Informed Consent
Episode 34

Increasing the Adoption Rate for Premium IOLs

John Sheppard, MD, MMSc, and Jennifer Loh, MD, join Marguerite McDonald, MD, FACS, to discuss obstacles to increasing premium IOL volume and how to overcome them.

MARGUERITE: Why aren’t more cataract patients choosing premium IOLs? Why has the adoption rate in the United States been so slow?

Those questions are what this episode of Informed Consent: Getting to Yes is about. I’m your host, Marguerite McDonald of Ophthalmic Consultants of Long Island, in Oceanside, New York.

Today my two guests are ophthalmic surgeons who have a lot of experience in getting patients to say yes to premium IOLs.

They are Dr. John Sheppard, who is a partner in CVP Physicians and President of Virginia Eye Consultants in Norfolk, Virginia, and Dr. Jennifer Loh, of Loh Ophthalmic Associates in Miami.

Welcome to you both.

JOHN: Thank you so much for having me. This is an exciting topic and truly the savior of ophthalmology.

JENNIFER: Thank you very much, Marguerite. It's such a pleasure as always to be part of your wonderful program.

MARGUERITE: Before we get into why advanced IOLs aren’t as popular as they probably should be, why don’t each of you tell us a little about your practice?

JOHN: We have a wonderful practice, as we're in a great community. Our practice is growing. Our surgical volume is growing. We have an outstanding management team and a great staff, and it's all about working with the team. And in our practice, we have all subspecialties represented. And we have three satellites and a main office with an internal clinical research team and an internal ambulatory surgery center.

JENNIFER: So, I have a practice in Miami that I started 4 years ago. I was originally the only doctor in my practice for the first couple of years. I have since hired my first optometrist, a medical optometrist, to work with me. I am a solo practice. However, I'm actually part of the large network of physicians, where we operate under one tax ID and have one centralized business office. It's a great hybrid because I really get to call the shots, if you will, in my own practice. However, it's wonderful in the fact that I also have the support of a larger centralized community.

MARGUERITE: We know that you're an early adopter, Jen, and that you've been doing premium-channel IOLs for some time now. We're also surprised that the adoption rate has been so slow in the United States. Do you have any theories as to why that is?

JENNIFER: I think actually from my many discussions with lots of patients and even thinking about it myself, I think one of the biggest obstacles actually is patients don't know what they want, and we don't know what the patient wants, to be honest. We get to spend maybe a few minutes with them. Maybe they fill out a survey about their likes and dislikes and their hobbies and activities, but really, it's just a brief glimpse into their life.

MARGUERITE: Do you have your patients fill out a survey, or you do it more face-to-face with the patient?

JENNIFER: I do it face-to-face. I have thought about incorporating a survey, and I think I will eventually, but because, again, I have a smaller practice right now, I do have the luxury of having some extra time with them. So, I always start off by asking, "In what situations do you wear glasses for? What are your hobbies? What do you want to do?" Those kinds of common questions to get a sense of who they are before I start launching into my discussion of the different options, because, if I get a sense of what they want, at least I can tailor the discussion. So, I don't overwhelm them with all of the options. So I think first understanding who the patient is and then knowing what they want, if they even know what they want, has really been the biggest barrier.

JOHN: There's so many reasons, Marguerite. I think the biggest reason is inertia—inertia in a practice to do things that they've always done, inertia by a physician or a surgeon to simply do everything that's been successful in the past and not go to the next level, and an inertia with the process itself, where new modalities and new equipment, and new calculations may be involved. So, if your patients are all happy, why change? And some doctors, I think this is proportionate to career length, frankly, are less likely to dive in outside of their zone of comfort.

MARGUERITE: Do you think that part of the reason that the adoption rate is lower than expected, do you think part of is the surgeons are afraid of that really unhappy patient?

JOHN: You are absolutely right. Surgeons are afraid of failure, and surgeons may underestimate the value of their ability to change lives and make patients glasses free, and they're fearful of charging a cash fee.

JENNIFER: I agree. I mean that you're right. That could be neck and neck or maybe even beat my initial thought about not knowing what patients want. I think that's definitely one of the number one causes. We never want an unhappy patient. And I think for a lot of surgeons, you know, taking that chance, going that extra step, may be too, too risky, especially in the case of they don't know how to fix it or they don't have the ability to fix it for whatever reason. Maybe they don't have access to a laser. So, I think that that's obviously a really, really important point. /// If we knew there was a way to fix every unhappy patient, right? I think everyone would be really happy to help to offer these technologies.

MARGUERITE: And we know that PRK can take care of, you know, refractive errors for distance or at any distance the patient wants.

JENNIFER: Mm-hmm (affirmative).

MARGUERITE: But most cataract surgeons don't know how to do a PRK. I think the big companies out there should have a weekend course teaching docs how to do a PRK. And I think the adoption rate for premium-channel IOLs would go up much higher.

JOHN: Because so many cataract surgeons do not have in-house or personal capabilities to perform a postoperative correction with a PRK or LASIK, they're truly afraid to refer that unhappy or under- or overcorrected patient out to another practice. That appears to be a huge motivating factor regulating the psyche behind referral patterns in virtually every community. It's not only professional jealousy, shall we say, but it's also fiscal jealousy, because you're removing a valuable patient, a valuable client, from the practice and referring them to another practice that has a capability not inherent to your own skill set. So that is truly an important issue for the many, many surgeons who are new to premium IOLs and who are new to patients who may need corneal refractive surgery.

Not every doctor is a member of a LASIK or PRK center. These are becoming less common as more and more practices bring the femtosecond and excimer laser in-house. So, if a capability is not immediately available, the novice premium surgeon is truly in a protective mode regarding committing patients to a cash-up-front payment and very, very high expectations.

JENNIFER: I found that as a big hurdle at first, too. I'm like, I don't own my own laser. Where am I going to go? A lot of places with their own laser don't let outside doctors come in.

JOHN: Many of us feel comfortable working with other doctors in town. However, if a doctor's volume is growing and they believe that they can make a significant inroad into the premium market, it truly makes a lot of sense to create that capability in-house. Or, what I'm seeing mostly is so many docs are recruiting cornea-trained surgeons to join them in practice. And that's a key point that you just mentioned is that, if that alternative surgeon is in-house, the newly educated premium IOL surgeon has a much better comfort level with that particular referral if, for any reason, that the friendly in-house surgeon will be obviously motivated to maintain your original patient-to-surgeon relationship.

MARGUERITE: Yes. You know, I've said many times, I've been surprised that the big companies in the premium IOL business don't have weekend PRK classes so that docs can learn. It's not that hard to learn PRK. It really isn't. And that would increase the conversion rate to premium IOLs.

JOHN: And the beauty is, you only have to buy one laser, so that does make a lot of sense, and truly the most strenuous and disconcerting procedure probably any of us have ever learned is the microkeratome. It truly has a series of potential complications and precision variations and infection and inflammation potential that ranks at the top of my list of elective procedures that we perform. And by either performing a femtosecond flap or using a PRK, we tremendously reduce the inherent risk and complication level of a post-IOL refractive corneal procedure.

MARGUERITE: Absolutely. Well, John, one of the things our listeners like the most is when our KOL pretends that I'm a patient. Let's pretend I'm Mrs. Smith and I've got ... . I'm in my mid-60s. I've got 2+ to 3+ NS. I've got, oh, let's say 2.00 D of astigmatism, but I want to be free of glasses, too, at pretty much at all ranges. What would you say to me?

JOHN: The first thing I want to know from any of my patients is, "Do you, Mrs. Smith, have any changes in your lifestyle because of your visual acuity? Are there things that you would otherwise be able to do that you cannot do now?" I ask about reading small print, their hobbies, outdoor activity, and, most sensitively, driving at night. And if they're here to see me because of a visual complaint and they have some nuclear sclerosis, the answer will usually be yes. If they say no, I say, "That's fine. I will see you in 6 to 12 months, and we'll have the same discussion."

It's a very good practice to make sure that nobody perceives you as overly eager to remove a cataract. If you have a healthy practice, you are just creating a pipeline. You got somebody on deck ready to come up next quarter or next year. "There is no reason to rush that decision, Mrs. Smith. On the other hand, the technology available for us now in terms of performing the surgery, controlling postoperative complications, and honing your vision to your very best potential is truly amazing, and I'm very excited about the technology that's been developed for intraocular lenses that we can put inside of your eye instead of glasses and the ways that we can bring you visual freedom.”

MARGUERITE: So, Jen, pretend I'm Mrs. Smith. How would you approach me? What would you say?

JENNIFER: Okay, so, “Hi, Mrs. Smith. Well, thank you for coming to our office today. We have diagnosed you with cataracts, and they are visually significant, meaning your vision has decreased according to our eye chart. And I see here that you've told my technician that you're having some trouble driving at night. So, this would make it reasonable to do cataract surgery. With cataract surgery, as you may already know, we remove the cataract, which used to be your natural crystal lens that was clear, and we replace it with an artificial lens or artificial implant.

We have many different choices now and how you want to see. So, I need to first ask you, you mentioned to my technician that you want to see distance and near without glasses. Is that correct?”


JENNIFER: Great. And what do you currently wear your glasses for now?

MARGUERITE: I currently wear them mostly for reading the computer and books.

JENNIFER: Okay. So mostly intermediate up-close activities. So, are you able to drive without your glasses?


JENNIFER: Okay, great. And you would like to be able to do pretty much everything without glasses? Okay.

MARGUERITE: With reduced dependence upon them, yeah.

JENNIFER: Okay. Great, great. So, I think that, you know, I've looked at all your testing here. All your testing looks very healthy. You don't have dry eye. Your retina's perfect. So, based on your hobbies and needs and wants, I think you could be a great candidate for a premium lens technology. There are several different options. I would like to recommend the trifocal lens for you, and I think this is going to give you a great range of vision.

Not only will you be able to drive, you're also going to see your computer well, and you're going to read most books and other objects up close well. I will caution you if something's very tiny print, a back of a medicine bottle for example, or if you're trying to read possibly like in a dimly lit environment, like a restaurant, there is a chance that you'll still need to have a pair of what we call over-the-counter magnifiers or readers occasionally. So, I will never promise that you will never pick up a pair of readers again, but I think we're going to be able to get you out of glasses most of the time for most of your active daily life.

MARGUERITE: Great. Now, is this covered by insurance?

JENNIFER: Ah, that's a great question. So, the cataract part of the surgery is luckily. However, the refractive part, which is the part that I discussed, where we're trying to reduce your need or your dependency on glasses, that part is not covered by insurance. And the reason it's not is, because insurance covers the medical part but not the vision or the refractive part. So in order to get that type of vision you would like, there's extra testing we need to do, extra evaluation, a special implant, and some other post-procedure testing that we may have to do as well in order to get you really happy with your outcome.

So, there is an extra fee, which we call a refractive fee associated with that cost. My surgical planner will discuss that with you in further detail if you're interested, but I think that this option could be a great option for you. I do also want to remind you with this technology that there can be, the one thing I always like to tell my patients, there is a slight chance of having some what we call halo or glare at night, especially when driving. It's reportedly minimal in this clinical trial, but it is a possibility. So, I do like to make all my patients aware of it in case that sounds like something that concerns you or if you'd like to discuss it further.

MARGUERITE: Jen, that was perfect.

JOHN: It's all about the patient. There are so many things we can do to help a patient. I love finishing a case and saying, "Mrs. Smith, we've just fixed your hyperopia, your astigmatism, your presbyopia, your glaucoma, and your dry eye, and you've only been here for 15 minutes. Have a great day and enjoy your breakfast."

MARGUERITE: I think that’s a great, upbeat place to end for today. Thank you both so much for talking about this, and I hope you’ll come back again.

JENNIFER: Thank you. I hope I can come back as well. Thank you so much for your time and efforts.

JOHN: God bless you all and stay safe. It was fun.

9/28/2020 | 15:58

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