Informed Consent
Episode 31

The Benefits of Premium-Channel IOLs

William Wiley, MD; Brandon Ayres, MD; and John Berdahl, MD, join Marguerite McDonald, MD, FACS, to share how they explain the benefits of premium-channel IOLs to patients.

MARGUERITE: This is the Informed Consent: Getting to Yes podcast, and I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York. This edition of the podcast is about the words leading eye surgeons use to explain the benefits of premium-channel IOLs and get their patients to buy-in—in other words, to get patients to say, “Yes, that’s what I want.”

I have three distinguished guests. First up is Dr. Bill Wiley, medical director of Cleveland Eye Clinic in Cleveland, Ohio. Welcome, Bill.

BILL: Thanks for having me, Marguerite. I appreciate it.

So, I'm a medical director of the Cleveland Eye Clinic. It was started in 1945 in Cleveland, Ohio, and my father had bought it from a gentleman named Dr. Rolf in 1988. And then I bought it from my father in 2002. So, I've been running it for the past 18 years, and initially we’re sort of a general ophthalmology practice, but we always had a focus on, you know, cataract surgery. And we also have a sister practice that's called Clear Choice Laser Eye Center where we provide LASIK and refractive surgery.

MARGUERITE: I’m also pleased to be joined by Dr. Brandon Ayres, who is with the Cornea Service at Wills Eye Hospital in Philadelphia and is also a shareholder in Vantage Eye Care, also in Philadelphia.

BRANDON: Hi, nice to see you.

MARGUERITE: Finally, I’m delighted to have Dr. John Berdahl. John is a partner in Vance Thompson Vision in Sioux Falls, South Dakota, as well as being an associate professor of ophthalmology at the University of South Dakota and an adjunct clinical professor at the University of Utah.

JOHN: Thanks, Marguerite. It's great to be here.

MARGUERITE: To give our listeners a little more context about the advice you’re all about to give, I’d like to ask each of you to describe your practice. John.

JOHN: We've got a nice practice in Sioux Falls, South Dakota, and we also have partners and sites in Alexandria, Minnesota, Fargo, Omaha, and Bozeman. And we have a surgically oriented practice, a highly comanaged practice. And we focus on trying to deliver the best available technology and do the right thing every time and create a wonderful patient experience.

Cataract surgery probably accounts for 70% of the surgery that we do, but we also do a lot of corneal transplants, a lot of glaucoma, and a lot of refractive surgery.


BILL: So, I'm a medical director of the Cleveland Eye Clinic.

I've been running it for the past 18 years, and initially we're sort of a general ophthalmology practice, but we always had a focus on cataract surgery. We also have a sister practice that's called Clear Choice Laser Eye Center where we provide LASIK and refractive surgery.

Traditionally we had those practices running very separate where we had a refractive center and a cataract center. But what we've seen over the past 10 to 15 years, we've seen this refractive cataract surgery, which is kind of a merger of those two philosophies and technologies where we have the refractive outcomes and the cataract result as well. So, we've kind of had a theoretical merger of those two sort of sister practices coming together, and now I focus a lot on what we call refractive surgery that can include traditional refractive surgery but also cataract refractive surgery with premium IOLs and technology.

MARGUERITE: And Brandon, your practice?

BRANDON: So, my practice is a little bit unique. I advertise myself as an anterior segment surgeon and cornea surgeon, and we have an almost 100% referral practice. And the majority of my referrals come from ophthalmologists, and a small number of our patients come directly from optometrists.

So, what we're mainly dealing with is more challenging than average cataract surgery, cornea surgery, and we do a lot of reconstructive or anterior segment reconstruction. And then we also have a second channel of patients, this is usually coming in from the optometric population, who are coming in for more routine cataract surgery.

MARGUERITE: So, you have been famous for many things, and you're an early adopter of all these new technologies. Do you have any idea why the nationwide adoption rate has been slower than expected?

BRANDON: No, we talk about this problem over and over again as to how come we aren't using more premium-channel IOLs, and it's been an issue ever since their introduction 10, 15 years ago. And I think there's not any single answer, but I'll give you my take on it.

One is physicians, eye doctor surgeons, we don't like problems. We like solving problems. And in especially the early generation of premium IOLs, especially in the multifocal and presbyopia-correcting market, there's always been a give-and-take. You've got very happy patients, and you've got a few unhappy patients. And those few unhappy patients are enough to take somebody who doesn't really believe in the technology and make them say, “You know what? They're not all happy. I'm not going to do any.”

BILL: It's basically, Do the physicians have the confidence to achieve the patient expectations? So, as soon as a patient is paying more out-of-pocket, their expectation rises, and I think physicians start to get a little worried. They're like, "Okay. Can I achieve those expectations? You know, I've set them now high with this, educated them that there's a premium lens out there and so raised their expectation, and now the jobs in my hands to deliver on that expectation." And so certain things have sort of hindered allowing physicians to achieve that expectation.

BRANDON: I do see that tide changing. We've had and are continuing to get newer and newer technology with better and better results. With that I do think we'll see an uptake.

BILL: I think early technology was maybe challenging, and over the years we've seen better sort of lens technology. We've seen better diagnostics to allow us to have less refractive misses, better diagnostics to determine who's going to be a good fit or not a good fit for premium lenses. We've got better intraoperative surgical techniques like femtosecond laser or intraoperative aberrometry. We have better technology afterwards, so if for some reason if patients aren't where they need to be, we have technology that can get them back online.

MARGUERITE: I do think there is a huge fear of the unhappy patient. What do I do to fix him or her? And if you don't know how to do a PRK or you're uncomfortable with an IOL exchange, this can be a real barrier.

MARGUERITE: And I think it could be they're uncomfortable talking about money or they don't know how to propose it properly to the patient. They're uncomfortable. So how do you do it in your practice? Do you have packages, or do you have the patient choose in an á la carte fashion?

JOHN: Sure. Maybe I'll start at the end and move to the beginning. The end of it is we do this all in packages and we try to simplify it as much as possible. So, I would say, "Marguerite, you've got a cataract, and if we take your cataract out, we can make you see better. The biggest question you're going to have is how do you want to use your eyes afterwards. Would you prefer to wear glasses? Would you prefer to not have to wear glasses much if at all for distance? Or would you prefer to not have to wear glasses much at all for distance, intermediate, and near?" And that's as simple as it is for the patient. We don't have an á la carte approach where they could choose a femto or not choose a femto, or choose aberrometry or not choose aberrometry. We don't charge extra for a LASIK enhancement if it's needed. We don't even charge extra if there's an IOL exchange that's needed. We want the patient to have as simple and clear of a value proposition as they possibly can.

BRANDON: We've changed over the past couple of years how we do things. It used to be here's your checklist. What do you want? Do you want to laser, nonlaser, aberrometry, no aberrometry. But it just gets to be way too confusing. So we simplified things for the patients. Just what do you want? Do you want your best distance vision? Do you want to have good vision distance and near?

I think having the trifocal available now has made things much easier because we used to have the distance, distance intermediate, and then distance near. There's a lot more discussion. But now with the trifocal, it's basically, you can have your standard lens, and you're probably going to need reading glasses or maybe a slight correction. We can give you good distance vision, which would include some kind of astigmatism correction, or you can have distance and near, and there we're going to use a trifocal.

And in those cases, when we're talking about distance and near, I don't necessarily even bring up astigmatism because it's going to be a given when we choose that implant. So, it's basically, straightforward distance, distance and near. The patient can choose. Then I can use whatever tool I feel is necessary to get them to that end point, and it's made it much simpler for patients.

BILL: We incorporate some technology early on that allows us to kind of gauge how the patient’s thinking. We use software called Surgiorithm that basically runs the patient through a survey, and that survey kind of does a couple things. Number one, it sparks the patient to think about what kinds of options they're looking for. Depending on how they answer that survey, it will send them videos about the different technologies. If they're leaning towards a multifocal lens, it'll have a video about that.

It gives us basically a sense of the patient's definitely interested in doing an upgrade. It sends us a green mark next to the patient's name. If they're definitely not interested, they're given a red mark. And if they're on the fence, they're like, "Tell me more about it," they're given a yellow mark that they're borderline.

The green ones are easy because they definitely want to do some sort of premium upgrade, so we go that way with them. The red ones are also sort of easy because they're sort of set in their mind.

The ones we spend a lot of energy on are the ones that are on the fence. We tend to focus our energy on education for those patients when they're in the office. So, it allows us to be efficient with our time and our messaging.

We tend to discuss visual outcomes with the patient, so we tend not to focus on the individual technology.

MARGUERITE: And who talks about the out-of-pocket expenses? Is that the coordinator, or does the doctor mention that it's not covered by insurance?

BILL: As far as when it comes down to discussing the finances, if a patient asked me directly, I'll go into that and describe. You know, if they say, "How much is this going to cost?" I'm armed with that information. But in general we have our surgery counselors or refractive coordinators discussing the cost, and then, at that point, they can break down into more manageable terms. Let's say they can discuss financing and say, "You know, what's important to you? Is it important to kind of pay for this over time? Let's say, you know, a certain amount per month? Are you looking to pay upfront?" That way you can also kind of manage their expectations and find the sort of financing package that suits their goals the best.

BRANDON: I get myself in trouble all the time, Marguerite, because what I'll say is, “You know, these are the different options. The standard cataract surgery is going to be covered by your insurance. As you choose these upgraded options, a portion of that surgery is going to be out-of-pocket. And I tell them—and this is actually true—I'm not even sure what those costs are because I really just want to defer that.

And so any discussion about finances I transition over to our IOL counselor or our surgical scheduler. That way it's out of my hands. The patient can choose what they want.

But I do very much try and show the upside of spectacle independence because I often will hear, “Well, I don't mind wearing the reading glasses.” But, I think a lot of patients are really happy, really thrilled, when they don't have to wear those reading glasses, so I do try and highlight that freedom from spectacles in the majority of situations.

MARGUERITE: I find that it's helpful to give an example. If somebody says, "I don't mind wearing reading glasses," you say, “You realize you will not be able to eat, you will not be able to see individual peas or rice on your plate …”.

BRANDON: Yeah, I've had that …

MARGUERITE: ... without your reading …

BRANDON: I've had that experience where people say, "Oh, well I don't read anyway.” I'm like, “Well, it's not just reading. It's eating dinner. It's the dashboard in the car. It's reading your watch or your phone.”

MARGUERITE: I've found that sticking my hands out and saying, "Anything within our arms' reach you will not see. It will be very blurry." But the example of not being able to see what's on your plate clearly seems to hit home.

JOHN: When I talk to a patient, almost everybody would like to be free of spectacles, and by the time I talk to them, they've usually heard the pricing. I would say, you know, a certain percent know they want it: 20% know they want it, 40% know they don't, and the remaining 40% is kind of up in the air. And I usually approach it like this. I say, "Do you want me to help you make your decision?" And almost everybody says yes. And I say, "Okay, I need to ask you a couple of questions. First, would you rather not have to wear glasses?" Most people say yes.

And I say, "Okay, then it's really a value question, if it's worth the money to you or not. And here's how I would make the decision if it was me. If it just means that there's less money in my bank account but I can still live life the way I want to live it and take care of my family and do my trips, then it's a pretty easy decision because every day, you're not going to have to fuss with your glasses and contact lenses as much. If it means that you're not going to be able to buy a Harley or take a vacation, then you have a value judgment to make. Is it more important for you to get that new motorcycle or to not have to fuss with glasses and contacts? And that's one that you've got to make. If it means that you're not going to be able to pay your rent, take care of your family, put your retirement at risk, then it's a decision that doesn't make sense for you. And that's how I would make the decision if I were you."

MARGUERITE: That’s a great way to take them through the comparative value of what makes the most difference in their lives.

And with that, I would like to thank my guests—Dr. John Berdahl, Dr. Brandon Ayers, and Dr. Bill Wiley—and ask them to join me again in the future for another edition of Informed Consent: Getting to Yes. Thanks for listening and stay well.

6/22/2020 | 14:53

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