept credit cards, checks, or we have financing opportunities, and they mention Care Credit or Alphaeon. We use both companies, because sometimes one approves it and one doesn't. This way, we have a greater option for our patients to be able to get financing for their out-of-pocket procedures.
MARGUERITE: So, I, of course, leave this, most of that discussion, the financial discussion, to the surgical coordinator, but I will say the price. I will mention it, and I'll say the vast majority of our patients use Care Credit or Alphaeon and pay a little bit each month with no interest for 2 years. Then I move on, and I only add that because I don't want them to feel badly that they're using a financing approach to having the surgery. I don't want them to think, "Oh gosh, I'm the only one who can't afford it. I've got to pay a little each month." So, I throw that sentence in, but basically, our approaches are very, very much the same.
Do you find that a high percentage of patients have 0.90 D or less cylinder where you're doing a manual LRI?
CYNTHIA: Well, you know, it depends. Some percentage have less than 1.00 D of cylinder. If it's 0.90 D and it's against the rule, I then may offer them a toric lens and flip them. You know, flip the axis to with-the-rule so they have a little bit more of a with-the-rule residual cylinder of maybe 0.25 to 0.50 D, which will then start to drift against-the-rule again with age. So, I never try to flip it from with-the-rule to the rule, but I do sometimes flip it from against-the-rule to with-the-rule if my choice is LRI versus a toric.
If it's between 0.50 and 0.90 D, I am very open and formally recommend that they have astigmatism correction because, as we always say, we would never leave somebody undercorrected with that amount of cylinder in their spectacles. So, why leave them undercorrected with their IOLs? We can enhance their focusing problem, at all distances, by correcting that small amount of residual astigmatism, especially if it's an EDOF or a multifocal lens. We don't want our patients to have but the best possible visual outcome, which means correcting astigmatism of anything greater than 0.50 D, in my opinion.
MARGUERITE: Excellent point. I also agree, and we certainly wouldn't leave it behind with LASIK, or laser vision correction. We wouldn't leave a small amount of astigmatism behind, but... but it's critical for the EDOF's, you're right. Wow. Cynthia, I've learned a great deal about your approach, and I'm going to take some pointers, and improve my approach. Are there any last thoughts you'd like to share with our listeners?
CYNTHIA: Oh, yeah. Patients value their vision very much, and they really appreciate any cataract surgeon who takes time to personalize, and customize the suggestions for their cataract surgery, the type of implant astigmatism correction, whether with a toric, or an LRI, or an AI, femto or not, and they really appreciate that they're not just a number, that the specific steps are being customized to each of their eyes.
MARGUERITE: I couldn't agree more.
CYNTHIA: And once they understand the why behind these steps, they're more than willing to open their wallets and pay for these out-of-pocket services because they then understand what it is that they're paying for and what it is that they're going to get out of it for the rest of their lives.
MARGUERITE: One last question, Cynthia, do you use a lot of educational videos, or do you do it mostly verbally or with a handheld tri-fold brochure?
CYNTHIA: I do it all. I talk to them about it. We do send our patients educational videos prior to this appointment. We use CheckedUp and Wendia videos in our offices, and we use MDbackline as well to help communicate with our patients before they even come to our office. So, we use many different modalities to connect with our patients—get to know them. They feel very much shepherded by us throughout their entire patient journey. As a result, they open up, understand, and are willing to pay for these out-of-pocket services.
MARGUERITE: Great tips, Cynthia. Thank you so much, and I hope you'll come back soon and talk with us on another topic.
CYNTHIA: Thank you very much for inviting me. Very much enjoyed the entire interview. Thank you, Marguerite. You're the best.
MARGUERITE: Same here. Thank you.
Well, I certainly learned a lot talking with my friend Cynthia Matossian, and I trust you did, too. Please join us again next month for another episode of Informed Consent: Getting to Yes.