Presbyopic 
and toric IOLs provide great promise to cataract sufferers. They offer significant vision improvement upon cataract removal, an improved range of vision and a decreased reliance on glasses after surgery. Educating patients about premium lens implants should be a simple, four-step process with the first letter of each step spelling out the easy-to-remember acronym IDEA.
► Inform cataract patients that advanced lens implant options exist
► Determine whether the increased vision range and glasses-free benefit are important to the patient
► Examine whether the patient fits candidacy requirements for an upgraded IOL, and
► Ascertain whether the increased out-of-pocket expense is acceptable to the patient.
Still, many practices are finding it difficult to inform and educate their senior patients about premium IOLs. Many are having difficulty adjusting clinic days to accommodate longer patient conversations. And even when a surgeon spends the extra time, practices often don’t achieve the patient conversion they expect. What’s wrong? Why is patient education proving to be such a challenge with upgraded IOLs?
This article will examine what you should do, when you should do it, and who should be responsible within your practice in order to effectively improve premium IOL conversions and enhance patient satisfaction of these lenses.
This sounds so simple, doesn’t it? “Let’s tell our patients that we offer premium lens implants.” But logistical challenges begin to surface at this initial step. Who do we tell? Our best prospects are cataract surgery patients, but how do we know which patients, or potential patients, have cataracts? When do we provide educational material to them? Do we send information in advance of their appointment or do we wait until they visit our office to present options? Do we provide printed brochures or DVD-based education? Can we direct this audience to our Web site, or is that learning method not well established among the senior population?
Our goal is to mail printed information about cataracts and implant options to patients before they attend their exam. In order to accomplish this, we’ve had to adjust several aspects of our scheduling methodology. First, we adjust the master appointment template to ensure there is a “Cataract Eval” or “Lens Eval” appointment type. Many practices have “Complete Exam” appointments, but the only differentiator is New Patient vs. Existing Patient.
It is vital that we segregate potential Lens Eval patients from standard annual exams to improve our educational and surgical conversion efforts. Second, create block days, where Lens Evals are the only appointment-type seen. Block scheduling simply involves moving all the Lens Evals you have scattered throughout the weekly clinic calendar onto 1 day, or 2 half-days. Eliminating other appointment types on block days allows every staff member, from check-in to surgical counselor, to focus on cataract patients exclusively. Block scheduling reduces lateness, improves testing accuracy and charting, and increases surgical conversions.
Next, we train the appointment scheduling staff to ask four questions of each patient when they call to schedule an exam.
1. May I ask how old you are? Anyone over age 55 remains a potential Lens Eval. Those younger than 55 are generally scheduled with an O.D. or non-surgical M.D., our “wellness doctors,” for a standard annual exam.
2. Have you had cataract surgery? If a patient has already had cataract surgery, they are not placed on the surgeon’s appointment calendar. Over the next 20 years, the patient population aged 55 to 80 will increase 54%.1 Patients presenting with cataracts will increase 60%.2 And the supply of ophthalmologists entering practice is expected to remain flat as new residents essentially equal the total of retiring physicians.3
It is simply not feasible to keep post-surgical patients on your calendar and satisfy the exploding demand for cataract surgery. Patients who have already had cataract surgery must be moved to a wellness doctor until a pathological diagnosis again occurs.
3. Have you ever been diagnosed with a cataract? If yes, this patient should be scheduled into a Lens Eval slot. Roughly nine million cataracts are diagnosed annually, yet only three million have surgery.2The remainder are either clinically insignificant or the patient declines to proceed with surgery. This huge pool of patients enters a recheck mode within your practice. Premium IOLs offer the opportunity to move these patients onto surgery. In our practices, I’ve found the average age of patients choosing upgraded IOLs is 8 to 10 years younger than those choosing monofocal, insurance-covered lenses. The opportunity to improve vision and remain largely glasses-free is a substantial motivator in moving forward with surgery.
4. What changes are you noticing in your vision? Patients over age 55, with descriptions of frequent prescription changes, increasing or debilitating night glare, and foggy or blurry vision, are probably cataract sufferers. Our appointment schedulers are trained to ask these questions and recognize significant answers, so that likely cataract patients are scheduled into Lens Eval slots.
Approximately 7 to 9 days ahead of the patient’s visit, a pocket-folder of information is mailed. Included are a personalized practice brochure outlining symptoms of a cataract, lens implant options, fees, surgeon credentials, patient testimonials and frequently asked questions. This is presented in an attractive eight-page brochure, personalized to the practice.
We include a Vision Preferences Checklist which the patient is asked to complete and bring to their appointment. We also include driving directions to the practice. We do not stuff this folder with various loose, photocopied forms, extensive intake paperwork or additional information on surgeon credentials or practice accomplishments. We want patients to consider only the key message: You may have a contaract — and here are the ways we can help you. Mailing the packet in advance is your opportunity to defuse the fear this person feels about losing their vision and inform them about advanced new options to help them see better.
The second phase of the education effort begins when the patient checks in for the appointment. The Vision Preferences Checklist is vital in encouraging the patient to define the vision they desire after surgery. I will venture that virtually 100% of the time, if you ask a 70-year-old sitting in your exam chair if they mind wearing glasses, they will say no. It’s an instantaneous response. They have worn glasses for so long, they don’t give it much thought. But if you begin with the Vision Preferences Checklist, and allow the patient to consider when during the day they would prefer not to wear glasses, when they don’t mind wearing them, and how a fuller range of vision without glasses might improve their quality of life, they become more thoughtful about implant choices.
This Vision Preferences Checklist must be filled out by all Lens Eval patients before the technician begins the work-up. This way, the tech can explore the answers and discuss vision preferences with the patient during testing. The most frequently asked question among surgeons in my presentations around the country is, “How do I determine who is a good candidate?” The psychological adaptability of upgraded IOL patients is often the critical factor in achieving success. Careful use of the Vision Preferences Checklist will assist you greatly in determining personal fit.
Next, it is vital that one of the testimonial videos for premium IOLs be shown to each Lens Eval while they are dilating. My preference is an excellent video produced by Alcon called “Sight Changing. Life Changing.” In this 8-minute video, patients describe their “before and after” vision, and what influenced them to choose either a presbyopic or toric IOL.
Just as in LASIK, we need to remember that the Lens Eval visit is about hope. Patients are hopeful that there is nothing seriously wrong with their vision and that you’ll offer solutions that may improve their lives. You are hopeful that you can provide patients with the exact postop vision they desire. Don’t circumvent this hopeful step within the evaluation. It is often where patients realize they can actually welcome the presence of a cataract and consider surgery a positive life-changing action.
The third phase of education begins when the surgeon enters the exam lane. You review testing results that assist you in determining physical candidacy. You hold the Vision Preferences Checklist, which frames the discussion about appropriate psychological candidacy. Now you must diagnose and recommend an appropriate treatment for this patient.
I work with each of our surgeons to simplify the decision-making process into four steps.
First, are you going to recommend cataract surgery or not? If not, you should go no further in reviewing options or new technologies. The patient is relieved that you told them nothing was seriously wrong and will tune-out the remainder of your conversation.
However, if you do recommend surgery, then the second step is to determine the patient’s desired vision post-surgery. Do they want optimized distance without glasses, which means you will discuss monofocal and toric options, or would they prefer to optimize full-range vision without glasses, which means presbyopic and/or monofocal monovision options. Once you’ve agreed on the desired vision, move to the third step.
Are the patient’s expectations reasonable or not? Review with the patient risks and benefits, side-effects and other lifestyle considerations. Determine whether the patient understands that the implant is not a guarantee against the use of glasses, and there are trade-offs with each lens selection. However, it is important that you do not introduce risks until after you have agreed the cataract should be removed and the patient has become vested in the post-surgical vision they desire.
It is equally important that you cover the risks you feel exist for this patient specifically. It is common for me to hear doctors address patients saying, “What I tell patients is ….” or “I often tell patients XYZ.” This always creates a disconnect, an impersonal perception, in the conversation because this IS a patient in front of you. It is much more effective and personal to say, “What I believe YOU might experience as side-effects are … and your most likely risks are …” This keeps you focused on specific issues this patient might experience, ensures they’ve heard the key risks rather than a confusing laundry list of possibilities, and allows you to chart the conversation effectively.
Once you determine the patient’s expectations are reasonable for an upgraded lens, move to the final step in the conversation. Are upgrade fees acceptable to the patient or not?
I believe strongly that the surgeon needs to state the implant fee at the end of the exam if this is the recommendation being made. Patients want to know what it costs. They are more trusting and accepting of the fee when it is stated by you. This does not mean you need to answer fee questions, discuss financing or mention any other payment details. It does mean that you should be willing to state your fee and gain the patient’s agreement that they want to move forward with a specific lens.
If you are leaving the final determination of lens selection to your surgical scheduler because you are reluctant to recommend or confirm acceptance within the exam lane, you are likely upgrading less than 15% of lenses.
Already, many surgeons are building substantial elective lens practices by assuming upgraded IOLs are their current standard of care. They structure their practice and patient interaction assuming a patient WILL choose an upgrade.
One aspect of their success is to willingly state fees. The most effective method I’ve witnessed is, “Mrs. Smith, based on what we’ve just talked about, I think the XYZ lens is the best option to give you the vision that suits your lifestyle. This lens costs about $5,000 per eye. But since you have a cataract, your insurance will cover the majority of this cost. You will pay just $2,200 for the upgraded lens, which will give you that full range of vision and allow you to be glasses-free the majority of your day. Now, do you have any questions about this recommendation?”
The two most critical aspects of premium IOL education are specificity and time. With specificity, you have the correct patient identified, share with them appropriate information about their condition and make a recommendation about how they should proceed. The opposite of specificity, generalization, means you tell every patient in your office about every condition at every waiting point within their office journey.
As we embrace specificity, we determine they likely suffer from cataracts. We mail them pertinent, informative materials. We provide Web content if they choose to seek out additional information. We provide testimonial videos that are individually viewed and informed consent videos after surgery has been agreed to.
In a practice offering generalized education, we won’t know if a patient is a candidate until we examine them in the chair. The patient will not receive any educational material in advance. An endless loop of disease and surgical-technique videos will play in the waiting room, whether or not the conditions relate to each patient. And the surgeon will attempt to educate all patients personally in the lane about upgraded IOLs in the typical 5 minutes of allotted patient/surgeon time.
Clearly, specificity will result in greater total surgical conversions and higher upgrade acceptance because the patient is better informed and better prepared to make a decision at the time of their initial visit. Which type of education, specificity or generalization, does your practice employ?
When committing to building a stronger elective vision practice, one that excels in all aspects of upgraded IOL implantation, remember the most vital aspect of patient education is time. We must take time on the phone to understand the patient’s condition. We must take time to modify our scheduling template so proper appointment types exist. We should create schedule blocks to improve the in-office patient experience. We welcome the time to visit with the patient in the work-up about their vision desires. And most importantly, the surgeon must spend time with the patient assessing their vision needs and recommending an IOL implant. Upgraded IOLs take more time than insurance implants at each stage in the process. We are well compensated for this time. We will benefit many times over from the increased satisfaction and referrals generated as word spreads that we are elective vision specialists.
Utilizing the methods recommended throughout this article will raise premium IOL conversions in your practice to between 35% to 65% of total lens surgeries. Patients want to see better while minimizing their reliance on glasses. If your patients are not choosing upgraded IOLs at 25%+, examine every aspect of your educational effort. Position yourself as a practice of excellence in education, service, outcomes and satisfaction. Out-of-pocket fees for upgraded services and devices will become increasingly prevalent in ophthalmology. Make sure that you are ready to make the most of this opportunity.